SAMUELxLILIENTHAL.xM.D.. 22C West 34th S -^feET. ■ '^iJi^JSt'^ '' THE PROKbRI N ^P_ ^ HataniffliiliiiHlCilItinftkiiPaalc. THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF Dr. E. BELT August ON EENAL AND UEII^AEY AFFECTIOI^S BY W. HOWSIIIP DICKINSON^, M.D.CANTAB., F.E.C.P. PHYSICIAJI TO, AND LECTURER ON' MEDICINE AT, ST. GEORGE'S HOSPITAL CONSULTING PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN CORRESPONDING MEMBER OF THE ACADEMY OF MEDICINE OF NEW YORK MISCELLAIN'EOUS AFFECTIONS OF THE KIDjS'EYS A]S[D UEIlSrE NEW YORK WILLIAM WOOD & COMPANY 1885 PREFACE. In presenting this work to the public I have to apologize for its tardy- completion. The delay has been partly caused by the demands of active professional work, and partly by my desire to incorporate the re- sults of the experience thus acquired. It was my design to follow the publication of Albuminuria^ with an account of the other renal and urinary diseases sufficient for the practitioner, and not too lengthy for the student. If I have, as I fear, erred in the direction of amplification, it has been from the desire to be clinical ; not merely to give conclusions, but the grounds of them. I notice with regret as a substantia] evil the bulk to which the book has swollen. Paper of some thickness was needed for the proper dis- play of the woodcuts, and I have not thought it well to save space by contracting tlie type. I am assured that much of any interest which may be found will be in the clinical and pathological cases, but never- theless it is possible that the value of some of them may not be thought commensurate with their weight. It was my intention to have pre- sented the work in one volume ; but I have thought that the con- venience of the reader would be best served by so far departing from the original plan as to issue each part in a separate cover, each with a separate table of contents. I have not hesitated to fill up the deficiencies of my own observa- tion with that of others ; and where my opportunities have been small, as with regard to parasites, I have been content to present the existing state of knowledge little else than as a compilation. I have considered in one place the structural alterations of the kid- ney, together with the results tliey produce ; and in another the lead- ing alterations of the urine, with the changes to which they are due. Many subjects have thus been shown from two points of view, and a certain amount of repetition entailed ; but not otherwise could the mutual relations as well as the individual characteristics of tlie several disorders be presented. With the existing abundance of works devoted to the purpose, I have not thought it necessary to give space to methods of urinary ex- amination ; nor have I attempted to deal at large with changes which ' See Am. Publisher's Note at end of Preface. IV PREFACE. tlic urine presents in connection with diseases external to tlie kidneys, and not manifested especially by their means ; but I have regarded with a somewhat wide ocoi)e its more promineni morbid states, and tlie conditions wliich attend its absence and its superabundance. I have dealt fully witli the circumstances of phospliatic excess, and of the additions 'of sugar, albumin, chyle, and blood. I have not given a separate chai)ter to ])uruk'nt urine ; since, so far as tliis can be con- sidered apart from surgery, 1 judged that it had found suthcient men- tion under tlie headings of Pyelitis and Abscess. I have entered Avith some detail into the conditions of urine and of system which occur with the formation of calcuH. In preparing for the press the portion of the work which is now presented to the public, pains have been taken to make each subject level with tlie time ; but even in the interval between printing and pubHcation some cases have progressed in a manner I sliould liave been glad to have recorded, and some researches have been made and opin- ions expressed which were excluded, not by choice, but by date. Cases in renal surgery have presented tliemselves which it was not possible to introduce, but tlie principles enunciated would not have been thereby altered. Tlie chapter on disseminated suppuration has received some additional experience in the shape of a postscript, together with refer- ence to some recent views on ''catheter fever." The chapter in Part I. referring to the pathology of diabetes, which was published in the year is 77, has been re- written, which was rendered necessary by the discussions which it has provoked, and the further researches which it has instigated. The publication of this work in portions has necessitated a mode of arrangement in which logical sequence has sometimes given way to convenience : but it is hoped that the disjointed parts will fall together without violence, and, with the help of the index, present a fairly accessible as well as a sutticiently inclusive account of the diseases of the kidneys, and the disorders mainly declared by their secretion. 9 Chesterfield Street, May Fair: January, 1885. j}^ote hy the American Publishers. The treatise on Albuminuria by the author of this work was pub- lished in Wood's Lil)rary of Standard Medical Authors for 1881. The numerous cases cited in detail in the English edition of this volume have been omitted in this edition in order somewhat to reduce its size. It will be perceived that the text of the work has been so prepared that this omission in no degree interferes with its continuity, nor does it limit its authority. WM. WOOD & CO. OOITTEE"TS. MISCELLANEOUS AFFECTIONS OF THE KIDNEYS AND URINE. CHAPTER I. ABSCESS, OR CIRCCTMSCRIBED INFLAMMATION OF THE KIDNEY. p Causes of renal abscess — Abscess from external violence; from irritant drugs; with pyaemia — The surgical kidney — Uriseptic abscess — Urinary or cathe- ter fever, .......... CHAPTER II. Pathological changes — Causes — Urinary alterations — Characters of healthy epithelium from different parts of urinary tract — Sj'^mptoms, course, re- sults, and treatment of pyelitis, . . . . , .16 CHAPTER III. SUPPURATIVE PERINEPHRITIS. Position and exits of matter outside kidney; its sources and causes — Ply- mouth Dockyard disease — Puerperal abscess. From perforation of gall- bladder, pyajmia, fevers, etc. — Symptoms, duration, urinary charac- ters, and treatment of perinephritis, . . . . . .23 CHAPTER IV. THROMBOSIS AND EMBOLISM. Thrombosis — Morbid anatomy; causes, organic antecedents, and symptoms — Mortality when complete and when partial — Embolism — Morbid anatomy — Symptoms — Urine — Aneurism of renal artery consequent upon embolic obstruction, . . . . . . . . .30 CHAPTER V. GENERAL RELATIONS OF RENAL TUMORS. Their anatomical relations — Position with regard to bowels subject to some variation — Abdominal presentation ; its varieties — Urine — Renal tumors how distinguished from those of liver, spleen, ovary, peritoneum, supra- renal bodies, and absorbent glands — Cases illustrating the similarity of the last with renal tumors, . . . . . . .37 CHAPTER VI. PATHOLOGY AND VARIETIES OF RENAL TUMORS. Their kinds enumerated — Malignant growths generally considered — Distribu- tion of growths secondary to those in kidney — Extension of growths from kidney — Minute anatomy and relations of carcinoma, sarcoma. VI CONTENTS. PAGE fibrous and fibro-fatty tumors, melanosis, villus, lymphadenoma, leuk- haemic tumors, angioma, syphiloma, fatty, bony, calcareous, and carti- laginous growths, . . . . • . . .47 CHAPTER VII. CUNICAL HISTORY, SYMPTOMS. AND TREATMENT OF MALIGNANT DIS- EASE OF THE KIDNEY. Its exciting causes— Symptoms— Tumefaction, pain, paraplegia, cachexia, hfematuria — Urine— Results of dissemination and encroachment — Dura- tion in children and adults— Treatment by excision and palliation, . 70 CHAPTER VIII. TUBERCLE OF KIDNEY. Patholog}'. broadly and with microscopic detail— How associated with tuber- cle elsewhere— Frequency in children and adults, and at different ages — Exciting causes — Symptoms, local and general — Abdominal tumor — Con- sequent lardaceous disease, extra-renal and psoas abscess — Urine — Dura- tion and prospects — Medical and surgical treatment . . .79 CHAPTER IX. HYDRONEPHROSIS AND PY'ONEPHROSIS. Greneral description — Subjects and causes of hydro- and pyo-nephrosis — Pathological changes with hydronephrosis — Dilatations and cysts simu- lating it — Double hydronephrosis — Single hydronephrosis, diagnostic errors, causes of death — Pyonephrosis — Treatment, medical and surgical, of both conditions . . . . . . . .94 CHAPTER X. CYSTIC DISEASE OF KIDNEY. Varieties — The large cystic kidney minutely descrilied — Its origin and nature — Subjects — Its frequent latency and distinctive symptoms — Urine — Tu- mefaction — Congenital cvstic disease — Solitary cysts — Paranephric cysts, . . '. . . . . . . . 109 CHAPTER XI. RENAL CALCTLI IN GENERAL AND PARTICULAR, WITH THEIR CAUSES. Classification of calculi; their relative frequency as indicated by the museums of London — General structure of calculi — Ord's views — Their geographi- cal distribution and relation to water, food, climate, and race — Uric acid stones; and diathesis — Urates — Xanthine — Oxalate of limestones, and the oxalic diathesis — Phosphatic calculi and the phosphatic diathesis — Calcic carbonate — Cystine and the cystine diathesis — Indigo stones — Fibrinous and blood calculi — Urostealith — Differential diagnosis of renal calculi, . 120 CHAPTER XII. PATHOLOGICAL CONSEQUENCES, CLINICAL RELATIONS, AND SYMPTOMS OF RENAL CALCULI IN GENERAL. Position and local effects of renal stones — Their clinical relations and sj'mp- toms — Ages at death icith and o/ renal calculi — Their various symptoms, pain, tenderness, grating appreciable to touch — Posture — Affections of testicle and bla,,.i ,.£..! !,,:, .1'. I 'i iMlH ,1 9 UA ,\. \y straight tubes as they approach their exit dilated by backward pressure. •the surface sometimes as purple blotches in which suppurative centres can be seen, or as discrete or confluent jiustules, often nearly resembling a cutaneous pustular eruption. With this condition the microscope shows more or less dilatation of the straight tubes, distention or morbid occupation of the associated blood-vessels, and disseminated intertubular suppuration, the distribu- tion of which is regulated by the course of the veins. Passing to detail, and taking the straight tubes first as the parts of the organ first affected, these as they converge upon their outlets are often strikingly dilated apparently from the backward pressure of the retained urine. The dilatation is irregular, widening the cylindrical shape of the tubes or converting tlicm into ovoid, globular, or shapeless 10 ABSCESS OF THE KIDNEY. cavities. They are variously occupied by saline matter, purulent secre- tion, fibrin, or epithelial growth. The straight tubes, thus stretched and filled, form tlie wliite lines which are evident to the naked eye. The change does not extend to the convoluted tubes, which remain for the most part natural. The veins, wliich appear to be next involved in the disease, are gen- erally distended with blood. The straight veins of tlie cones often dis- play in section a partial distention which is probably the result of coagu- lation which has occurred during life. The larger veins of the cortex arc often similarly filled, and it some- times liappens tliat the arteries which pass in companionsliip with them are likewise jjcrmanently occupied. As a general rule, however, the arteries are natural, as also are the Malpighia'n vessels. The venous position of the clot in the condition under consideration differs from the similar result of ordinary pyaemia, in that the obstruction there is essentially ai'terial. The third stage of the disease is the scattered suppuration which is / jo I •^ 'I ''I, 1 Irritative plugs in small vessels surrounded bj pus corpuscles— from cone. the most obvious result of the com]ilicated process. The disseminated abscesses, or regions of cellular infiltration antecedent to abscesses, are intertubular, and have relation to the course of the veins. Cells gather at isolated spots, sometimes obviously accumulated around a minute dis- tended vessel. Occasionally the new formation oversiireads considerable districts, insinuating itself more or less evenly between the tubes, its vascular origin being chiefly evinced by its obvious intertubular position. The Malpighian bodies remain unalfected by the disease, though the ad- ventitious corpuscular formation often collects abundantly outside them. The convoluted tubes are generally clear, though where they cross the districts of infiltration their epithelium is sometimes superabundant, and sometimes they appear to be encroached upon, or confused by. ABSCESS OT THE KIDNEY. 11 the cellular formation around them. They are sometimes displaced or compressed. Taking the structural changes in their mutual relation, the dilatation of the tubular exits, tlie morbid occupation of the veins, and the general absence of signs of tubal inflammation, the nature of the process is clear. The disorder has its origin in the regurgitation of urine charged with morbific products. This, forced backwards by the retention gen- eral in these cases, distends or occupies the straight ducts. Thence by transudation, or similarly, it enters the neighboring blood-vessels, and charges them with an infection resembling in its results that of pyaemia. This is distributed by the veins to the rest of the gland, sowing ab- scesses in their course, and ultimately causing constitutional symptoms analogous to those of pyaemia otherwise derived. The condition of the kidney may be described as one of pyaemia arising within itself. It has a close general resemblance to that caused by a distant infection, differing from it in the usual dilatation of the urinary outlets, and in the fact that, while with pyaemia from a remote source the materies morbi is necessarily distributed by the arteries, in the condition under discussion it is scattered by the veins into which it was first received. The disorder in its frequency and fatality has great practical impor- tance. Inflammation of the bladder, or of the pelvis of the kidney, either as antecedent to the change, or associated with it, is so invariably present as to give a seeming warrant to the old view which regarded the disease as a mere extension by contiguity of inflammation beginning in the urinary cavities. The nature of the organic change, however, plainly declares its origin, not in the mere creeping of inflammation from mem- brane to gland, but in the absorption of morbific matter. Of this the urine is obviously either the source or the vehicle. It remains to inquire whence and in what circumstances the poison is engendered. To help in answering these questions I have collected the particulars of sixty-nine cases of the disease from the post-mortem books of St. George's Hospital. The following table shows the urinary disease upon which the suppurative condition of kidney followed: Disease antecedent to disseminated supjniration of kidney in sixty-nine cases. Obstacle to escape j Stricture of urethra, 19 of urine. \ Disease of prostate, enlargement, tumor, or abscess, . 12 f Paralysis of bladder from fracture of spine, . . 5 I " " " disease " ... 3 Loss of expulsive! " " " '* of cord, . . 4 power 1 " " " " of brain, . . 3 I •' " consequent upon exhaustion (_ from disease or accident, .... 2 ( Stone in bladder, no operation 6 Vesical calculus. \ " " lithotrilv, 6 ( " " lithotoniy, 3 r Cystitis from vesical growths, etc., .... 3 •Cystitis from other J " unexplained, 1 causes. ) " from discharge of lumbar abscess into blad- t der, 1 Complicated. — Stone in kidney, with enlarged prostate, ... 1 69 Reaction stated. 12 ABSCESS OF THE KIDNEY. I have next classified the descriptions of the urine in each case. The state of this secretion was noted in 47 of the number, in the following terms: — State of the urine in forty-seven of the cases previously referred to. f Ammoniacal or foetid, and mixed with various pro- I ducts of vesical inflammation, . . . .21 Aniraouiacul, 1 "< Alkaline .md turbid, or containing mucus, ... 3^ Alkaline, blood}-, and purulent 1 Alkaline or " pliosphatic," 3 f Rop}-, containing mucus, pus, and blood, ... 1 I Containing mucus and pus, 1 T, ^. .... .^ 1 I Purulent and bloody, 4 Reaction not stated, j p^jj.^,l^.jj^ -^ ^ I Bloody, .4 l_ Albuminous and turbid, or purulent, . . .2 47 Looking first at the urine as directly connected with the origin of the disease, it appears that three conditions of this secretion usually concur — retention, ammoniacal decomposition, and admixture with the products of mucous infiammation. Of these an essential circumstance aj)pears to be ammoniacal decomposition, which retention may induce, and cystitis either precede or follow. The urine was generally foetid and more or less mixed with vesical products, pus, mucus, and blood. There is reason to believe that it Avas invariably ammoniacal. Wherever the reaction was stated, it was persistently alkaline except in one instance. In this exceptional case, the secretion was alkaline when tlie inception of the disease was declared by rigors, then for a short time acid, and alka- line again before death. In the cases, comparatively few, in which the reaction Avas not stated, the condition of retention or the state of the urninary mucous membrane was generally such as to point unmistakably to ammoniacal change. The simple presence of pus or mucus in the urine, though lasting for years, does not appear to set up the renal disorder so long as the urine re- tains its acidity and resists putrefaction. I have myself known no instance in which the mischief has arisen except in connection with ammoniacal urine. The ammoniacal change, however, though it may arise independently of mucous inflammation, produces it so constantly that the origin of the disease is always thus complicated. Sometimes, as with stone, the inflam- mation of the bladder has led to the change in the urine; sometimes, as in cases of paralysis, the change in the urine has caused the inflam- mation of the bladder. Whichever comes first, so long as the necessary foulness of the urine is attained, a condition which is promoted by the admixture of diseased vesical secretion, the renal suppuration may follow. AVhether primary or secondary, the inflammation of the urinary mucous membrane is invariable. This is usually of the bladder, though the re- nal change has been known to follow inflammation and retention confined to the pelvis caused by a stone situate in that cavity. Passing from the state of the urine to its clinical antecedents, these may generally be stated to be of three kinds — obstacles to the escape of the urine, loss of expulsive power, and vesical, or very rarely, pelvic irritation. ABSCESS OF THE KIDNEY. 13 Stricture of the urethra is of all causes the most common, giving rise as it does to the needful urinary putrefaction, and in its chronic form insuring the dilatation of the glandular exits which makes them ready recipients of the poison. Enlargement of the prostate, scarcely less common as a cause of the disease, acts in the same way. Next in order of frequency to such impediments come the diseases and injuries of the nervous system, by which the expulsive power of the bladder is destroyed. These, giving rise to retention and decomposition of urine, and its contamination by the products of vesical inflammation, cause changes in the same sequence as those which arise from stricture, but more rapid in progress. The loss of vesical innervation in these cases hastens the disorganization of the mucous membrane, which gives the extreme foulness to the urine observed in such circumstances, and sets up early and severe renal mischief. Similar symptoms may fol- low from cerebral disease, and occasionally from the general prostration which follows from disease or accident not directly connected with the nervous system. Lastly, severe vesical irritation, though unconnected with retention, may cause the same results. The disorder was traced to stone in the bladder in fifteen of the sixty-nine cases previously referred to. Though differently begun, a similar putrescent state of urine to that of retention is here in the end produced, contamination by mucous discharges which promote decomposition being apparently the incipient evil. Putrescence appears to be always present. In connection with the frequent origin of the renal suppuration from vesical stone, its rarity as a consequence of stone in the kidney is worth remarking. The difference probably lies in the less putrefactive tendency of the discharges from the pelvic mem- brane or the less ready intrusion of septic agents. It is frequently to be observed that the conditions of bladder and of urine apparently sufficient to produce the disease will exist for years without doing so, but that at once upon some surgical procedure, of which the use of a catheter is probably the essential part, it will start into activity as if the ready train were thus lighted. The term " sur- gical kidney," so generally used in reference to the disease, bears witness to its association with the use of instruments. Linking the secondary renal mischief with ammoniacal or putrid urine, and having regard to recent researches, which have connected the lower kinds of organic life with pyaemia,' it is worth noting that the con- dition of urine which causes the disease now in question is one in which vibriones and bacteria abound; but considering the different circumstances in which such organisms appear, it would be unsafe to draw more than a provisional inference as to the nature of the virus beyond the broad fact that it is associated with, and apparently dependent upon, decompo- sition of urine. The frequency of the disease after the introduction of instruments may lead to a surmise which must have practical influence, that the es- sential virus is capable of being conveyed into the bladder by their means. Since this conjecture as to the origin, or at least an origin, of the sur- gical kidney was made public, Dr. Ferrier has published some experi- ments which corroborate it. He found, as indeed had before been ob- ' Dr. Sanderson, Pathological Transactions, vol. xxiii., p. 303. 14 ABSCESS OF THE KIDNEY. sei'ved, that urine, if preserved from external contamination, might be kept witliout putrefaction for an indefinite time, but that the simple contact of a snrface not freed from germs' was enough to initiate the putrefactive process. In this view the ammoniacal state itself is due to con- tamination from without. Whether this be so, or whether urine may be- come ammoniacal by causes acting only from within, as appears not im- probable, it is none the less likely that the especial virus, of which tiie ammoniacal urine may be only the vehicle, may be introduced by such means. The practical suggestion as to the invariable carbolization of catheters and bougies is too obvious to need insistance. In connection with the pathology of the disease I may briefly sketch the symptoms, drawing chiefly from the cases to which I have already alluded. The disorder, particularly when the abscesses, as is too often the case, are widely disseminated, runs a rapid and fatal course. The patient generally dies within three weeks of the first symptom, sometimes within a few days. In fourteen cases in which the dates and symptoms were carefully recorded in the hospital books, the duration of the com- plaint varied from two to eighteen days. As an example of its rapid course I may refer to an old woman who was brought in with a simple fracture of the tiiigh. Two days after the accident she became unable to pass water. A catheter was used, and the urine found to be natural. It then (piickly became oflfensive and loaded with mucus, and death oc- curred within a week of the injury, three days after the urine changed its character. Small purulent deposits were scattered through both kid- neys. The course of the disease resembles that of pyaemia, differing from it in the usual exemption of other organs from the suppurative process. The symptoms are general rather than local; they point to contaminated blood rather than to disturbance of glandular function. Pain in the loins, however, sometmies occurs; and often the urine is much dimin- ished, or even for a time nearly suppressed. Shivering happens early and is apt to be often repeated, and is sometimes as strongly declared as in the case of ague. Febrile symptoms rapidly follow, Avith typhoid pros- tration. The pulse becomes rapid and feeble, the tongue dry and brown, the appetite absent. Vomiting is a frequent and often an urgent symp- tom. Not seldom hiccough occurs, and sometimes diarrhoea, or profuse sweating. The countenance becomes anxious and haggard, the complex- ion cadaverous or yellow, and possibly with low delirium, the patient sinks into utter prostration, unconsciousness, and death. Erysipelas is an occasional complication, as also is a condition of pul- monary congestion or oedema short of that which results in pyaemic de- posits. Dropsy is uniformly absent, as in the case of pyaemia. The disease is not always fatal. In examining the bodies of persons who have long suffered from disease of the urinary organs it occasionally happens that there are found upon the kidney obvious scars, often much pigmented, in place and dimension such that they may fairly be attrib- uted to ancient abscesses. Dr. Wilks tells me that he has made the same observation, and a case of the sort Avas related by Dr. Moxon in the twenty-third volume of the "Pathological Transactions." As complicating the less rapid forms of the disorder must be men- ' "Septicaemia and the Catheter," by Dr. Ferrier, British Medical Journal, April, 1873. ABSCESS OF THE KIDNEY. 15 tioned perinepliritic abscess from perforation of the capsule of the kidney and discharge into tlie areohir tissue. In a body recently examined at St. George's Hospital, a pint of pus lay outside the suppurating kidney; and preparations in the museum of St. Mary's Hospital illustrate a case in which a vast collection of pus reaching from the diaphragm to the groin, pushing forward the bowels and infiltrating the lumbar muscles, had the same origin. The treatment of the established disease may be briefly described as that of pyasmia, upon which it is not needful to dwell. When the sup- puration has taken a general hold of the renal structure, there is probably litcle chance of recovery, though this may follow the slighter or more limited forms. The symptoms are mainly those of septicemia, and our efforts called for to obviate death by the attendant febrile prostration. Quinine and alcohol are largely needed, as well as special reme- dies to relieve special symptoms. The vomiting so often present may be controlled by ice and creasote, while active purgatives are often called for by obstinate constijnition, and it appears that, especially when the urine is much reduced in quantity, the general state of the patient improves under their operation. It is sufficiently clear with regard to this disorder that our efforts must be directed rather to prevention than cure; and our knowledge of the conditions under which it arises is encouraging in this respect. The frequent appearance of the disease after the use of instruments makes it imperative never to do so without antiseptic precautions. The association of the disease with vesical inflammation, and the admixture of its products with the urine, must furnish a warning to both surgeon and physician, which the latter may take as an indication, in cases of paralysis and prostration, to insure the regular and complete emptying of the bladder. It is necessary to have regard to the conclusion that the disease is produced not simply by cystitis, but by septic changes conse- quent upon it, which are associated, as it seems invariably, with an am- moniacal state of urine. If, therefore, this can be prevented, so may be the disease. Next to the proper evacuating of the bladder, the greatest service in the prevention of ammoniacal decomposition may be rendered by acid injections into it, of which I have found one containing nitric acid and quinine — 15 drops of dilute nitric acid, 10 grains of quinine, and 10 ounces of water — to give the best results. The bladder may be washed out daily with this or less often. Towards the same end acids may be given by the mouth. The mineral acids are more efficacious than ben- zoic or any of the ordinary vegetable acids, and of the mineral acids I have got more decided results from sulphuric than from the others. But perhaps nitric or nitro-hydrochloric are not greatly less effective in acid- ification, and may be preferable in other respects. CHAPTER 11. PYELITIS. Pyelitis is inflammation of the membrane of the pelvis of the kid- ney; it should not be confused, as it often is, with the disseminated sup- puration of the renal substance which may be associated with it or may occur independently. Pyelitis is chiefly known as a consequence of other diseases and tlie immediate cause of many of their symptoms. It is con- sidered in connection with stone and tubercle, and referred to, perhaps sufiicicntly, as the result of malignant gro\vths, parasites, and poisons of the type of cantharides. As [)roduced by retention of urine and the cystitis associated with it, pyelitis lias a large importance, already accorded to it, as a frequent, but not necessary, intermediary between those conditions and the dissemi- nated renal suppuration which they give rise to. It is further taken into question as the common first stage of perinephritic abscess, and is re- garded as originating in so many different ways, and producing so large a variety of results, that little can be said separately concerning it which would not involve useless iteration. The pelvis of the kidney is not quick to inflame, though under such irritants as have been mentioned it may do so somewhat intensely, and give issue to discharges so i^rofuse and persistent as to cause death by exhaustion, with the intervention either of hectic or of lardaceous dis- ease. Under recent irritation the pelvis of the kidney may become highly injected, spotted with ecchymoses, and coated with soft, false membrane, which may have almost diphtheritic separability. I have seen a very dis- tinct false membrane in this situation as the result of tinctura lyttae medicinally given. The woodcut at p. 81 shows a well-marked sepa- rable membrane formed upon the pelvis as the result of tubercular dis- ease; the membrane is seen to occupy the infundibulum, and had par- tially obstructed the ureter, as the consequent dilatation shows. This result, however, of pelvic inflammation is not one of the most common. As the condition becomes chronic, it is usually marked by tiie white opacity which is so often associated with the production of pus, varied, if the disease be tubercular, with much roughening, ulceration, and thick- ening of the pelvis; it is not necessarily accompanied with dilatation, though the two conditions occur togetiier far more often than either separately, owing to the frequency witli which causes of pyelitis are causes also of obstruction to the pelvic exit. The forms and results of pelvic dilatation have been further referred to in connection with stone and perinephritic abscess. Occasionally the suppurating cavity will become closed, cease to stretch, and the secretion stop apparently because there is no room for more; that which there is becoming reduced by time and absorption to PYELITIS. 17 little more than its mineral residuum. The kidney may be converted by th^s process into a partitioned cyst, of wliich the walls consist of little more than fibrous tissue, and remain as harmless as useless. An example of this result, from the museum of St. Bartholomew's Hospital, is repre- sented in the woodcut. Of the kidney little remains but a shell of fibrous tissue, which contains a substance like mortar, consisting chiefly of phos- phate of lime, with a small admixture of carbonate of lime and animal matter. It was found in the body of a woman who died at the age of sixty-two, having for twelve 3'ears before had no sign of renal disease. The septa of such cysts have become calcified, and true bone has been found in them, as in an instance recorded by Dr. Roberts. Little remains to be said except to indicate one or two causes of pye- litis which do not find place elsewhere, and to refer to some results of it Kidney converted into bag of earthy matter, as the result of pyelitis. which may be attributed rather to itself than to the diseases with which it may be associated. The lesser degrees of pyelitis, more often evident after death than during life, may ensue upon almost any change in the urine, more espe- cially if it be alkaline. Advanced albuminuria and diabetes may be thus accompanied, though usually to an unimportant extent. With regard to chyluria, I have recently seen an instance in which this disease, contracted in India by a boy at the age of four, was found to have been succeeded at the age of seven by a profuse and constant discharge of puS; presumably from the pelvis; the urine retained its acidity, and there was a total ab- sence of bladder symptoms. This discharge continued under observation for a year and a half; I then lost sight of the child for three years, at the 2 18 PYELITIS. end of which time the urine was natural and the child well. "Whether ia connection with urinary change or the extension of vesical inflammation, pyelitis often takes place in connection with stricture, stone in the blad- der, and paralysis, together with the disseminated suppuration which lias been considered elsewhere. And often when this graver complication has not been induced, pyelitis alone, or accompanied only with inflamma- tion of the bladder, may ensue from the same causes, any, to wit, which involve retention and decomposition of urine — diseases and injuries of the nervous system, typhus, and all other states attended with inaction of the bladder, whether from paralysis or prostration. When thus uncomplicated, this disease is transient, if the cause is so, and has little clinical importance. It may be observed in passing that pyelitis, unattended with dissem- inated suppuration, does not give rise to the signs of septic absorption, resembling those of pyaemia, which belong to the latter disease, though it may produce results, as will presently be seen, allied, though dissim- ilar. The failure to mark the distinction between the two conditions has caused much confusion. Apart from urinary changes, gout, gonorrhoea, and apparently preg- nancy, have definite place as causes of pyelitis. With gout and gonorrhoea the inflammation creeps from the bladder up one or both ureters — if both, often successively rather than simultaneously — and so reaches the cavity of the kidney. Gouty inflammation of the bladder, with its dis- tressing frequency and sometimes intolerable pain, the urine first highly acid and then purulent, is a phase of tiie constitutional disease which has received little notice, though sufficiently striking. It would seem that the pelvis of the kidney may be similarly affected in sequence to it. I saw, with Dr. Baber, a lady between sixty and seventy years of age, the member of a gouty family, though never herself the subject of gout in any ordinary form. After exposure to the severe cold of January, 1881, together with the mental shock attendant upon the partial destruction of her house by the explosion of a boiler, she had severe cystitis, constant vesical pain, incessant micturition, and the passing of highly acid scanty urine, loaded with lithates and containing pus. After about a fortnight, the pain and tenderness passed up the course of the left ureter, and be- came fixed in the position of the left kidney ; a week or two later pre- cisely the same process took place with regard to the right ureter and kidney. It was next found that the pain in the right side was enhanced when the patient turned upon her face, a tumor at the same time falling forwards from the loin, possibly a kidney dilated as the result of j^yelitis. Siie had never passed stone or gravel. I have more than once recognized a similar ascendiYig inflammation as the result of gonorrhoea, cystitis being succeeded by pain along the ureters, and that by pain of a more lasting character, together with deep tenderness in the position of both kidneys, the urine containing pus but givrjig no evidence of disease of the renal substance. A form of renal colic, preceded by chill and fever, and regarded as pyelitis, has boon described as occurring in the puerperal state. The urine is said to be albuminous, and to contain such epithelium as the pelvis affords. I have known severe renal colic at the close of pregnancy to be succeeded and explained by the abundant escape of gravel. The pyelitis of pregnancy, if there be any, apart from such irritation has nothing in common with the suppurative extension known to occur after delivery, and produce perinephritic abscess. PYELITIS. 19 The general symptoms of pyelitis, independently of those of the dis- ease, whatever it be, which has given rise to it, may be briefly indicated. Pain may travel up the ureters, as in the cases referred to, and be- come fixed in the lumbar regions, as dull or weighty ; but in many in- stances and for long periods there is no ])ain at all, or only what must be attributed to the disease in which tlie pyelitis has arisen. If the exit is free, there will be no such tumor as can be appreciated from Avithout, except, as sometimes in the case of tubercle, the original disease be at- tended with this degree of tumefaction. If the ureter be closed, the swelling may be felt from before and behind, more often as a small than as a large renal tumor. Such are detailed too fully elsewhere to need description here. There may be at the beginning a discharge of mucus or of blood, and the latter may be repeated at intervals throughout the course of the disease, particularly if associated with stone, and sometimes if with tubercle. More characteristic is the persistent, or persistently re- curring, discharge of pus with the urine, together with evidence that it is derived from the pelvis, or, what may be equivalent, that it is not de- rived from the bladder. If the exit is unimpeded the pus is " laudable " and inoffensive ; on standing, it separates somewhat abruptly from the urine, which retains its acidity. It has been stated so frequently that a discharge from the pelvis of the kidney can be distinguished by the epi- thelial cells Avhich are shed with it that I almost hesitate to assert, what I have taken some trouble to ascertain, that there are no characters by which detached cells of pelvic e])ithelium can be positively recognized, however practicable it might be to distinguish the pelvic membrane could it be seen in mass. Roberts describes the epithelium shed as the result of pyelitis as be- ing "very irregular, spindle-shaped, tailed, three-cornered, elongated, rudely circular, etc.," and as thus affording certain evidence of its origin. It will be seen, however, that these varieties of form, even to the "etc.," are equally cliaracteristic of vesical disease. Ebstein in '"' Ziemssen's Cyclopedia," describes the pelvic epithelium as characteristic in virtue of its shapes — " flattened, laminated, and caudate " — terms equally ap- plicable, as the annexed woodcut will show, to epithelium derived from other parts of the urinary tract.' ' In view of the localization of disease by the urinaiy deposit, it is necessary to ascertain how far tiie epithelium from each part of the tract can be distin- guished. The accompanying woodcut shows the varieties of cells which were ob- tained fi-om each part of the urinary course in a succession of individuals not tlie subjects of urinaiy disease. The results are not valueless, but perliaps disap- pointing; they amount to this: The solid polygonal figures of the renal epithe- lium, of small andunifoi'm size, can be easily recognized; diseases in which they are abundantly shed are commonly evident enough without them. Between the pelvis and the ui-eter no distinction can be made with certainty; both abound with club-shaped and tailed cells, and yield also others variously squared, rounded, and flattened, but none which are distinctive of either situation. In the bladder are abundant club-shaped fusiform aiid rhomboidal cells, not to be distinguished from those which belong to the pelvis and ureter, and others which are more significant, though perhaps none which aie absolutely limited to this organ. The most characteristic cells are large and numerously scooped for adaptation with smaller cells below; these are not often to be recognized in morbid discharges, but must be accepted as valuable indications when they are. Besides these are other cells, the like of which are to be found in other situations, but w^hen large, well marked, and numerous, may be generally reckoned as vesical. These ar<» large, rolling globes or spheroids, with a well-marked outline and usually a single nucleus. The urethra may yield cells of many sorts, some globular and coherent, probably of glandular origin, others flattened, spindle-shaped, and of solid poly- 20 PYELITIS. '0 © @3 Cones of kidnej-. Pelvis. Ureter. Bladder. ®®_0 Urethra. o ;p. Vagina. Varieties of Epithelium from Urinary Tract in Health, x 220. PYELITIS. "21 Often., as the result of pyelitis, the urine may be foetid from the presence of putrescent i)urulent matter and still be acid. The alkalinity of the discharge from the diseased kidney is overpowered by the acidity of the normal urine from the healthy one. Had the decomposition taken place in the bladder, it would have affected all the urine alike and made it ammoniacal throughout had it proceeded to any extent. Another indication of pyelitis which admits of a similar explanation is the pres- ence in acid urine of triple -phosphate crystals, Avhich in these circum- stances often show signs of superficial solution, from their exposure to acid urine after their formation necessarily in alkaline. The urine of pyelitis is often peculiarly disgusting, redolent rather of sulphuretted hydrogen than ammonia, or distinctly of both. The urine of bladder disease is more simply ammoniacal. The discharge tlius foetid is apt to intermit completely or partially, being retained and decomposing in the cavity. When it appears it may present to the microscope a mere shapeless debris, from which all cor- puscular shape lias disappeared. Tlie collection and decomposition of the urine in the pelvis is sometimes attended with signs of blood-poison- ing, different, Jiowever, from .those which proceed from disseminated suppuration. With the latter the symptoms have a ]na3mic type, "witli fever at best remittent, and often with a jaundiced skin. With pyelitis there are fever and eruption, but, as far as I have seen, no jaundiced or py^emic tint. The fever and eruption are both transient, the fever often without eruption, but the eruption seldom without some degree of fever. Febrile attacks with a temperature up perhaps to 101° may come on, last for a longer or shorter time, and then pass away completely. These are usually without organic change, but sometimes associated with a degree of pneumonia. The eruption which presents itself, though by no means regularly, as the result of pyelitis is usually to be classed as ery- thema, at least it consists of little more than injection of the skin, with- out the separation of serum or pus. This may occur in vivid spots or blotches, the latter often confluent. They occur mostly on the face, but occasionally on the trunk. The eruption may somewhat resemble that of measles, or more often what is called German measles. It sometimes presents itself as herpes, the blotches being succeeded by the character- istic vesicles. The course and duration of pyelitis vary as widely as its causes, and cannot be considered but in connection with them. When from stone, the disorder is indefinite in length, and may intermit completely for con- siderable spaces. When from tubercle, it is more brief; the discharge is constantl}'' present while it lasts ; if it ceases the cessation is linaL Among the results of the disease the lardaceous change takes a ])romiiient position, though death may be brought about independently of it by fever and hectic, or nuiy ensue upon rupture into the i)eritoneum, into the bowel, or externally in modes which are considered in relation to stone, tubercle, and perinephritic abscess. Urtemia is not a consequence of pyelitis, though it may ensue from many of the disorders, obstructive or destructive, with which pyelitis may be associated. To show the chronicity or tolerance of the disease, I may refer to a gonal shapes. When many strongly marked squamous cells are to be seen, par- ticularly if they are imbricated, they may be attributed to the vagina. It is to be noted that some of tlie vaginal cells in the woodcut were obtained from the bodies of children, and are smaller and less strongly marked than at more ad- vanced ages. 22 . rvKLiTis. young hidy now (1882) fifteen years of age, and in fair general health, who has been under my care with it for eleven years. The cause is prob- ably stone. The urine is never quite free from discliarge, the quantity and fcBtor of wliich are exasperated at irregular intervals. There have been occasional attacks of fever and eruption such as have been described, and the cliaracter of the dislodged epithelium was such at least as to ex- clude a vesical origin. That it was not from the vagina was not equally certain. Occasionally, particularly after increased exercise, the urine disi)laced translucent flakes like bran or very minute fragments of silver paper. These consisted of masses of flat epithelial scales, placed with some regularity, and crossed here and there with lines of fibrous tissue. This patient apparently owed her endurance of the disease to quinine, mineral acid, and frequent change from London to the country or sea- side. The treatment of pyelitis resolves itself into the treatment of stone, tubei'cle, and gout, together with the correction of alkalinity and foetor in the urine, and the compensation of exhausting discharge. No pro- cess of counter-irritation has found support by my experience ; indeed the disorder is, as a rule, too deep to be benefited by any local treatment. "Where the urine has been persistently or occasionally alkaline, or even where it has been only reduced in acidity, I have found the greatest use in nitro-muriatic acid, together with quinine and other tonics. Where it is fojtid, and a source of mischief by its retention and absorption, I have thought decided benefit to ensue from the administration of crea- sote. It is more easy to recognize the effect of this antiseptic upon foetid discharges of many kinds than to explain the transmission of it as such to the place in question. When the discharge is chronic and exhausting, much may be done by liberal diet, quinine, iron, and change of air, es- pecially to such seaside places as are reputed ''bracing." Where pyelitis is conjoined with obstruction of the outlet and has led to so much ac- cumulation of pus as to cause bulging in the loin, the question of punc- ture or incision from that surface may be entertained ; but I think it is generally safest to wait until the matter has worked through its renal in- vestment and presented in the back, and even then until it is nearly s>ubcutaneous rather than to seek for it deeply. The consideration of this question belongs to the subject of perinephritic abscess. CHAPTER III. SUPPURATIVE PERINEPHRITIS. If the terms perinephritis and perinephritic abscess were confined, as in strictness they might be, to abscess or inflammation beginning in and essentially belonging to the renal circumference, there would be little to add to what is to be found under several headings of renal abscess, stone, and tubercle. But though in the large majority of cases suppuration on the outside of the kidney is directly produced by suppuration within it, yet there are enough cases in which this is not so to make it necessary to refer to perinephritis independently as well as in its relation to renal dis- ease. Irrespectively of its origin, pus, issuing from the kidney or formed in contact with its surface, commonly remains behind the peritoneum, bur- rowing among the deep muscles and fascia of the lumbar, pelvic, and ■crural regions. An abscess of extra-renal origin more often begins be- hind the kidney than in front of it, and thus has this organ between itself and the serous cavity : the same will of course happen should a renal abscess open posteriorly. If it break anteriorly it may penetrate the peritoneum directly and set upon fatal peritonitis ; but even when thus escaping from the front this result is not inevitable, for the matter may either lift up the peritoneum and spread laterally behind it, or in perforating it may become so circumscribed by adhesions that the abscess is as good as post-peritoneal, though not actually so. The capsule of the kidney itself often displays a remarkable power of confining matter within it. There is a preparation at the College of Sur- 'geons in which at least half a pint of matter had collected between the capsule and the gland, which retain but few points of contact. The fat and cellular tissue around the kidney are in close apposition with the muscles of the back, and not separated from the origin of the psoas muscle, the structures behind the iliac fascia, the sacro-sciatic fo- ramen, or the course of the great vesselsfrom the trunk to the thigh. Pus will easily traverse areolar and muscular tissues, but penetrates fasciie and membranes with difficulty. It thus readily crosses the lumbar re- gion, or, taking advantage of natural channels, passes down the psoas muscle to the inguinal region, or with the blood-vessels to the front of the thigh, or through the sacro-sciatic foramen, to appear upon the glu- teal surface. The passage of such matter down the psoas muscle is of interest in relation to diagnosis. It is usually accompanied with flexion of the tiiigh, a symptom which may therefore be produced by disease of renal origin as well as by disease of the spine. I published a case many years 24: surrL'KATivE perinephritis. ago in the " Pathological Transactions,'"' in which a psoas al)scess had taken its origin in tubercnlar disease of the kidney, and have since known the same resnlt to ensue from suppuration arising in stone. ^ Another mode of exit which is comparatively frequent is by the bron- chial tubes. Matter of renal as of hepatic origin often passes upwards. It enters the muscular lamina? of the back and readily si)reads between them, thus passing behind the diaphragm into the root of one of the lungs, commonly evading the pleura and penetrating the lower part of the lung directly. By this means localized i)neunionia has been set up, and not infrequently the pus has found its way into one of the bronchi and so been coughed up. It has been known also to be discharged by ulceration into the vagina, into the bladder, and through the prostate into the urethra.^ The great- est; variety of exit is presented by abscesses of calculous origin. These have been known, as detailed elsewhere, to discharge themselves super- ficially upon tiie loin, the gluteal region, the groin, the thigh, to enter the ]ieritoneal cavity, the ascending transverse and descending colon, the duodenum, the stomach, and the bronchial tubes. The commonest issue is upon the back, where a wide, brawny, doughy, or boggy surface, possibly erysipelatous or phlegmonous, pre- sents itself between the last rib and the crest of the ilium. The hands before and behind the renal position may distinctly appreciate a fulness in it which will not move with respiration, as it might were it connected with tiie liver or spleen. It is upon the loin that incisions are most often called for, and from it that calculi more often make their exit than from any other part of the cutaneous surface. Circumrenal abscess in its more ordinary forms, as the result of in- trarenal suppuration, has found sufficient mention elsewhere. By far the most frequent of these is that in connection with calculus and pro- duced by dilatation of the pelvis, disproportionate extension of one of the calyces, and perforation by it of the renal capsule. Tubercular sup- puration also will sometimes reach the outside of the kidney, a suppu- rating mass impinging upon and penetrating the capsule and possibly entering the duodenum or descending colon. Pus of this origin, how- ever, docs not as a rule travel far or collect in great abundance. Ab- scesses of wide range have been known to ensue from the perforation of the capsule by pyajmic and "surgical" renal abscesses. Instances of extensive extra-renal abscesses are related in connection with both these subjects. Wounds and contusions involving the kidney or its surroundings have been followed by su[)puration about it. Wounds from the front neces- sarily open the peritoneum and are fatal by extravasation of urine within. But the kidney may be pierced from behind by a bullet or otherwise, so that the escape will take place into the posterior tissues, and spread more or less round the organ, with matter widely disposed but still behind the serous membrane. Such a case is described by Baudeur.' A musket-ball ' Pathological Transactions, vol. xvi. 1865, p. 175. ^ See Chapter XIII. As touching the relationship between urinary and psoas disease, I may mention that there is a preparation at King's College in which there has been a reversal of the process here described. An ordinary psoas ab- scess lias discharged itself into the ureter, the matter from tiiis source'thus escap- ing by the urinary channels. So far the symptoms of renal were produced by psoas abscess. *See case quoted by Feron, loc. cit. p. 33. < Quoted by Parmentier, L' Union Medicale, August, 1863, p. 408. SUPPLKATIVK rEKIAEl'HKlTlS. 25 entered the left loin of a soklicr, nc:ir the second lumbar vertebra; re- traction of the testicle and painful emission of urine followed; a collec- tion of matter then formed ajjparently between the kidney and the wall of the abdomen, which at last was reached by a sound introduced through the wound, and thus successfully got rid of. Bruises of the lumbar region may also be followed by suppuration around the kidney/ A French peasant fell from a tree and severely bruised the right loin; hoematuria at once followed, and then deep-seated jiain, fever and lumbar swelling, with recurrent rigors; an incision out- side the lumbo-saci'al mass, where fiuctualion had become evident, gave exit to a quantity of "^ phlegmonous " pus, and was followed by recover}'.'^ In another instance a nurse fell down-stairs and struck her right side upon the edge of a pail. The urine became slightly and temporarily bloody; slie had fever, delirium, and diarrhcea; swelling appeared in the lumbar region, levelling the costo-iliac hollow and extending into the right hypochondrium, filling the interval between the liver and the iliac fossa, and reaching to the left across the median line. An openingin the loin, begun with caustic potash and completed by puncture, gave exit to a profuse discharge of pus, and- led to the recovery of the patient. The right leg had been paralyzed for four or five days during the height of the disorder. Violent strains of the back have been followed by, and apparently have produced, abscess in the renal vicinity. Trousseau mentions the case of a workman in the plaster quarries who felt acute pain in the left lumbar region while lifting a heavy load. Tumefaction, redness, and widely lancinating pain were succeeded by deep fluctuation in the af- fected loin, incision, and the discharge of a quantity of pus, which was ascertained by means of a probe to come from immediately behind the left kidney. The patient recovered. It is probable that when suppura- tion thus follows a strain, there occurs either some deep rupture of mus- cle or tendon, or possibly the final giving way of some part of the renal surface previously undermined by disease. But there are other causes and shapes of perinephritis which are more obscure, and perha})S some are adduced which are problematical. Tiie large amount of cellular tissue about the kidneys, and generally between the pelvis and the ribs, presents this interval as a favorable seat for dis- orders which are proper to this tissue, while the proximity of the region to other organs and to large vessels renders it liable to be invaded by mat- ter which has taken its origin elsewhere. An abscess beginning in con- nection with some other organ, or in the cellular tissue itself as a result of pysemia or some febrile or other general condition which invites sup- puration, or possibly from some local cause, whether hydatids or of some sort to be less readily discovered, may, though entirely independent of the kidney, either begin in its immediate neighborhood or so soon reach it to expatiate in the loose tissue around as to behave as if it had taken its origin in this organ. The apposition of the large bowel to each kidney without the inter- vention of peritoneum is important, not only as allowing of the passage of matter from the kidney to the bowel, but also permitting it to pass in the reverse direction, from the bowel to the kidney. Abscesses, es- pecially from stone, may escape into the ascending as well as into the ' Berounbioux, quoted by Trousseau, loc. cit. vol. v. p. 338. ' Bienfait, quoted by Trousseau, loc, cit. vol. v. p. 339. 26 SUPPURATIVE PERINEPHRITIS. descending colon,' tliougli they do not so often do so; and we have evi- dence that matter may be directed from the circumference of the ascend- ing colon to that of the right kidney, this transference of the disease being, as it would seem, more frequent on the right side than the left, possibly because the looser peritoneal arrangements of the ascending colon give more room for the accumulation of pus than is to be found on the left side. A man swallowed a pin; this caused perforation of the ascend- ing colon, and an extra-peritoiK-al abscess in the right lumbar region, which contained gas and ftecal matter.- And there is much probability tliat the anatomical associations of the beginning of the large bowel with the right kidney may serve to explain other cases of circumrenal suppuration, of which the origin is less obvious. A large abscess in this situation is described by M. Lemoine^ as having its anterior wall formed by the ctecum and tiie ascending colon. No ulceration of the bowel was found, but the beginning of the disorder had been marked by violent colic and vomiting; pus discharged through an incision made during life had been extremely foetid; the kidney, which was surrounded by the mat- ter, was softened externally, but evidently not its source; and it may at least be surmi-sed that the origin of the disorder was intestinal. A remarkable febrile disorder was described by Butter as the Ply- mouth Dockyard disease,* which must be considered to have been an endemic forni of septicaemia, due to some localized poison which was not traced to its source. The symptoms were more nearly analogous to those which sometimes follow dissection wounds than to those of any of the specitic fevers. Slight wounds or abrasions received in tlie dockyard were succeeded in a number of instances by intense fever, erysipelatous iiidammations, effusions of serum and pus into the cellular tissue, local- ized gangrene, intense injection or inflammation of the ileo-crecal region of the bowel, as discovered on posf-morfem examination, and in two of fifteen cases by suppurative nephritis, or perinephritis. In one of these instances, " the mesentery and meso-colon were vascular with red patches, the whole being amassed in sero-purulent fluid. Tiie right kid- ney was completely disorganized, and changed into a mass like thick cream in color and consistence. The left kidney was sound."' In the other case, the lower part of the ileum and caecum were inflamed nearly to gangrene, while behind the bowels and around the right kidney, which itself was healthy, was found a pint of pus. It may be conjec- tured that in these cases the pus may have travelled backwards from the ileo-cteeal region of the bowel, by way of the meso-colon, and a similar explanation may possibly apply to the origin of perine[)hritic abscess in typhoid — a pathological secpience which has been noticed though not ex- plained.^ Pus, also, which has taken its origin in disease of, or operations npon, the rectum, has been known to creep up the subiDcritoneal tissue and reach the renal vicinity." ' See Case related by Parmentier, L' Union Medicale, September, 1862, p. 441. ' Parmentier. " Sur les Abscess perinephretiques," Z,' Union Medicale, August, 1862, p. 408. ^ " Abscess Perinephrique," M. Letnoine. L! Union Medicale, June 19th, 1863, p. 551. ■• Remarks on Irritative Fever, commonly called the Plymouth Dockyard Dis- ease, by Dr. Butter. Devonport, 1825. '' Trousseau, Clinical Lectures (Sydenham Eklition), vol. v. p. 343. * K()fni<<, quoted by Ebstein, Zieinssen's Cyclopaedia, vol. xv. p. 589. SUPPURATIVE PERINEPHRITIS. 27 The consequences of labor are unequivocally associated with suppura- tion in the neighborhood of the kidney. Iliac and otlier abscesses are apt to form, as is well known, in these circumstances, as results of venous absorption, and there is nothing to prevent the extension of matter from the iliac to the renal region. A case is described by Trousseau, in his admirable lecture on perinephritis, in which pus so produced invaded successively the right broad ligament, the circumrenal and the iliac regions. The abscess was first found in connection with the right uterine appendages, and acquired from thence two outlets, one into the bladder, the other into the vagina. An inter- val of improvement was followed by rigors, fever, pain in the right side, and swelling which filled up the right costo-iliac hollow. The iliac fossa at the same time was free from both swelling and pain, though later an abscess was detected in this situation. Both the lumbar and iliac ab- scesses were opened, and the patient sank with diarrhoea and hectic. There was no jiost-mortem examination, but it was evident that the peri- nephritis was of uterine not renal origin, probably by way of the iliac veins, and also that tiie iliac was subsequent to, if not secondary to, the perirenal abscess. Pus collected around the kidney might easily, as Trousseau suggests, pass with the psoas muscle to the cellular tissue of the iliac fossa, and its passage in the contrary direction is equally easy. Among the extra-renal causes of circumrenal abscess must be men- tioned, upon the authority of Trousseau, one wliich rests, like some of the other causes which receive credence, upon inference during life rather than ascertainment after death. Perforation of the gall-badder by a calculus was believed by this acute observer to have been the cause of sup- purative perinephritis in a case which he relates. Severe hepatic colic, in the person of an old lady, was followed by sym})toms of acute hepatitis, with inflammation of the gall-bladder and intense pain in the sub-hepatic region. Then there was fever, and severe general disturbance of the system; when all at once the pain extended to the right renal region, with the formation of an abscess there, which was ultimately opened, with a favorable result. In Trousseau's view a gall-stone had travelled through an ulceration in the gall-bladder, and reached, through inter- vening adhesions, the perinephric cellular tissue. Whether or no the stone traversed the considerable interval which separates the gall-bladder from the renal region, it is at least clear, as the narrator observes, that hepatic colic was succeeded by circumrenal abscess. Circumrenal, or deep lumbar abscess, has been traced to hydatids, originating probably in the cellular tissue. In a case recorded by Feron ' these, mingled with pus, came out of an incision which had been made in a tumor in the lumbar region, and was succeeded by recovery. An abscess in the adipose tissue about the kidney has been known to ensue upon removal of the testicle and the subsequent application of a ligature which included all the structures of the spermatic cord. The pus was serous and foetid, and the cellular tissue about the spermatic cord was infiltrated with the same matter. It was supposed that the secondary suppuration was due in this case to the irritation of the nerve and the attendant pain; but I venture to think it more probable that the inflam- matory process was conveyed by mere continuity either of cellular tissue or of venous channels from the place of the ligature to the place of the abscess. I have seen a bulky inflammatory infiltration of the whole ' Thesis, by M. Feroii, De la Perinephrite primitive, p. 42. 28 SUPPURATIVE PEKINKPIIUITIS. length of the spermatic cord as the result of an operation involving its lower end. Mere neuralgia has been supposed by Trousseau, though perhaps on insuflBcient evidence, to be efficient as a cause of similarly localized su]i- puration. It has been traced to pyi^mia, and stated to have followed ujion other febrile conditions, among which variola and typhus have been mentioned. It has also been attributed to cold, but this must be regarded as more than doubtful. The leading facts in regard to the symptoms of this morbid condition have been involved in the preceding account of its nature and origin. Occurring as it does in widely different circumstances, it takes as different shapes, appearing sometimes, as in tiie Plymouth Dockyard cases, as part of a severe and acute febrile disease, at other times with the slug- gish temper of lumbar or psoas abscess in their most ciironic forms. In its more ordinary kind an early symptom is deep-seated lumbar pain, severe and lancinating or of a pricking character, with tenderness, possi- bly not superhcial, but evident upon deep handling of the lumbar region. With this, or soon after it, or possibly before there is enough of either pain or swelling; to attract notice, comes fever. This is of the continued type, with evening exacerbations and })Ossibly nightly sweatings, like tliu fever of tuberculosis, which it often resembles, or with which it is often associated. Eigors are commonly observed, and have been known to occur with quotidian regularity. With all this there is much general illness and loss of api)etite, and of flesh, with possibly nausea, vomiting, and constipation. Sooner or later the swelling which I have already referred to shows itself in the back, filling one of the lumbar hollows, giving an undue sense of fulness between the hands placed before and behind, and finally causing the brawny or doughy state of surface which indicates the approach or i)resence of pus. The posture is supine, or, if the psoas be im])licated, the patient may sit, as described by Dr. Bow- ditch, on one gluteus, and have the bent leg characteristic of psoas abscess. The great range of duration Avhich the disorder presents is sufficiently evident from what has been already said. It often terminates, as in the Plymouth cases, before the matter has had time to present externally. When it has so done, the course of disorder, according to Feron, is still so rapid that in most cases the abscess is completely formed and evacuated within three months. But there are many instances, such as those con- nected with calculus, in which the abscess, perhaps sometimes partially closing and opening again, may extend over years, or last indefinitely. The urine in these cases has relation rather to the presence or ab- sence of some of the causes to which perinephritis may be due than to the affection itself. It gives no evidence of the presence of the extra- renal suppuration, but may declare, by blood or pus, the i)resence of a bruise or laceration of the kidney, or of stone or tubercle within it. Dr. Duffin collected twenty-six cases to ascertain the frequency of urinary complications. ''Two had been produced by an injury to the loin, and had bloody urine; six had free pus; two, bladder signs; five, kidney disease without bladder signs; and no less than twelve had no urinary complication whatever."' With regard to the treatment of circumrenal abscess, it is needless to say that, if once the matter be formed, there is nothing to be done but to jirovide for its escape. Incision or puncture has usually been practised ■ Duffin. Path. Trans., vol. xxiv. p. 141. SUPPURATIVE PERINEPHRITIS, 29 in the loin, an opening sometimes having been effected, at the bottom of which the kidney could be felt with the finger. The average of success has been good, and would have been better were it not that the suppura- tion is dependent, perhaps, in most cases, upon incurable disease. Dr. Duflfin tells us that of twenty cases he collected, in which abscess in this position was treated by early puncture through the loin, the operation in two was followed by death — in one from peritonitis — while in eighteen it was ".attended with a considerable modicum of success," in twelve with complete recovery.* It is to be presumed that, in these days of the aspirator, puncture by its means will sometimes supersede the old inci- sion, though it must often happen, as when stone or tubercle have given origin to the matter, that a continuous opening is inevitable. As one of the dangers of incision must be mentioned reiterated ligemorrhage, wliich proved fatal in a case recorded by Parmentier.'* ' Duffin. Case of perinephric abscess, Medical Times, September, 1870, p. 362. See also conclusion of case, Path, Trans,, vol. xxiv. p. 138. * L" Union Medicate, September, 1863, p. 575. CHAPTEE IV. THROMBOSIS AND EMBOLISM. Trombosis. When the blood coagulates in its own vessels and there remains, thrombosis is said to occur; euiholism when the vessels are obstructed bj matters brought from a distance. These two conditions are, as will be- seen, different in their cause, in their seat, in their progress, and in their results. Our present concern is with thrombosis. It has long been recognized that the blood is apt to coagulate in its vessels during life as well as after death. This may occur in many situations and circumstances; sometimes in arteries, more often in veins. It may be limited to one vessel or one system of vessels, or may occur simultaneously in many parts of tlie body. Tiie knowledge that clot sometimes forms during life in the veins of the kidney is nothing new in pathology, though, from its comparative infrequency, it occasionally drops out of notice, to reappear like an old fashion restored with the freshness of novelty. John Hunter has de- scribed it minutely. The coagulation takes place, almost without exception, in the veins, not in the arteries. Dr. Moxon has related two cases in which, after injury, clots were found in the renal vessels of both kinds. These cases, which in many respects resemble embolism rather than throm- bosis, form the exception. The clotting may involve one gland onl}', or both simultaneously. A kidney in which general thrombosis has re- cently occurred is increased in size and feels unnaturally hard. In sec- tion, it is seen that many or all the veins which can be followed with the naked eye are occupied with coagulum, which, according to its date and degree of decolorization, may be black, brick-red, or buff. These coagula are usually continuous through many subdivisions and ramifica- tions, and sometimes occupy the entire venous system of the organ, from the vena cava to the finest branches which can be reached by dissection. Beyond these, the microscope will sometimes show that the minutest veins and capillaries are loaded with blood, sometimes even to bursting. The clots are often adherent to the veins, the coats of which remain natural. In many cases, this change befalls kidneys which have previously been the seat of disease whereby the circulation through them has become impeded. Sometimes, besides the renal system of veins, those of the lower extremities and the portal vein are similarly affected, while clots have also been found at the same time in the heart and other situations. The rapidity with v/hich the disease, when general throughout the kidneys, proves fatal, gives no time for such slow degenerative changes as occur in coagulum in less lethal situations. When, however, it has THKOMBOSIS AND EMBOLISM. 3L been limited to one kidney, or to a part of one kidne}^, a process of fatty softening occurs, such as is very common in connection with an embolic block. In the case of a man who died at St. George's Hospital with thrombosis, evidently of old date, affecting the renal, supra-renal, and iliac veins, the anterior half of the affected kidney was occui)ied by a soft pinkish mass, of the consistence of putty, which under the micro- scope ai^peared to consist mainly of oil-globules.' Coagulation of the blood during life may be produced by inequality or change of character in the surfaces over which it flows, by retarda- tion of its current, or by a morbid change in the blood itself.^ We often see coagulation determined by alterations of surface in the collection of fibrin upon valves and arterial surfaces; but in the kidney, where, apart from embolism, it takes place especially in the veins, we seldom see the operation of this cause. With regard to this organ, it may be stated that the causes of coagulation are mainly of two kinds: — 1. Retardation of the circulation by narrowing of the vessels. 2. Morbid coagulability of the blood. Considering, first, narrowing of the vessels as a cause of renal throm- bosis, this occurs in its simplest form when the veins are narrowed and their current obstructed by morbid growths outside them. A case of tins' kind is reported by Mr. Sibley, in the " Transactions of the Pathological Society,"^ in which coagula were formed in the vena cava, the veins of both up])er and lower limbs, and the renal veins, in consequence of the infiltration of the tissues surrounding the inferior cava, iliac, and axillary veins, by a cancerous growth. We see the same result produced by vascular constriction of a differ- ent kind, in the frequency with which renal thrombosis is associated with chronic disease of the kidney. This must be in part, though, as I shall presently show, not entirely, attributed to the hindrance which occurs to the circulation from the encroachment of fibroid growth, the pressure of distended tubes, or the lardaceous thickening of the arterial coats. Under these conditions the blood reaches the veins with its velocity unnaturally diminished, and is accordingly disposed, until it reaches the main stream of the vena cava, to coagulate. The degree to which the renal vessels are obstructed by disease may be easily demonstrated by the simple expe- dient of allowing water to flow into the renal artery of a healthy and of a granular kidney. It will be found that water traverses the diseased organ with extraordinary slowness compared with the healthy one.* Independently of local or organic alterations coagulation may depend upon an unnatural tendency of the blood to deposit fibrin. This is fully as important in relation to renal thrombosis as narrowing of the vascular channels. There are many conditions of system in which the blood is apt to congeal where its current is slowest. Such a state appears to belong to many conditions of j^rostration, exhaustion, and fe- brile disturbance. Under such general influences coagula are apt to form simultaneously in more than one system of vessels, the renal clotting being associated with a similar change elsewhere. The renal ' Reported by Dr. J. W. Ogle in the Patli. Trans, vol. vii. p. 177. "^ I have discussed the causes of the coagulation of blood in the living body in more detail in a paper upon the Coagulation of Blood in the Cerebral Arteries, St. George's Hospital Reports, vol. i. p. 257. ^ Path. Trans, vol. ix. p. 128. ■• I have related some observations of thia kind in the Med, Chir. Trans, for 1860, p. 242. 32 THROMBOSIS AND EMBOLISM. veins sometimes share with the femoral in the coagulating process which js apt to follow parturition. A young woman, who had been delivered six weeks before, was brought into the liospital with plilegmasia dolens affecting both lower extremities. After death, which occurred nine days later, ooagula of distinctly «M/e-j//or/!e?;i character were found generally distributed in the veins of the uterine organs, pelvis and lower extremi- ties, and also in those of the right kidney. Renal thrombosis has been known to occur in other states of systemic disturbance, as in typhus. The febrile condition, of whatever nature it be, appears to be a possi- ble cause of coagulation; that this could be produced experimentally by an increased temperature Avas long ago shown by Hewson. It is not needful, .however, to discuss the causes of thrombosis in general; its as- sociation with antemia and prostration, Avith gout and, though rarely, with rheumatism, is well known. On whatever cause it depend, the kid- ney may be its location. Finally, as a cause of thrombosis which is directed especially upon the kidney because it is usually associated with structural disease of that organ, must be mentioned the effect upon the blood of long continued albuminous discharges, whether purulent or of the nature of all)uminuria. By such means we must infer that the composition of the blood is altered by the withdrawal of its albuminous part, leaving the coagulable element in relative excess. Thus we may account for the frequent occur- rence of thrombosis in connection with lardaceous disease. The lardace- ous change and the morbid coagulability of blood result in common from exhausting discharges. When the kidneys themselves are the seat of chronic disease, involving the loss of albumin, they are exposed to a double chance of thrombosis. The blood in their vessels, as elsewhere, is rendered morbidl}' coagulable by the drain; their circulation is impeded by local disei^se. This co-operation of obstruction with coagulability ac- counts for the frequency of thrombosis in connection with chronic albu- minuria. The symptoms of this fatal alteration are not sufficiently definite, or are too often masked by the results of antecedent disease, to lead to its detection during life; but the salient points of its clinical history can be discerned by following back the history of the cases in which it has been discovered. Originating, as it does, in connection with exhausting dis- ease, albuminuria, or some febrile state, its especial manifestations are apt to be overlooked or misinterpreted. From the fact that instances of general renal thrombosis seldom come to view, as more partial clots often do, in a state of degeneration or change bearing record of the handiwork of time, but the condition is nearly always recent at the time of death, we must infer that it is usually rapidly fatal. The condition of the patient is generally, either from the disease itself or its antecedents, one of extreme prostration. The urine aiipears to be highly albuminous, sometimes bloody, and much reduced in (juantity, as if from any other cause the kidneys were in a state of intense injection. If the arteries as well as the veins are generally obstructed, there may be, or rather, if the condition is complete, there must be, total suppression. The presence of albumin or blood in the urine in con- nection with thrombosis is sometimes equivocal, as when this con- dition ensues upon renal disease; but it is equally to be observed when the kidneys have been previously healthy, as in the instance re- THROMBOSIS AND EMBOLISM. 33 lated by Mr. Pick. Eenal pain has not been noticed in connection with this disorder. Limited or general oedema is necessarily often present with it, as the iliac veins may share in the condition, or kidney disease cause it; but it does not appear that this symptom has been traced to renal thrombosis pure and simple, though such a result is probable. Recovery may ensue when the renal coagulation has been only partial. An instance has been given in whicli thrombosis affecting one kidney only was found after death in a state which sufficiently proved that it had occurred a long time before (p. 31). It is probable that partial renal coagulation would produce symptoms resembling those which belono- to the more common and more easily recognized condition of embolism. The infrequency of renal thrombosis is such that one may wait long for opportunities of observation. As this affection of the kidney has hitherto escaped recognition during life, the consideration of its treatment would seem superfluous. Should the condition be detected, it is obvious that drugs which lessen coagula- bility, of which the fixed alkalies are the most trustworthy, would be called for. Embolism. The impaction of erratic masses of fibrin in the vessels — embolism, as it is termed — has, since the observations of Kirkes and Virchow, been clearly distinguished from the fixation of coagulum in the place of its formation, which is known as thrombosis. The results of embolism vary in different organs, with the distribution of the arteries and the proper- ties of the tissue, but they are generally easily recognizable, and nowhere ])resent more striking and constant characters than those of the well- known " fibrinous block," which is the form they take in the kidneys. Tiie left cavities of the heart furnish, as would be supposed, the ordinary source of the emboli which enter the kidney. Whenever accumulated, fibrin is broken from the valves or walls, an accident whicli is of con- tinual occurrence in cardiac disease, more especially in endocarditis of recent date, the fragment is liable to be swept, by their copious and direct arterial supply, into one or other kidney. There is certainly no organ in which the results of embolism are so often noticed as in this, though it would be too much to assert that there is no position in which they so frequently occur. The earliest alteration in the kidney which declares to the naked eye that loose fibrin has been swept into its artery is circumscribed injection or extravasation. Of this there may be one or many patches, each patch indicating a separate lodgment. Often a patch or ring of injection of considerable size is found upon the surface, or, as luippened in a case in which I detected the change at a very early period,' a congested circle about as large as a sixpence was surrounded by a white margin. Later the appearances become more characteristic. Hard, dense, straw-colored edges, bordered by vivid con- gestion, are seen in section, the point of the wedge being in a cone, the diverging lines crossing the cortex, the base abutting upon the cap- sule. When the wedges or cones are small, as is the case when the fibrin is confined to the territory of one of the smaller arteries, the arrangement as described is distinctly seen. More rarely the change involves a large ' Pathological Transactions, vol. xiii, p. 46. 34 THROMBOSIS AND EMBOLISM. proportion of the organ, often at one end; the conical disposition is then necessarily obscured. As much as a third of the gland, or even more, may be thus transformed, the fibrin filling one of the larger subdivi- sions of the renal artery, and permeating the whole of its field of distri- bution. Under these circumstances, a careful dissection will often show that the artery leading to the block is plugged with fibrin; this, however, is not always the case. Unless the intruded material is very abundant, the minute vessels fill first. The blocks are so different in color and texture from the surrounding tissue that they look like masses foreign to the \^' '' Embolic block in kidney, the obstruction extending into renal artery. (From a drawing at St. George's Hospital.; kidney, and inserted into it. A close examination, nowever, even with the naked eye, will often reveal pale lines and spots, which show that the vessels and Malpighian bodies still hold their position, though they have lost their color. The blocks are sometimes raised upon the surface, ow- ing to the distention of their vessels by the intruding material. As time goes on, the vivid injection around them fades, their light bright color becomes duller and yellower, the resilient hardness gives way to a puffy, greasy friability; they no longer protrude upon the surface, but they shrink as they soften, and, through stages of fatty transforma- tion and absorption, disappear, leaving a depressed indurated cicatrix as the only record of their existence. If the infiltration has been extensive. THROMBOSIS AND EMBOLISM. 35 a large proportion of the organ may be destroyed by this means. Dr. Van der Byl describes a kidney from a case in which embolic blocking had occurred in many organs, which "weighed only an ounce and a half; it was much deformed, and consisted for the most part of firm yellowish substance, very little of the renal structure remaining free from deposit."^ It was clear, from tlie history and surroundings of the case, that this extreme destruction of renal substance had been produced emboli- cally. The microscope enables us to add a few particulars. At an early stage there is no change in the kidney save blocking of the vessels in a limited, area, and sanguineous distention of those around. The obstructing ma- terial is amorphous or finely granular, sometimes blood-tinged or mixed with corpuscles. It appears to consist mainly of comminuted fibrin. It is found in the arteries and capillaries, not in the veins. The material evidently penetrates the smaller arteries with facility, but cannot get through the capillaries. In the capillaries, therefore, or in the smallest arteries, the arrest takes place, and the intruded material accumulates, behind the stoppage, mounting, according to its abundance, in larger and larger vessels. The straight vessels of the cones, and those which pass thence to the cortex, are more often blocked than the Malpighiaii capillaries. The clot passes more readily into the branches of the renal artery which enter the cones directly than into those which supply the Malpighian bodies. The latter are perhaps less easily entered, given oR as they are at an abrupt angle. The knowledge that the cones receive vessels directly from the renal artery enables us to understand facts con- nected with renal disease which would be otherwise incomprehensible. It used to be thought that all the blood of the renal artery passed through the Malpighian bodies before going to the tubes. On such a supposition the disposition of fibrinous blocks is inexplicable. Did such a disposition of vessels exist, it would be hard to explain the fact, often observed, that fibrin injected by the arteries should be found in the intertubular, wliile none is to be seen in the Malpighian capillaries. The coarse material appears to be unable to pass through vessels of the capillary size, and must necessarily be arrested in the Malpighian bodies, if it reach them first. Dr. George Johnson* has been led by this imperfect view of the renal circulation to maintain that the blocks, which are generally, and, as I have endeavored to show, truly, regarded as embolic, are the result of the coagulation of blood w situ. This view, however, is refuted by the exemption of the veins from obstruction, by the abrupt limitation of each block to the territory of its own artery, and by their invariable association with fibrinous deposits in the heart or elsewhere in the course of the blood which flows to the kidney. Coagulation i7i situ occurs, as has been shown, in different circumstances, mainly in the veins, and without abrupt limitation. In recent blocks the only change is in the contents of the vessels; the stationary structures within the block soon, however, along with the contents of the vessels, undergo degenerative transformations. The impacted fibrin rapidly becomes fatty, and a similar alteration affects the tubes and other renal elements. General fatty disintegration ensues within the affected region, the broken-down tissues are absorbed, until at ' Path. Trans, vol. vii. p. 168. ' " On the Minute Anatomy of the so-called Fibrinous Deposits in the Kid- neys," Path. Trans, vol. ix. p. 305. ^6 THRiniBOSIS AND EMBOLISM. last only the puckered cicatrix remains, which has been referred to in connection witli the naked-eye apjjearances. Tlie renal changes which have been described necessarily result, as a rule, from disease of the left side of the heart. Rheumatic endocarditis often gives rise to tliem, as also do more chronic valvular affections, i)ar- ticularly if they be accompanied Avith the deposition of fibrin upon the iiuricular or ventricuhir wall. The blocking of the kidney, if it occur alone, is seldom of much clinical importance; unless extensive, it often escapes recognition during life, the symptoms being obscured by the otiicr results of the cardiac disease in whicii it takes its origin. The im- paction may be marked by shivering and succeeded by fever,' but these ])erhaps more often occur when the dissemination is general or Avidely distributed tluin Avhere it is only renal. The symptoms of the renal localization are, however, tolerably well marked, and would no doubt be more often found were they more generally understood. The urine be- comes suddenly albuminous, often bloody, and at the same time there is sudden and sometimes violent pain in one or the other renal region. With this, should the affection of the kidney be extensive, there may be vomiting and more or less collapse. When the impaction is of small ex- tent, little further may occur than a suddenly albuminous state of the urine, which is usually of high, or at least of unaffected, specific gravity. It contains, besides albumin, blood-corpuscles and numerous tube-casts. The casts are of moderate diameter, and are more often simply fibrinous than of any other kind. It is probable that the change in the urine is not due to any general disturbance of secretion throughout the kidney, but simply to a species of circumscribed nephritis in the block itself and its intensely congested vicinity. The urine gradually resumes its natural character; the pain, should there have been any, is of short duration, and, after a few days or weeks, all sym])toms of the disturbance have passed away. The block is still in the kidney, but it is no longer a source of irritation. Blocking of other systems of vessels, particularly of the cerebral, often occurs simultaneously with the renal impaction, and proportionately aggravates the symptoms. Cerebral embolism especially is ai)t to be attended not only with cerebral disturbance, but with severe, and often rapidly fatal febrile prostration. Such symi)toms, however, do not appear to occur Avhen the kidney only is affected. The account of renal embolism would not be complete without men- tion of a result which is occasionally produced in the renal as well as in other arteries by embolic obstruction. Apparently chieily in consequence of the hurt inflicted upon the vessel by the lodgment, aneurism in the place of it has been known to occur in the arteries of the brain, of the limbs, of the lungs, of the heart, and of the kidneys. With regard to the treatment of embolic obstruction of the renal vessels little need be said. The question resolves itself into the larger inquiry, the treatment of cardiac disease. Generally speaking, the re- sults of embolism in the kidney are not serious or lasting. The block is rapidly disintegrated and absorbed, and its jdace knows it no more. When, as sometimes happens, severe pain results from the impaction, opiates, by injection or otherwise, may be resorted to; beyond this, treat- ment of the affection may be left to the secret workmanship of nature. ' See cases reported by W. H. Dickinson, Brit. Med. Journ. May 21st, 1881. CHAPTER V. GENERAL EELATIONS OF RENAL TUMORS. The subject may be conveniently taken in two parts, the tirst dealing- with the general relations of renal enlargements, whatever be their nature; the second with morbid formations, whether attended or not with obvious tumefaction. Swellings of the kidney are perhaps more often the subjects of errors; of diagnosis than those of any other organ, which as frequently presents; itself in the guise of an abdominal tumor. Doubtfud tumors are apt to present the riddle of their nature in the shape of the question, ''Is it renal or is it not?" This answered, the rest is clear. To suppose a solid renal tumor to be splenic, or a hollow one to be ovarian, are errors of not infrequent occurrence; while a list of the enlargements which have either been erroneously supposed to be renal, or for which renal swellings^ have been mistaken, would be little short of a complete catalogue of abdominal tumors. It would include tumors in connection with the liver and with the uterus; enlargements of the supra-renal bodies, of the lumbar glands, and of the mesenteric glands; intestinal accumulations, abscesses, especially such as are in connection with the vertebra, and, strange to say, ascites, for which not only have renal cysts been mis- taken, but even solid tumors. In a child three years of age a fluctuating renal sarcoma was thus misinterpreted.' The marks whereby renal tumors are to be recognized are mainly ana- tomical. It is not necessary to say that the kidneys extend from the front of the eleventh rib to near the crest of the ilium, the right coming a trifle lower down than the left. They are supported behind by the flat muscles of the abdominal wall, which are themselves backed up by the great erectors of the spine, and their attachments to the lumbar vertebrae. In front they are separated only by the peritoneum, and partially by the large bowel, from the abdominal cavity, so tliat, should they become the subjects of swelling, their bulk will probably come forwards as the direction of least resistance. It is only in excej)- tional circumstances that a renal tumor obtrudes in the loin as more than an indistinct fulness; this, indeed, may be the only backward mani- festation of a swelling which may fill a considerable portion of the ab- dominal cavity. But, however apt to encroach upon this cavity and confuse themselves with the organs which lie within it, there are certain characteristics which cleave to them as post-peritoneal. One is the direction of such diseases as, like cancer and abscess, advance by con- tiguity from the kidney to the other organs placed with it behind the serous partition. We see this in the invasion of the vertebras by adjacent renal cancer, and in the erosion and possible penetration of the vertebral ' St. George's Hospital Museum Catalogue, Series xi. Prep. 38. 38 GENERAL RELATIONS OF RKNAL TUMORS. column by pus of renal origin. In the next place, renal tumors so seldom fail to have bowel in front that the exceptions have the interest of lusns oiatnrm. To state the rule before the exceptions, the ascending colon usually is to be found in front and towards the inner side of a right renal tumor, the descending colon in fi'ont of one belonging to tlie loft side ; besides ■which tumors of either ]' n 11 I ^gbjco.S.sg-a-s oi o ® 3 2« o-S^ O a _ ''••^ o P ° = > jii!5 cs 5S 0.2 5:; f.SS' rt „ d » f;'-~ t) o i!=^..i; ?>.= 'y bis S ? m " a - ^ Jo '- _ .„ ■ 5^ « O^^ O ; ■e S 2 S "eo I cs„3 -/ i 3 = ^- ^ '^ fe I "!; o. 3 ^ 5 "o ^■^ «' ® c o ^ J- = o -l* 1 ^ m he cS 3^ ■w o f^ ^ fs o^V-2 aj_; . F "*• « O &.— ~ 2 4J 5 « . • ^" ..,^ --'-'^-;/l '^S'0:.-r^ :i"Si-:! \:*w^ ■.^: : -'jiV *'■ %yhiphani in the " Pa- thological Transactions," and described by him as lymph- adenoma. The kidneys and the uterus of a woman who died at the age of forty-three, apparently of bronchitis, were found to be studded with small elevated patches of dark color and irregular shape, which were at first thought to be simple extravasations. A further examination of the spots in the kidney showed, however, that a new growth was comprised within each hemorrhagic patch. This con- sisted of a multitude of some- Avhat irregular nucleated cells m^ WW^' Largre rounrJ-celled sarcoma, from the case of Tem- pero. Very largre irregrviliir more or less rounded cells inclosed in a delicate nieshwork which is inseparable from the normal matrix of the kidney. '^:,,/,' ^iM< Small round-celled sarcoma, the cells arrangjed along partitions of fibroid tissue and blood-ves- sels. (From a preparation at St. George's Hospital formerly described as scirrhus.) Similar g^rowths found in other parts of body. ' Path. Trains, vol. xxiii. p. IfiG. 58 PATHOLOGY AND VARIETIES OF KENAL TL'MORS. imbedded in a delicate reticulum, which was apparently a swollen condition of the interstitial tissue. The new growth was rich in cells in .^'i;-;..' -Ui'.l ^ 3 "^ 'llr-^^i^^^^^'^^ (^ >:&>^ Round-celled sarcoma which in the recent state resembled a mass of coagulum. The blood, to be (listinKuislieil from the growth by the small size of tlie corpuscles, is contained partly in large vessels, but chiefly as extravasation in the sul)stance of the tumor. f5!??j=s r;l-'' 'JJ^ Malignant spindle-celled sarcoma consisting of intertwisted bands of delicate fibroid tissue with few nuclei. proportion to the interstitial substance, and was largel}' mixed with ex- travasated red corpuscles. The growth would appear to be of connective- PATHOLOGY AND VARIETIES OF RENAL TUMORS. 59 tissue origin, and to be entitled to be called sarcomatous; a view which, I may say, has the concurrence of the excellent pathologist who formerly described it as lymphadenoma. The marks of distinction, however, are not so sure but that there might still be room for difference of opinion, were regard had only to the microscopic characters and not to the organic situation. The next instance was brought under my notice by Dr. Grigg, who sent me the kidney of an infant, whicli proved to be the seat of a growth in some respects similar to that already described. The cellular inter- space between the gland and the pelvic mucous membrane had been ac- acurately and uniformly filled with what looked like recent blood-clot. It ^)7 // 1, i^J//-^^ '■s.-Ife;^/ /* Malignant spindl-^ celled sarconxi, the twisted fibrous ti&bue iiivoUing a number of cavities con- taining shapeless dei)ris had the color and somewhat tlie granular texture of raspberry jam, a shade lighter^ that is, than sim[)le coa.^alum. The maximum thickness of this mass was about half-an-incii. Hardened and examined in section, it proved to be, as had been conjectured, a cellular growth, into the inter- stices of which bleeding had occurred. It consisted of a mass of small cells or nuclei, much like white blood-corpuscles; these were sometimes in apparent contact with each other, but in places were separated by the threads of a very definite reticulum composed of small si)indle-cells. In some places the mass was traversed by thick bars of common fibrous tis- sue. It contained in places crowds of red blood-corpuscles and large sprinklings of haematin. Blood-vessels of considerable size were found in it, their edges in some places fringed with extravasated blood. The mass, though in some parts not unlike a lymphoid growth, and in others like a mere extravasation, presented on the whole rather the characters of sarcoma, with v/hich accordingly it is classed. Although the round-celled sarcoma is the more common renal form, the spindle-celled variety is not unknown. A remarkable instance of tliis 60 PATHOLOGY AND VARIETIES OF KENAL TUMOKS. kind, which might be called fibro-plastic or fibro-recurrent, is illustrated by the woodcuts on the preceding pages. The tumor is described in the next chapter. Though hard and slow of growth, it proved eminently malignant in character. Fibrous and Fibro-fatty Tumors. Tumors which have been thus described would probably in most in- stances fall within the definition of sarcoma, or at least be so nearly allied, to it as scai'cely to call for separate consideration. Some years ago I ex- hibited a large renal tumor' as fibro-fatty — a term which its constitution appeared to Justify; it consisted of a gray translucent fibrous basis, in which no cells or nuclei could be found, which inclosed a yellow, opaque structure chiefly composed of aggregated oil-globules. Dr. Bristowe* produced, as a companion to this, another renal tumor whicli presented precisely tlie same admixture of fibrous tissue and oil-globules. I am now enabled, by means of methods of section which were not in use when these growths were presented, to add to, and in one respect to correct, the descri})tion of the one for which I am responsible. Though consider- able districts of this consist, as described, of mature fibrous tissue, yet in other parts it proved to be densely nucleated, notwithstanding that the nucleation was not apparent under the rougher methods by whicli the growth was at first examined. It was also traversed by wide thin-walled blood-vessels, and had, in short, the characteristic structure of a small- celled sarcoma. The growth, in fact, is but a variety of sarcoma in Avhich extensive fatty degeneration has occurred. Simple fibrous tumors have been described in the same relation, but it is not improbable that further examination might i^h^ce them in the same category. Dr. Wilks' displayed one about as large as a child's head, in which the form of the kidney was almost exactly preserved. It was very hard and looked like fibro-cartilage, but proved to consist of fibrous tissue only. It had been of such a size as to attract notice as an abdominal tumor for six years; four years before this there had been haematuria and pain in the loins; so that ten years may fairly be assigned as the duration of the growth. Beside such larger tumors as have been referred to, small fibromata, from the size of a pea downwards, have been found harmlessly disposed in the midst, of healthy renal tissue. Tubes have been traced into them, and they have been thought to be, as indeed are most renal tumors of the sarcomatous kind, mere exaggerations of the interstitial tissues.'' Melanosis. Black growths or deposits have been met with in the kidney, and sometimes described as cancer, though it is probable that the term, in its present ]-estricted sense, would not always apply. Walshe observes that the melanotic discoloration of cancerous masses is occasionally, ' See Path. Trans, vol. xiv. p. 187, where the growth is represented in a colored plate. ■' Ibid. p. 190. * Path. Trans, vol. xx. p. 244. ■• Rindfleisch, Path. Hist. (Sydenham Society), vol. ii. p. 168. PATHOLOGY AND VARIETIES OF RENAL TDM0R8. 61 though rarely, met with iti this organ/ and the similar pigmentation of sarcomatous tumors is not au unfamiliar experience. But melanotic formations may take place independently, as it would seem, of any other morbid growth, simply as a development of pigment-cells in the intersti- tial tissue of the organ. The accompanying woodcut represents a typi- cal example of this in the Museum of the Royal College of Surgeons, which, by the courtesy of the curator, Professor "Flower, I was enabled to examine with the microscope. The black spots, which were unattended Scattered melanotic deposits in kidney. (From a preparation at the College of Surgeons.) with any obvious swelling or displacement of structure, were caused by the sprinkling of the interstitial tissue with large pigment-eells, or black debris, which liad apparently resulted from their disintegration. The cells were situated wliolly in the intertubular district of the kid- ney, leaving the tubes and Malpighian bodies unaffected, but often strikingly outlined by the black matter. There was no evidence of new 1 Walshe, On Cancer, p. 380. 62 PATHOLOGY AND VAKIETIES OF RENAL TUMORS. Gbroid growth or stroma. It is to be noted that the discoloration affected the capsule wliere this was op])osite to the black spots. In the same collection is another kidney, which is uniformly blackened through- out by a change to which the same name would be applied. At the London Hospital is a kidney apparently similar to the first-mentioned, in which the structure is dotted with black deposits varying in si-ze from pins'-heads to peas. These have a powdery look, and are abruptly cir- cumscribed, looking as if lampblack had been inserted into round cavi- ties. There is no history. At King's College are several specimens. Sf^'^^MW- Magnified section of one of the black spots represented in the preceding woodcut, showing melanotic cells and granules in interstitial tissue. The Malpighian bodies and tubes are exempt. showing melanotic deposition in the same organ, in one of which it is associated witli villus. Clinically the history of melanosis is that of the growth with wliich the pigment is associated; in addition ' to which we have the fact that in certain instances the urine has been found to con- tain black pigment, either in casts, granules, or diffused color. Villus. Villous disease of the kidney is of great rarity. In most of the cases of which wc have knowledge, it appears to be analogous to the Avell- known villous disease of the bladder, Avhich is not malignant, and which belongs especially to the trigone. A striking example of villous disease of the kidney was related at the Pathologic-'^l Society'^ by the late Mr. Campbell de Morgan; and by his courtesy I was enabled to have made the representation which is annexed. This was obtained from the body of a woman who had died at the age of seventy-six, after an operation for strangulated hernia. During ' Paper by Dr. Hilton Fagge. Path. Trans, vol, xxviiL p. 172, « Path. Trans, vol. xxi. p. 239. PATHOLOGY AND VARIETIES OF RENAL TCMORS. 63 the preceding two years the urine had been albuminous, and she had had, at intervals of from two weeks to two months, attacks of haematuria, at- tended with pain in the renal region, so profuse as, on two occasions, to endanger life. On posi-7)wrfe!u examination the pelvis of the left kidney was found to be dilated and full of what at first appeared to be a mass of thick shreddy pus. From this a fluid separated, which contained not pus- corpuscles, but nucleated cells, granular corpuscles, and the debris of cells, such as would give the impression that they belonged to a cancerous ^'''fW^' Villus of kidney (from preparation at Middlesex Hospital), described hy Mr. Campbell de Mor- gan. Tlie kidney is laid open, and the growtii seen to hang freely from the pelvis. growth, leaving behind a soft mass of the size of a damson, which on washing spread itself out into the shaggy beard-like growth which is represented. The larger portion grew from tlie wall of the ])elvis by a broad but thin pedicle, wliile smaller tufts were attached to other parts of tlie same membrane. A microscopic examination of the villi showed that many of them were coated with epithelium. They resembled those found in the non-cancerous villus of the bladder, though the latter, as 64 PATHOLOGY AND VARIETIES OF KENAL TUMORS. Mr. (le Morgan observes, are not commonly surrounded with an exuda- tion so full of nucleated cells. The compact portion of the tumor was made up of a delicate fibrous stroma, from which a juice containing nucleated cells exuded. But that this structure was not truly cancerous was inferred from a disposition within the stroma to forms like those which constituted the villi, wliile in cancerous growths with villous sur- faces tiie structure is purely that found ordinarily in cancer. The ab- sence of secondary deposits bears out this view. A somewhat similar case is reported by Dr. Murchison in juxtaposi- tion with Mr. de Morgan's. A man sixty-five years of age was subject to attacks of profuse iiaematuria for fourteen months before his death. Latterly, after severe pains shooting from the right kidney to the pubes, he became drowsy and nearly unconscious, with dry tongue, muttering •delirium, hiccough, vomiting, and frequent convulsive movements. After death these symp- toms, which had been correctly regarded as urae- mic, were explained by the obstruction of both ureters by coagulum, and the filling of the jielvis of the right kidney with the same material. The urae- mia was evidently the re- sult of obstruction, but though no urine is men- tioned as having been passed during the last four days, its suppression is not \ ' ' ^---y^'',--''''''.' :{ \\W^fM^J^'^'i^^'^A distinctlv stated. >,■,.., . //^^'"■'/^■■■■'r ■' ^^ '^^Wiu'<-0 ^^^^ bladder was stud- Mlii!,.! ', ,,> .'. ..,';j''i-^:sKf' ded with long villous pro- cesses, especially about the orifices of the ureters; while the pelvis and calyces of each kidney were similarly beset. These were from one to several lines in length ; they were covered Avith a thin layer of epithelium, and included a ca})illary vessel full of blood. Tlicre was no secondary deposit, nor any formation of the ordinary type of cancer. In Guy's Museum, there is a preparation which displays a large amount of villous growth in connection with a diseased kidney, which is enor- mously dilated, evidently from calculi, one of which still remains in one of the calyces. The colon is adherent, and its cavity is connected with that of the kidney by a sinuous opening. From the lining of the pelvis hangs a quantity of shaggy villous growth, and to a different part of the same cavity is attaclied a quantity of more solid pendent matter, which looks like villous structure associated with some more solid material. The disease is described in the catalogue as malignant, but there is no reference to cancer or growth in any other organ. Through the kind- ness of Dr. Hilton Fagge, I was enabled to examine this interesting speci- men with the microscope. The solid growth of whicli the walls chiefly •consisted was made up of spindle cells of the sarcomatous type, with inter- :(• ' Section from the cortical structure of the villous kidney <(at Gu3-'s Hospital). A Malpighian body is seen surrounded •by nucleated fibroid growth of sarcomatous character. I PATHOLOGY AND VARIETIES OF RENAL TUMORS. 65 Tills here and there in which numbers of small round nuclei were closely packed. These (vere related to the interstitial tissue of the kidney, and could often be traced abundantly surrounding the Malpighian bodies, which themselves were unaffected. The vascular loops which constituted the villi were thin tubes of simple and bare membrane. The growth is clearly related to sarcoma rather than cancer. Its apparent origin in cal- culous irritation is of interest. In the Museum of King's College is a preparation showing the concur- rence in the kidney of villous structure with melanosis. The symptoms of villous disease of the kidney are sufficiently indi- Single detached pendent blood-vessel. (From preparation referred to in preceding figure.) The process displays little more than thin and bare membrane. cated in the preceding cases. Attacks of hasmaturia, which completely intermit, but so profuse as to endanger life; possibly some dull pain in the lumbar region, but no acute pain anywhere; urine simply mixed with blood, without deposit to indicate its source, or, if we may reason from the analogy of the vesical villus, with which indeed tlie renal villus ap- ]iear3 to be generally associated, containing loops of blood-vessel without surrounding tissue. Tliese are, of course, pathognomonic; but they may be searched for repeatedly and in vain. On the other hand, though the 5 66 PATHOLOGY AND VARIETIES OF RENAL TUMORS. disease be villus, it is possible, if the bladder be affected, that the urine may abound with epithelium, the result of secondary cystitis. Tliis in- deed, besides the blood, may be the only product of a villous growth. Its situation as between the kidney and bladder must be determined by the general indication of the symptoms, as pointing to one organ or the other as the seat of disease. Lymphadenoma. The kidney is by no means an infrequent seat of lymphadenoma. The growth as it occurs in this organ presents points of contact with sarcoma, insomuch that tumors occur of which it is difficult to determine whether they belong to one or tlie other; one part of such a mass may resemble a growth of lymphatic origin and another part be indis- tinguishable from one of the small-celled sarcomata already described. To take first the common and unequivocal form of the disease, it oc- curs in the kidney only as part of a general disorder, formations of the same nature being found also in the lymphatic glands, probably in the spleen, and occasionally in the liver and lung. The importance of the disorder is rather general tlian local, or so far as local symptoms ob- trude themselves, they relate to the swollen glands rather than to any internal organs. The renal symptoms, if such there be, have been hith- erto overlooked in the presence of the signs of lymphatic anasmia, which mark the fatal tendency of the disease. It is worth noting that, in Dr. Murchison's case,' which furnishes the most extreme example of renal lymphadenoma which I am acquainted with, the urine was found to be pale, clear, and free from albumin. The appearance of the kidneys under the disorder is sufficiently strik- ing. Bounded masses of variable size beset the renal substance, more especially in the cortex, and present themselves, often numerously, under the capsule. In this position they usually display a circular outline, though when cut at right angles to the surface, they may give one which is elongated or pear-shaped. In the typical example figured by Dr. Murcliison, the masses, of which about a hundred are displayed on the lateral aspect of one kidney which the drawing presents, vary in diameter from about three-eighths of an inch to the size of a mustard-seed. The growths, however, have often been known to exceed in size the largest of these. They are yellowish-wliite, somewhat like large masses of tuber- cle, but are harder, closer in grain, and less apt to caseate. Microscop- ically, they present the characters which belong to lymphoid growths generally — a strongly marked fibrous reticulum, which blends with the intestinal tissue of the organ, in the substance of which are crowds of small circular uniform nuclei, and in its spaces nucleated cells. Leukh^mic Tumors or Extravasations. "White marrow-like tumors, consisting of white blood-corpuscles in a very delicate reticulum, varying in size from a mere dot to a cherry, have been described as occurring in the kidney in connection with the general condition of leukhaemia.^ ' Path. Trans, vol. xx. p. 192. "With the report of the case are excellent illus- trations of tlie naked-eye and jnicroscopic appearances. See also case published by Dr. Coupland, Path. Trans, vol. xxviii. p. 126. ° Riudfleisch, loc. eit. vol. ii. p. 168. I I PATHOLOGY AND VARIETIES OF RENAL TU1VI0R8. 67 Sometimes the extravasations, thongli mainly consisting of white corpuscles, present so much the appearance of ordinary hemorrhage that they are not to be distinguished by the naked eye from such sanguineous outbreaks as have been described in connection with some of the varie- ties of sarcoma. Dr. Greenfield gives an instance of this in the " Pathological Trans- actions " for 1878.* A child four years old, born of syphilitic parents, became the subject of purpura, and lapsed into a condition of extreme ansemia, in which it died. The blood displayed during life an excess of white corpuscles. Not to mention many external ecchymoses, the most remarkable changes found after death were in the liver and kidney, and were due to the extrusion of white corpuscles into the interstitial tissue of these organs. In the liver, this took the form of a white veining, cor- responding with the interlobular divisions of the portal canals, which was found to consist of extravasated leucocytes. In the kidneys, patches of extravasated blood were found underneath the capsule. The cortical surface was marked by large irregular hjemoi'rhagic blotches, which were slightly raised, and were but the bases of cone-shaped haemorrhagic masses, which penetrated deeply into the organ. These masses consisted of ex- truded leucocytes, which had collected abundantly between the tubes and outside the Malpighian bodies. These were not separated by any stroma, save a delicate interlineation of fibrinous threads. Angioma. Cavernous tumors, such a-s are found in the liver, have been described in the kidney, but these have no practical importance. Syphiloma. Syphiloma must be briefly mentioned as a renal tumor, though the local is of quite secondary importance to the constitutional affection. A syphilitic tuber as large as a small potato is described and figured by Dr. Moxon,^ occujiying the renal glandular substance nearly from the pelvis to the capsule. A minute examination showed that the tumor es- sentially consisted of a profuse nuclear growth in the intertubular por- tion of the organ. Both kidneys were enhirged and lardaceous; the pair weighed twenty-two ounces. The enlargement of the left, in which was the tuber, was felt from the front during life. The jiatient had the gen- eral signs of syphilis, together with general dropsy and pale albuminous urine. The latter symptoms were probably to be attributed to the lar- daceous disease; the localized swelling, however, is more distinctive. A few similar tumors have* been described by other writers; they ap- pear to have been invariably imbedded in lardaceous kidneys, by wliich the symptoms are necessarily masked. I have seen patches of fibrosis in the kidney in connection with con- genital syphilis; it is probable that general fibrosis of the kidney, as of the liver, may sometimes have this origin. ' Path. Trans, vol. xxix. p. 298, plate xiv. ' Ouy's Hospital Reports for 1868, p. 393, plate i. See also Cornil, Joum. de I'Anat. et Phys. 1865, p. 96. 68 pathology and varieties oe kenal tum0k8. Fatty Tumors and Transformation's. The kidney offers no exception to the law that morbid growths are but exaggerations of normal structures. Thus the growths wliich arise in this organ are conijniratively few; possibly cancer from the tubes, certainly sarcoma from tlie interstitial structure. This structure may also degenerate into oil, and in certain circumstances become converted into fat, as is rendered probable by the occasional substitution of the glandular tissue by this material. Under irritation, more particularly such as is connected with stone, pyelitis, or the retention of urine, fat is apt to increase in connection with the capsule and in the pelvic or inter- lobular cellular-tissue, until it may happen, should the growth be associ- ated, as it often is, with a corresponding atrophy of tlie glandular struc- ture, that fat may largely take the place of the shrunken oi-gan. This is a form of fatty substitution rather than tumefaction, and there is another change to winch the same term may be applied. Instances have been described in which the whole glandular ticsue of the organ has been transformed into fat, in which little or no trace of the proper structure remains, though the cones and the cortex are distinguishable from each other. ' Circumscribed growths of fat, of the nature of fatty tumors, have been described underneath the cajasule, but these are small and of no practical importance. Bony, Calcareous, and Cartilaginous Groavths. True bone very rarely occurs as a renal growth, though an instance has been referred to in connection with ])yelitis (p. 17). Cartilage is of less irequent, and even doubtful, occurrence. There are many preparations in museums which show formations "within the kidney of bony hardness; these appear to be usually derived from the transformation of hydatids. There is such a specimen at Guy's Hospital, which is described in the catalogue as a " kidney containing a mass of bones." Under the microscope, however, no trace of osseous structure could be seen; the mass was simply cretaceous. There is a preparation at the College of Surgecuis, in which the kidney of a man who for ten years had passed hydatids in the urine is transformed into an irregular ovoid mass of cretaceous matter, which has lost all renal semblance.' Instances have also been described in which the capsule of the kidney has been partially "ossified," to use the term commonly applied to the change. J)r. Elliotson sent to M. Eayer an atrophied kidney, of which Jjoth the pelvic mucous membrane and the capsule were represented by hard shells, but whether bony or only calcareous we have no means of ascertaining, probably the latter. The same writer' gives a rep- resentation of a tumor of bony consistence, as large as an orange, which occupies one end of the kidney. This was enveloped in a cyst of carti- ' Rayer, loc. cit. vol. iii. p. 616. Ebstein, Ziemssen's Cydopcedia, vol. xv. p. 635. Dr. HuUett Browne, Path. Trans, vol. xiii. p. 131. ^ Guy's Hospital Museum, 2,034 : College of Surgeons, No. 1,925a. See also a preparation at St. Bartholomew's Hospital, No. 26, 17. * Rayer, Maladies des Reins, vol. iii. p. 608. Atlas, plate xxxvi. fig. 6. PATHOLOGY AND VARIETIES OF RENAL TUMORS. 69 laginous hardness; and altogether the description is suggestive that it may have been the residuum of a suppurating hydatid. Abscesses, Avhether arising in hydatids or in tubercle, or independent of either, may become quiescent "in the kidney, and be represented only by the cretaceous residue of the pus they have once contained. Thus the kidney may be practically destroyed by pyelitis, and the products shut up in the pelvis, until at last nothing remains but an innocuous though useless cyst, containing a mass of chalky or mortar-like substance. CHAPTER YII. CLIXICAL HISTORY, SYMPTOMS, AXD TREATMENT OF MALIGXANT DISEASE OF THE KIDNEY. Touching the symptoms of malignant disease of the kidney, no dis- tinction is possible between cancer, properly so-called, and tlie sarcoma- tous growths which take their rise in the connective tissue of the organ. And in regard to the literature of the subject, it is needful to bear in mind that what is generally described as cancer is seldom to be more nai'rowly interpreted than as an encroaching and destructive growth. In most cases the cause is undiscoverable. Those which present them- selves to our notice are of two kinds: mechanical violence and stone •within the kidney. Hereditary predisposition is not strongly declared, though sometimes apparent, as in the instance Avhicli is illustrated by a ■woodcut at page 56. Falls, kicks, and violent blows of several kinds ■which appear often to have affected the lateral aspect of the trunk, towards which the kidney is more exposed than directly to the front or rear, have been mentioned by many writers in this relation. Ha^maturia has been recorded in most instances iis an immediate result of the accident. The growth has made its appearance at varying periods subsequently : in a case mentioned by Bright in little more than three months after the fall down-stairs to which it was attributed, in other instances in six months, in another in two years. Renal stones are equally distinct antecedents of renal growths, whether the nature of the sarcoma or cancer, though they have attracted less attention in this relation than have injuries by ■violence.' A case of malignant sarcoma which ensued upon years of suffering from renal calculi is reported. An instance of villous disease associated vvitli sarcomatous tliickening. is referred to at page 64, and an instance of colloid subsequent to calculous obstruction at page 55. There ap- 2)ears, indeed, to be no form of renal growth which may not be insti- gated by this irritant. Pathology abounds with instances in which ma- lignant and other growths have been started by accidental irritations; cancer of the gall-bladder from biliary calculus is a parallel instance to cases in which the pelvis is the seat of the villous or other growth sequent upon renal stone; cases where the growth has begun apparently in the substance of the organ are less easily to explain as the result of pelvic irritation; but that stone is more often a precursor of renal growths than can be explained by chance concurrence is certain. The symptoms by which malignant disease of the kidney is commonly declared, are tumor, pain, hajniaturia, cachexia, which must be held to include loss of flesh and strength, and embrownment of the skin, and the several signs which denote the extension or transplantation of the growth ' Abdominal Tumors (Sydenham Society), p. 230. CLINICAL ASPECT OF MALIGNANT TUMORS. 71 to other organs, as to the spine or hiiig. In a large majority of cases the renal swelling presents itself as a ])alpable tumor; of all the signs of malignant renal disease this is the most constant. The swelling, partic- ularly in children, may appear as a prominent, or even as an exception- ally large, abdominal tumor. The relations and means of identifying renal tumors have been already stated (p. 37); it only remains to say, with regard to those of malignant character, that they are not always conspicuous; deep handling of the belly may be needed for the detection, and even this may be ineffective until the muscular resistance has been overcome by means of chloroform. The enlargement of a renal growth is almost always chiefly in front, though some degree of fulness and levelling uj) of hollows is to be felt in the lumbar region. As an excep- tion must lie mentioned a man who was in St. George's Hospital, under the care of Mr. Holmes, and whose case is related in the "Pathological Transactions." ' A large pulsating swelling occupied the lumbo-sacral region on the left side, and emitted a low soft blowing murmur. This was fonnd to have been produced by a highly vascular malignant growth belonging to the corresponding kidney, which was enlarged thereby to the weight of 30 oz. Among nineteen cases of malignant tumor primary to the kidney of which I have the particulai's before me, there were but three in which a tumor was not detected during life. Among the three exceptions was one in which, though a large tumor existed, and was sus- pected, tenderness from peritonitis forbade its being adequately sought; in one of the others a tumor which could have been easily felt escaped notice, for no other reason than that it was not felt for; in the third, the renal mass weighed 17^ oz., and possiljly would have been detected had not implications of the brain or skull withdrawn attention from what was probably the first seat of the growth. Thus in all a renal tumor was, if not perceived, at least jierceivable; those which escaped notice were not indeed so small as some wliich were found. But though renal growths are generally to be distinguished as palpable swellings, they are not so easily to be known as renal; in one of the cases referred to, the tumor was supposed to be a slight enlargement of the spleen, in another to be an ovarian cyst. Next to swelling perhaps comes pain in order of frequency as a symp- tom of malignant disease of the kidney. Children with large soft tumors often apj)ear to be free from it, but elder persons with harder growths are seldom so, and sometimes suffer severely and persistently. The harder the growth, as a rule, tlie greater the pain. It is dull and wearying rather than acute, and is not generally intensitied by movement, these circumstances marking the distinction between pain from this source and that from stone. The pain of malignant growth is usually most marked ^bout the proper renal region on the affected side, and is accompanied by tenderness, which may make the patient keenly conscious that the fingers of the explorer are exactly adapted to the seat of the disease. The line of the ureter and the testicle are less affected than with stone. The ex- tension of the pain to the spinal region, more particularly if tenderness over individual vertebrse belonging to the lower dorsal or upper lumbar region can be recognized, is a sign of the extension of the disease in this direction, and an indication at once of its nature and of its impending termination. Pain down the thighs may accompany this extension, and Vol. xxiv. p. 149. 72 CLINICAL ASPECT OF MALIGNANT TUMORS. be shortly followed by paralysis, first of the bladder, and possibly not ex- tending to an observable extent further, to be succeeded, should time allow, by paralysis of the lower limbs, and the sphincter ani, and uncon- trollable bedsores. Perhaps the next degree of significance must be attached to the con- stitutional results of malignant disease in loss of flesh and change of color; with the rapid growths of childhood the complexion may remain perfectly unaffected, and loss of flesh be at least not observable until late, but with older subjects both emaciation and tinting of the skin may be very conspicuous, the lean figure and brown face possibly giving a delusive suggestion of tropical experience. With this, or apart from it, is sometimes an extraordinary failure of strength, spirits, and vitality ; the patient may sicken of a vague disease, get thin and weak, take to his bed without pain or definite complaint, and at last die without giving up his secret. Urasmia rarely, if ever, appears as a result of renal growths. Hasmaturia has been variously estimated as a symptom of malignant disease of the kidney. It perhaps has no greater value in tiiis relation than as present in an important minority of cases. I have before me the notes of seventeen; of which hematuria was known to have occurred in six, in one of which it was probably due to stone, which existed as a com- plication. Eoberts, out of fifty-nine cases, collected mostly "from published records, found mention of this symptom in thirty-one, in five of which there was intervention of other possible cause — stone, Bright^s disease, or external violence. Ebstein, in his larger compilation, found notice of haematuria in twenty-four out of fifty cases. Kenal cancers, though possibly tubal in their origin, are commonly separated by encapsulation from the })r<)per glandular structures ; sarco- mata, though often diffuse, are interstitial in their position. Cut off as both are from the tubes and Malpighian bodies, neither, as a rule, bleed into the urinary passages, except as the result ©f fungation into the pelvis, either by participation of the mucous membrane in the disease, or by protrusion by way of one of the mammillary processes. Thus haematuria is by no means of necessary occurrence, but when it does occur is constant. Earely in the history of such cases an isolated hemorrhago has been reported early in the disease, where the urine was said to have- been bloody four years before death, and to have recovered its normal cliaracters. Possibly in such circumstances the kidney becomes con- gested under the early process of morbid growth, but the rule that hem- orrhage in connection with renal tumors indicates ulceration into the urinary passages admits of few exceptions. The bleeding, once begun, is generally continuous, if left to itself, though it does not entirely ignore styptics. It is often profuse enough to cause anaemia, though less so than that which proceeds from villous growths of the bladder. The renal characters of the luematuria are generally at once evident. The blood is generally more tawny or embrowned than when from the bladder, and is so uniformly admixed with the urine that each micturi- tion is bloody from first to last; the latter portion perhaps more so than the earlier, but not with the accumulation of blood at the end which be- longs to vesical hemorrhage. The bloody sediment is powdery and inco- herent. Clots, if any occur, are small and generally somewhat fibrinous- or decolorized ; they may have a slenderly vermiform shape which they have taken from the ureter, but this is infrequent. Bladder-clots aro usually soft and red as if newly congealed; they are shapeless, and often i CLINICAL ASPECT OF MALIGNANT TUMORS. 73 of such bulk tliat their escape by the urethra would seem an impossibility; tlioy are often indeed shot out only after prolonged effort. Renal hemor- rhage, on tiie contrary, though it has been known to cause obstruction of the ureters, and fatal supj^ression, seldom if ever impedes the urethral exit. The hemorrhage, unlike that from renal calculus, is not more abundant on going to bed at night than on rising in the morning — in- deed, the reverse is often the case, as if the discharge were favored by the horizontiil position; and the distinction from the bleeding of stone is further marked by the almost invariable cessation of the latter after some days in bed, while that of malignant disease is not much, if at all, less- ened thereby. The urine, when not bloody, is usually perfectly natural — the growth has not broken into the pelvis, and the secretion is that only of the healthy glandular structure. As to the microscopic appearances of tlie urine, into which a morbid discharge has found entrance, it necessarily contains blood-corpuscles, usually in vast abundance, but never anything; pathognomonic of their source. Casts as a rule are absent — a negative symptom of some importance, as excluding a form of nephritis in which bleeding may be profuse enough to suggest a growth, but with which these evidences of disease are many, dark, and striking. Exceptionally casts are to be found. These may be the result of renal disease, only accidentally associated with the growth, or they may proceed, as may happen in connection with many localized renal changes, from tubal disturbance in the immediate neighbor- hood of the growth. Pus, if present, is so only as an accident. "Cancer-cells," or nucle- ated bodies which could pass for them, are conspicuously absent. With bladdei'-cancers and villi, squamous cells, exhibiting every form of morbid luxuriance in nucleation and shape, are often abundantly found, and even considerable masses of cellular growth are sometimes expelled, within which blood-vessels can be detected. The pelvic and vesical mucous membrane may be stimulated to des- quamation by a variety of circumstances, some of a transient nature; and from one part or another, cells of every degree of rotundity or flat- ness may proceed. But with renal tumors, such evidences of disease are seldom, if ever, found. Keviewing my own experience, I have found cases in plenty where large cellular deposit has been associated with cancer of the bladder. I have known several in which the presence of cancer in some })art of the urinary tract has been confidently presumed, in consequence of the abundance in the urine of nucleated and prolifer- ating cells, and in which the recovery of the patient has negatived any such supposition. I have met with not a few in which a discharge of cells of epithelial type, together with blood, has been supposed to indi- cate cancer of the kidney, but not with one in which this supposition has been verified. If I am told that such a one is passing " cancer-cells '" in the urine, I conclude that, whatever his disease may be, it is not can- cer of the kidney. A deposit consisting of blood-corpuscles, mixed, if with anything, with indefinite sanguinolent material, and that constant, during repose as well as under exercise, is a sign in this i-espect of more meaning. It is to be borne in mind that a f ungating tumor of the kid- ney is less often cancer than sarcoma, the cells of wiiich, associated as they are with connective tissue, are not to be easily and abundantly shed, while, even should they reach the urine, they are at least in the small- 74 CLINICAL ASPECT OF MALIGNANT TUMORS. celled varieties, which are the more numerous, too small to attract at- tention when confused with red and white blood-corpuscles. The remaining symptoms of the disease may be termed accidental; they relate to extension of the disease to other organs than that prima- rily affected. That most distinctive of renal growths, whether cancer- ous or of the nature of sarcoma, is the spinal complication. With a considerable propoi'tion of malignant renal growths, tiie adjacent ver- tebral surface is more or less eroded, and tlie spinal column is sometimes cut througii, with evidences of spinal disease, severe pain in that situa- tion, localized tenderness, and possibly, as noted in one instance, crepi- tus, like that of broken bone, between the adjacent halves of a severed vertebral body. With these come the various stages of paraplegia, which, as far as I have seen, are apt to begin with paralysis of the bhidder, and be evident tliere for a little time before the extremities are affected. Tiie suffering which this extension may involve, the pain of the encroach- ing growth, the paralytic helplessness, the retentiion of urine, the non- retention of faeces, the deep and extending bed-sore, is more than is often comjn'ised in the process of natural death. Another result of malignant renal tumor, which, though indirect and not peculiar to disease of this origin, has yet been so striking in some instances which I have seen, as to deserve special mention, depends upon the conveyance of the morbid process to the lung, and takes the form of asthmatic or laryngeal dyspnoea. In one instance, attacks like severe asthma occurred, which were unaccompanied with stethoscopic evidence of disease, completely intermittent, and were found after death to have been associated with scattered growths throughout the lungs. In another case there was severe dys})noea on exertion, particularly on going up- stairs, wdiich the patient referred to the larynx, together with spasmodic cough, like whooping cough, and the occasional raising of peculiar hol- low sputa, around which a cellular or corpuscular growth was detected, foreign to the proper structure of the lung, which gave the only conclu- sive evidence as to the kind of disorder from which the patient was suf- fering. Cancerous or malignant matter belonging to the kidney may be dis- charged, or intrude itself variously. A child three years of age, who was in St. George's Hospital with a large cncephaloid (?) tumor of the left kidney, passed blood by the bowels, and then after an interval had much abdominal pain, vomiting, and purging, under which it sank, seventeen days after the discharge of blood. It was found that the descending colon and the tumor were firmly connected by adhesions, and that in the midst of the tumor was a cavity, due to breaking down of growth, the products of which had es- caped into the colon by an ulcerated opening through its walls. The duodenum has likewise been penetrated by a renal cancer, as in an instance recorded by Kayer,' in which a portion of a tumor of this nature, belonging to the right kidney, was found to have intruded itself through an ulcerated opening into the cavity of the bowel. Death had been preceded by obstinate vomiting and hiccup. Perforation of the abdominal wall by renal cancer has been recorded at least in one instance: that of a child, three years old, mentioned by^ Abele, in whom a medullary growth of renal origin sprouted artificially. • Maladies des Reins, vol. iii. p. 705. CLINICAL ASPECT OF MALIGNANT TUMORS. 75 carrying with it a loop of intestine, which became gangrenous, and dis- charged faeces superficially. The duration of malignant renal growths, most conveniently esti- mated independently of their division into cancers and sarcomata, varies with age. The growths of childhood are softer and more rapid than those of later life; and, besides this, they are more often painless, so that the apparent may be often much out of proportion to the real duration, since there may be no sign of the disease until the abdominal tumor be- comes obvious. It is indeed evident that under most circumstances a o-rowth so deeply seated, and one that usually does not seem to interfere with the function of the organ in which it is placed, is likely to remain in obscurity for so mucli of its early life that to every statement of the duration of the disease an uncertain time must be added. In fifteen of the cases to which I have referred from hospital and pri- vate records, the time from the advent of the first symptom to death is stated with distinctness. This varied from eighteen days to four years: Duration of Malignant Renal Growths. Prom first symptom to death under 6 months Prom first symptom to death from 6 months to 1 year Prom first symptom to death from 1 year to 2 years Prom first symptom to death from 2 years to 3 years Prom first symptom to death from 3 years to 4 years Children 13 months to 4 years old Adults 25 years to 58 years old. Total Collected experience shows a similar distribution. Of nineteen cases among children, collected by Roberts,* the mean duration was nearly seven months; the minimum ten weeks, the maximum over a year. With adults twenty-one cases gave an average of two and a half years, the ex- tremes ranging from five months to seven years. Ebstein'" gives the ap- parent duration in children at from five weeks to two years, in adults the time being variously extended to a maximum of eighteen years, for which length of time the disease " was demonstrated to have lasted" in an in- stance in which it took its origin from a fall. Roberts observes justly on the frequently long duration of renal "can- cer," and refers it in part to the duplication of the organ; but a more fundamental reason presents itself in the fact that renal cancer of clinical medicine is commonly not cancer, but sarcoma — a sarcoma sometimes of exceeding malignancy, but in other cases having the hard structure and slowness of extension which belongs to the more sluggish forms of the recurrent fibroid tumor. ' Roberts's Renal and Urinary Diseases, 2d Edit. p. 252. ' Ziemssen's Cyclopcedia, vol. xv. p. 684. 76 CLINICAL ASPECT OF MALIGNANT TUMORS. Treatment of Malignant Disease of the Kidney. Witli regard to the treatment of renal growths, the first consideration must be of the feasibility of operation and cure. Modern surgery lias demonstrated the possibility of the removal of one kidney withouta neces- sarily fatal result. Malignant tumor of the kidney will surely kill if left alone; with the rapid growth of childhood this end is seldom long delayed after the detection of the growth. If excision could cure even a considerable minority a gain of life would ensue, even though the death of the rest shoiikl be hastened. Looking first at the question in the light of morbid anatomy, I must refer to page 51, where is a statement of tlie frequency of malignant growths in otiier parts of the body secondarily to those arising in one kidney — since I presume that no surgeon would think it right to extirpate the kidney were the operation to leave progressive and fatal disease elsewhere. It appears that of nineteen cases of malig- nant renal tumor which were examined after death, which had occurred in the natural course of the disease, there were but three in which the growth was confined to one kidney. Allowance must of course be made for the fact that in all these cases the disease was permitted, in the ab- sence of operation, to extend to the utmost limits consistent with life. It is to be presumed that at an earlier date the proportion of secondary disease would have been less; nevertheless it is of grave significance. Looking now at the results of experiment, there have been up to this date (July, 1882), as far as I know, eleven instances in which a kidney, the seat of a malignant tumor, has been extirpated, either by design or as the result of an operation begun with some other view. The results are briefly — six deaths as the immediate results of the operation, five recoveries.' Thus it must be allowed that excision of a cancerous kidney ' I subjoin a brief enumeration of the cases of excision to which I have re- ferrei-l, for which I am mainly indebted to Mr. Barker's tables in the Med. Chir. Trans, for 1880 and 1881, and to which I must refer for further particulars. Among the eleven cases mentioned are four in which the operation was under- taken on erroneous diagnosis — once for a cj'st of the liver, once for a tumor which was thought to be either splenic or ovarian, once for ovarian tumor, once for renal calculus. The description of the tumor removed is probably not always to be accepted as the result of minute observation. Enumeration of Cases of Excision of Kidney for a Malignant 'Tumor. Operator and Date. Sex,' Age. Place of Incision. Result. Condition of Organ. Walcot (America), M Death in 15 days, from Enceplialoid, 2^ lbs. 1S61. 58 suppuration and ex- haustion. Kocher (Bern), April F Ventral Death on 3d day, from Extensive sarcoma 1876. 35 peritonitis. Opera- tion not completed. which involved meso- colon. Heuter (Greifswald), F Linea Death under operation Perinephritic sarcoma, July, 1876. 4 alba from hgemorrliage. 5 lbs. in weight. Jessop (Leeds), Jan. M Lunibar'Temf)orary recovery. Malignant tumor. 1877. 2i ' Disease recurred probably in lumbar glands. Died about 9 months after opera- tion. CLINICAL ASPECT OF MALIGNANT TUMORS. 77 IS practicable without such inordinate danger as to put it out of consid- eration. The question must turn on the permanence of tlie cure; and here our evidence is as yet imperfect. Lossen's case recovered from the operation, but we have no fiirthei- knowledge of the patient. Martin's patient was in good healih two and a half years afterwards; Byford's two vears and four months afterwards. Jessop's patient died under a return of tiie disease, within a year; Adams's patient in about six weeks; both with disease of the same nature, in the lumbar glands and elsewhere. Tlius, in the whole number we have but two cases, or possibly three if we incUide Lossen's, in which the ultimate result was favorable. It is clear that both cancer and sarcoma of tiie kidney are highly malignant; neither are as a rule discoverable until they have attained the bulk of palpable aljdominal tumors, and reached therefore a comparatively advanced stage; and on the whole I doubt whether a permanent cure is to l^e anticipated in a sufficient proportion of cases to justify the large risk of immediate death which the operation entails. The palliative treatment of malignant renal growths has to be directed for the most part towards the relief of pain and the control of hasmor- rhage. The use of morphia by the mouth, or, better, by the skin, is of ilie first value; its systematic use will sometimes prove of the greatest omfort. A smaller measure of relief, with a complete absence of any injurious effect, is to be obtained from the a]iplication of plasters of opium or belladonna, or the aconite liniment. Sometimes in connection with renal or vesical growths, a burning sensation over the kidney or ureter is a source of distress; for this, as observed by Prout, an ice-bag is the best remedy. Hemorrhage, when present, is usually the symptom which most urgently seeks relief. That the bleeding is from a growth may be Operator and Date. Kocher (Bern), Dec. 1877. Byford (America), March, 1878. Martin (Berlin), Dec. 1878. Czerny (Heidelberg), Jan., 1879. Lessen (Heidelberg), Aug., 1879. Barker (London), Dec, 1879. Adams (London), March, 1882. Sex. Age. Place of Incision. M 2i Ventral F 39 Linea alba. F 53 Ventral M 50 Ventral F 37 Linea alba F 21 Linea alba M 30 In loin, parallel with last rib Result. Death on 3d day, from peritonitis. Recovered rapidly. Pa- tient in good health, July, 1880. Complete recovery. Known to be in good health 2| years after- wards. Death in 10 hours, from shock. Recovery perfect. Later history not known. Death in 45 hours, from pulmonary thrombosis. Recovered from opera- tion, but died about 6 weeks afterwards, from recurrence of disease in lumbar glands. Condition of Organ. Large adeno-sarcoma. Encephaloid, 4| lbs. Malignant new growth weighing 28 oz. Soft sjjongy mass left in situ. Angio-sarcoma 5 times size of kidn(\v grew fi'om its surface. Two-thirds of organ converted into en- ce])haloid. Carcinoma. 78 CLINICAL ASPECT OF MALIGNANT TUMORS. more certain than either the position of the growth or its nature; but, whether from the kidney or bladder, whether compact or villous, internal astringents are often attended with advantage. Striking and speedy re- sults have indeed sometimes ensued upon such remedies, where, from the case having presented itself only in its clinical phase, it has been impossible to define it with certainty further than as one of a bleeding growth. I have seen the best results from iron alum, tannate of alumina, gallic acid, ergot, and the witch-hazel. Gallic acid and ergot, given together, have been followed by the complete arrest of profuse hgemorrhage, pre- sumably of villous origin, while I have often known bleeding, evidently from malignant disease, to be conspicuously controlled by the tannate of alumina or iron alum. I CHAPTER Till. TUBERCLE. Pathology. Looking at tlie kidney itself, and first at the manifestations of dis- ease which are evident to the naked eye, tubercles and tubercular con- cretions present themselves in it of every size and grade. These range from delicate, scarcely visible, gray tubercles of the finest miliary dimen- sions, up to caseous and softening- masses which may be as large as peas, ir nuts, or even larger than to be so comj^ared, and which may be sa numerous as to present a considerable bulk in comparison witli what is left of the renal tissue. It is not practicable to make any definite dis- tinction between the miliary and the caseous, the miliary become caseous ;is they enlarge, so that, though in some cases there may be only one or Mily the other, yet they are continually intermixed and inseparable, as different results of the same process. The growths, especially when miliary, are more often found in tlie cortex than in the cones, though often in both. They are com- monly distributed apparently at random through the cortex, with no further bias than one towards the surface, upon which they display tiiemselves in circular outline while they push inwards in somewhat conical shape. Occasionally it is to be discerned that their distribution IS determined by that of some arterial branch. Where recent, they ;tre often surrounded by zones of injection almost like emboli or ])V£emic abscesses. When of larger bulk, as considerable caseous masses they may soften in their centres and form abscesses, which may be long locked up, or may possibly escape by the surface or through one of tlie cones into the pelvis. But Avhen such discharge occurs it is more often from the deposition of tubercle in tlie cones themselves than by way of exit to an abscess of cortical origin. T'hus the occurrence of tubercle in the pyramids, though less frequent than in the cortex, has especial interest in relation to the symptoms of the disease. These por- tions of the organ are apt to display some small tubercular masses at their apices or to be extensively, or some even completely, replaced by caseous tubercle or abscesses of tubercular origin. The cone splits be- tween its converging lines, and the pus thus fiiuls its escape into tlie pel- vis where the manimillary process points. Often the opening is delayed, and a considerable globular cavity formed in the place of the cone, before the narrow orifice has been formed; thus the vomica may have the shape of a flask or bottle, a rounded cavity discharging by a narrow neck. Many pyramids may be thus excavated, and the kidney so converted into a mere cyst, with many septa, each septum or partition being the con- densed remnant of the portion of cortex between adjacent cones, wliile the pelvis is the common vestibule with which all the chambers commu- 80 TUBERCLE. nicate. The process may extend until the outer cortex is so excavated, and so mucli transformed by the concurrent processes of glanduhir atro- phy and fibrous increase, tluit it also may be reduced to little more than fibrous tissue, and tlie whole organ to a chambered shell. The process of transformation is sometimes aided by stoppage of the ureter, and accumu- lation of the renal contents, as a consequence of which the organ may be distended as well as excavated. The organ may at last shrink, and be- Tuberculoiis kidney. Tubercles, which in manj' instances have be^un to soften, scattered throiij. ^V (' NX., condition of some of the tubes. Another outline shows also the stalk- like arrangement produced by the section of the vessel in the midst of the mass. The tubal obstruction is not the only, or even the chief, in- fljinimatory change which the kidney undergoes in consequence of the tubercular action: interstitial nucleation, or fibrosis, is often conspicu- ous, not only in the immediate neigh- borhood of the tubercles, but also some- what widely distributed. Sometimes tlie common interstitial nucleation is connected inseparably with the tuber- cular, as if they were but different parts of tlie same process. The tubercular masses, when they occur in the cones, are sometimes col- lected into wedge-shaped groups lilvc the iisposition of emboli or pysemic ab- ^nesses, and the resemblance may be in- ci-eased by a circumference of vascular injection. In one instance which came under my observation, the minute anatomy ])roper to tubercle was remarkably inter- mixed with that of a large-celled growth. The kidney to the naked eye had ordi- nary tubercular characters. There were several collections of half-caseous pus in the cortex, which were regarded as suppurating tubercle ; and their tuber- cular character was confirmed by the presence of an apparently tuberculous ulcer in the bladder, and an abundance ■)i miliary tubercles in the lungs. Under tlie microscope the kidneys displayed in parts the nuclear and caseating appearances which usually belong to tubercle, but in other parts were aggregations of very large nucleated Mass of tubercle upon an artery cut diagonally so as to give stalk-like appear- ance. Amorphous matter next vessel, nuclear growth outside. (From cortex of kidney of same subject as preceding.) lArgfi cells within a fibrous reticulum from a kidney which to the naked eye was tubercular. (From a woman whose case is also referred to in woodcut at p. 90.) cells lying together like the cells of cancer or of an alveolar sarcoma. In some places were fibrous bars or partitions, which divided groups of cells in mutual contact; elsewhere — and this was most stritcing, as forming the lining of one of the considerable abscesses — these cells were heaped 84 TUBERCLE. together without any further evidence of reticulum than a few ragged shreds protruding from the edge. If we regard this as a concurrence of two growths, as tiie mixed characters would suggest, we have to observe that tlie sarcoma broke down with suppuration, certainly not a habit with tliat growth. On the other hand, if the large cells were tubercular, they were at least exceptional in that relation. Tlie disintegration and excavation of the tubercular masses is an im- portant step in the destructive process. These, having attained a certain size, break down in their centres and form cavities which, so long as they are confined to the cortex, are more or less circular; but on reacliing the cones tiiey are apt to elongate in pyriform shape with the narrow end toward the pelvic cavity, into which they eventually discharge. A cavity in the lung empties itself by a broncluis; a cavity in the kidney should by analogy relieve itself through a renal tube, or a channel formed out ■mm Trom same case as precedintf woodcut. Section of the wall of tuberculous (?) cavity. The lar^e cells above form the wall of the cavity; the smaller below are in coatact with the renal structure. Section of the pelvic membrane of a tuber- culous kidney, showinjr profuse nucleation underneath the epithelium. of one. But, as far as I have been able to observe, this is not the case. Collections of debris, somewhat, but not much, larger than the sections of tubes, are sometimes seen to be surrounded with a membrane which might pass for the wall of a tube, but I have never been able to discern an epithelial lining upon it, or to satisfy myself that such apj^arently tubercular cavities were really of tubal origin. Enlarged and obstructed tubes are sometimes seen in the neighborhood of tubercular excavations, but 1 have never been able to trace a continuity between them. Thus it would api^ear that the renal vomicae find exit otherwise than by the reiuil ducts. It has been said that the cavities, which are more or less round in the cortex, tend to become elongated should they touch the cones. In the cones the whole structure is disposed in nearly parallel lines, between which ic tends to yield under encruacliment like wood before the wedge. TUBERCLE. 85 The lines of cleavage converge upon the apices of the pyramids, and it is here or hereabout, often by a constricted channel, that the renal vomica finds its exit. When it happens, as it often does, that the growth of tubercle begins in the cone, its discharge into the pelvis is of course the more ready. The mucous membrane of the pelvis, ureter, and bladder may be affected by tubercular disease, together with the kidney, either independently or consequently. When the kidney has been excavated so as to discharge, as it usually does, into the pelvis/the mucous membranes in the line of exit are so constantly affected that concurrent evidence of cystitis is of the first importance in leading to the diagnosis of tubercular disease. The pelvis of the kidney in such circumstances is commonly injected^ inflamed, thickened, even into a stiff caseous layer, or variously ulcei"- ated. It sometimes presents considerable tubercular bosses, it is some^ times sprinkled with miliary tubercle, while in some cases a definite nuclear layer, apparently of a tubercular nature, may be traced in the submucous tissue. It is to be noted sometimes that a distinct layer of false membrane will line the pelvic interior almost like that of diphtiieria. (See woodcut at p. 81.) The connected ureter shares in the same changes; it be- comes thickened, ulcerated, and transformed into, or occupied by, case- ous material, often so as to lead to its complete and permanent closure,, while the same result is in some cases attained by the protrusion into the- channel of tuberculous nodules or bosses. The bladder commonly participates, more especially near the entrance of the nreter which leads from the affected, kidney, if there be but one involved, and in other j^arts, perhaps particularly, at least I have seen it so in several instances, about the exit of the urethra. The membrane often displays tubercular nodules and isolated or diffused, ulcerations. The arrangement of such localizations in the line of the discharge is often suggestive of their dependence on its irritative or infective contact. It may indeed be inferred that tubercular disease of the ureter or bladder is commonly secondary to, and produced by, that of the kidney, from the circumstance that tubercular disease of the kidney is seldom asso- ciated with a similar condition of these cavities, unless the disorder in the glands have proceeded to ulceration and discharge. Among the cases I have referred to were thirty-four of excavation of the kidney, the tubercular character of which was testified to by tubercle in other oi'gans. Among these, disease of the bladder or ureter was recorded in twenty- three instances, and would probably have been found even more ofteni had the examinations been conducted with this question in view. Among thirty-eiglit instances of non-ulcerated renal tubercle these cavities were noted as diseased in but one example. It is undoubtedly i)ossible, though perhaps not very common, for the bladder to become tuberculous while the kidney is not so; but such is the tendency of tubercular suppuration of the kidney to produce disease of tlie same nature in the bladder that the absence of vesical symptoms in i)resence of a purulent discliarge from the kidney would indicate, with little chance of error, that the source of the jnis is not tubercuhir. The kidneys may participate in a general or scattered tuberculosis, or may suffer alone. The former is by far the more common, insomuch that, of ninety-five cases examined after death, there were but eleven in which the disease was limited to one or both of these organs. Of all but one of these the subjects were adults. 86 TUBERCLE. It might be supposed that, where the kidney only is affected, the disease would reach in this organ a stage of furtlier destructiveness than when it is liable to be cut short by similar changes elsewhere; but, however this may be, among the cases recorded were numerous instances of almost total destruction of the kidney by tubercular disease, in which other or- gans shared. Among the ninety-five cases referred to, there were forty-eight in which the disease had progressed to extensive excavation: in forty-one of these, tubercles were found elsewhere than the kidneys, in seven not. These facts lend little su])port to the views which have recently been ini])orted, according to which caseation is in a considerable proportion of cases in-dependent of tubercle. In the cases before us, it was declared, by the ])resence of widely scattered tuberculosis, that the "consumption of tlie kidney" was, in a large proportion of cases, associated with unmis- takable tubercle. Among eighty-four cases of tubercular disease of the kidney associ- nted with tubercle in other organs (sixty-one from St. George's Hospital, twenty-three from the Hospital for Sick Children) were fifty-nine in which pulmonary tuberculosis existed, not including those in which the lungs took part in acute general tuberculosis. Among these were thirty-four instances of extensive pulmonary phthisis, eighteen in which the chronic tubercle was generally distributed, seven in which the lungs contained tubercular cicatrices or tubercle in small amount. Including the cases in which the lungs were involved as part of acute tuberculosis or tubercular meningitis, at least two-thirds of the number were the subjects of ])almonary tubercle — a fact of much diagnostic importance. Next to pulmonary tubercle in order of frequency came tubercular meningitis, which occurred in seventeen instances. It is worth remarking that, of four of these, the subjects were over twenty years of age, in three over forty years of age, so that, in this, as in other associations, tubercular meningitis presents itself as by no means limited to childhood. In five of the in- stances of renal disease under discussion, acute tuberculosis occurred without meningitis. Peritoneal tubercle, or tubercle of the abdominal glands, occurred in eight cases, tubercle of the supra-renal capsule in two, of the prostate in one, of the ovary in one. Caries of bone was found in sixteen cases. Roberts' observes on the comparative frequency of tubercular disease of certain of the male organs of reproduction, the prostate, the vesi- culge seminales, and testicles, while with the female the generative or- gans have little tendency to be implicated. The clue to the local dis- tribution of tubercular disease in cases of excavation of the kidney of this nature is to be found in the tendency of tubercular discharges to produce disease by their contact: thus the pelvis, ureter, bladder, and possibly the prostate and urethra, are apt to be involved. Nothing of the sort happens with cancer or other malignant disease of the kidney, vvliich, however generally it may be disseminated, has no tendency to in- volve the outward passages. Apart from communication by discharge, organs other than the kidney become involved much according to their general proclivity, the lungs taking the lead. Both kidneys are affected together in about as many instances as one separately. If only one be affected, it is more often the right than the left, though in childhood this difference is not apparent. Of ninety- > Roberts, 2d edit. p. 547. TUBERCLE. 87 five cases, both kidneys were affected in forty-seven, one only in forty- €ight. Taking childhood, apart from other periods of life, of twenty- eight cases of which the subjects were under twelve years of age, both kidneys were concerned in nineteen instances; one only in nine — the right in five, the left in four. Of sixty-seven cases in persons over twelve years of age, both kidneys were affected in twenty-eight; the disease was limited to the right in twenty-two, to the left in seventeen. The accompanying table, compiled from the 2^ost-moi'tem books of St. George's Hospital and the Hospital for Sick Children, shows the fre- quency of renal tubercle in childhood and afterwards in persons dead from all causes. Considering liow rarely consequences attributable to re- nal tubercle are detected during life, it might not have been anticipated that this formation is to be found on an average in about a tenth of all who die — in children in nearly a sixth. Tubercle is especially a disease of early life, as the table shows; but the proclivity of the disease in this respect is more strongly displayed in regard to the brain, the abdominal structures, and the kidneys than with regard to the lungs. Renal tubercle is nearly three times more fre- quent under than over the age of twelve. Table slioiuing the frequency of tubercular formations in the kidney, and other organs, in 600 jjost-ninrtem examinations; the subjects of 300 being under the age of 13 years, the subjects of the other 300 being of the age of 12 years and iqnuards. Tubercle present in some part of the body, in Tubercle in lungs, in Tubercle in peritoneum or mesen- teric glands, or tubercular dis- ease of bowel, in Tubercle in brain or its membranes, in Tubercle in kidney, in s S^ o 126 104 97 63 49 54 51 22 9 17 o.S ^ "3 £ o O i. c e3 S|.2 = 180 155 119 72 66 Clinical History and Symptoms. Tubercular disease of the kidney during childhood affects the sexes with impartiality ; in later life it attacks the male more often than the female. Of twenty-eight hospital cases wliich occurred under the age of twelve, fourteen affected male and fourteen female subjects. Of sixty- seven cases over this age, forty-four related to males, twenty-three t@ fe- males — a proportion of nearly two to one. So far as we may trust the experience of a general hospital, at which cases of every kind and of all ages are admitted, tubercular disease of the kidney is most frequent between twenty and forty, rare after fifty. That it is common at all the epochs of cliildhood the records of the Hospital for 88 TUBERCLE. Sick Children abundantly show. It occurs in early life as part of acute tuberculosis and in association with tubercular meningitis, and tlierefore presents itself with frequency under the age of four, when these condi- tions are most common. In such circumstances, and indeed more often tiian not at every time of life, renal tuberculosis occurs merely as a small part of a scattered disease, with the incidence of which its distribution corresponds; while it may be added, that in such circumstances its presence is seldom declared by any symptoms which are recognized as. renal. Age at Death with Tuheixular Disease of the Kidney. St. George's Hospital— 70 Cases. Number fatal at Age in years. stated age. Ito'lO, 4 11 •• 20, 13 21 '• 30, 18 31 " 40, 20 41 " 50 11 51 " 60 1 61 " 70, 2 71 " 80, 1 Hospital for Sick Children — 24 Cases. Number fatal at Age in years. stated age. Under 2 years old, 3 2 years old and under 3, 4 3 ^' " "4, 3 4 " '• "0, 3 5 •• " "6 1 6 " " "7, 3 7 " " "8 8 " " "9, 3 9 " " "10 3 10 " " "11, 11 " " "12 1 The most frequent causes of renal tubercle are those of tuberculosis in general, among which inherited proclivity takes the first place. Caries of bone, as with tubercle in general, is often noted as an antecedent. Measles, so often to be recognized as incentive of tuberculosis, is occasionally followed by tubercle thus localized. This occurred in two of the cases I have referred to from the Hos})ital for Sick Children. Lastly, as giving rise to the disease primarily and chiefly localized in the kidney, blows and falls upon the lumbar region are conspicuous. Among the cases to which I have referred were three in which tlie injury was so directly followed by the symptoms of the disease that there could be no hesitation in regarding them as cause and effect. A man was knocked down by a cart and injured in the right lumbar region. This remained persistently painful. Four years afterwards the rigiit kidney was found to be exten- sively excavated, and the pelvis and ureter thickened; the lungs contained scattered tubercle but no vomicae. A man iiad a fall u])on his back, which was followed by symptoms of psoas abscess, with which he died three years afterwards. Tiie psoas abscess was found to be connected, as was expected, with disease of the spine; but, in addition, both kidneys were stuffed with softening tubercle, and the pelvis, left ureter, and I TUBERCLE. 89' bladder ulcerated. In the last case a man hurt his back, and for some time afterwards passed bloody urine. He died in three months, after an epileptiform attack, apparently uremic . Both kidneys were full of tu- bercle, miliary in the right, caseous and suppurating in the left. Miliary tubercle was also found in the lungs. Cold has been assigned as a cause of renal tuberculosis, but my cases give no instance of this association. The symptoms are those of sup}nu-ative pyelitis, usually with an ele- vated night temperature and vesical irritation. The constitutional signs of tuberculosis, chronic fever and wasting, are commonly present, while the subject is often of scrofulous appearance or antecedents. There is sometimes pain in the loins and occasionally down the ureter, though less sharp in either situation than may be produced by stone. The bladder-symptoms are possibly so urgent as to raise a suspicion of calculus: there may be much discomfort referred to the position of the bladder or to the penis, while micturition is frequent, even hourly, and sometimes difficult ; there is, however, this distinction from stone — when the bladder is empty relief is complete. The patient is usually sounded, and only a little roughening detected. Another distinction from stone is to be found in the Continuance of the purulent discharge with the urine; when from stone the discharge is apt to stop, often for months, and tlien recur; if from tubercle, the first complete stoppage is final, as it is due to the occlusion of the ureter from extension of the disease, or to the consumption of the tubercular growth. The constitutional symptoms are more tuberculous than renal, unless, as is no infrequent complication, lardaceous disease be superadded. Among ninety-five hospital cases to which I have before referred, in some of which it must be allowed that the disease had not advanced so far in the kidney as elsewhere, convulsions and coma were recorded as the direct result of renal tuberculosis only in three instances; less often than in this series of renal cases similar symptoms occurred as tlie result of the partici- pation of the brain m the disease, in the shape of tubercular meningitis. It is strange that uncomplicated tuberculosis should so seldom cause either uraemia or suppression, consklering how frequently both kidneys are involved in the disease. The symptoms are mostly those of exhaus- tion, as a result of the discharge, together possibly with the effects of the advance of tubercular disease in some other organ. The patient under- goes slow wasting, much as if the consumption were of the lung instead of the kidney — too often it is of both, as the foregoing statements sliow — has evening fever and night-sweats, and often lapses into fatal prostra- tion, with a dry tongue and a typhoid aspect. An important ]ioint in the diagnosis of renal as of other tubercle is the temperature. In the case referred to on page 810, the morning and evening records were generally 98° and 103°, frequently 97° and 103°, giving a nightly rise of from 4° to 6°. In many other instances the temperature was that proper to gen- eral or pulmonary tuberculosis. It is comparatively rare for tubercular disease of the kidney to pro- duce ])alpablo tumor, but I have met with two instances in wliich this occurred, and to a sufficiently noticeable extent. In both, the right kid- ney was the one to which the tumor belonged, and the hypochon- di-ium the place in Avliich it became evident. The outlines of the swell- ing in each case are represented in the annexed woodcuts; its renal character in each was clearly declared during life. In one case, that of a woman named Ann Evans, sixty-one years of age, the tumor was felt extending from the edge of the ribs to the level of the umbilicus: the 90 TUBERCLE. inner part was overlaid by bowel, the outer Avas immediately beneath the abdominal wall; tlie mass could be felt deep in the lumbar depression. After death the right kidney was found to be enlarged by tubercular Tuberculous kidney as felt during life; be- tween the outer and the dotted line the tumor was overlaid by bowel. Tuberculous kidney as exposed after death, showing its relation to colon and duodenum. K, Diseased kidney ; L, Liver. disease, but appeared less prominent than it had done during life. It had the ascending colon immediately in front; the duodenum was closely ,a,dherent to its inner edge, where Avas a tubercular abscess, the outer wall Tuberculous kidney, wliicli had been tapped in the belief lluit the tumor was hepatic. As felt during life. The place of the ptmcture i.-; indicated. The tumor was superficial outside the faint vertical line, very deep inside the stronger vertical line. Tuberculous kidney, as shown after death (from same case as preceding). The upper part of the tumor was uncovered by bowel. ■of which consisted of this ])ortion of the bowel. In the second instance, the morbid features were almost the same. A mass lay in the right hy- pochondrium, reaching from the edge of tbe thorax to three inches down- wards in tlie nipple line. I'lie mass, which Avas on its inner part covered TUBERCLE. 91 by bowel, could be traced under the abdominal wall, round the side, to the lumbar region. The patient came into the hospital as having an ab- scess of the liver, and a depressed cicatrix was pointed out as the place of its puncture some five years before. But though in contact with the liver, the mass was unequivocally renal. There was no depression of the liver edge, or indication of increase of size in this organ, while, on the other hand, the mass could be traced into the lumbar region and grasped in this situation between the hands. Post mortem, the right kidney was exposed to view below the liver as soon as the integuments were put aside — across the lower part lay the beginning of the colon. The duodenum, as in the preceding case, was in contact with its inner edge. The kidney, little changed in shape, though much in size, measured six inches in length, extending from the last dorsal to the last lumbar vertebra. When the kidney excavates, and the process is not cut short by dis- ease elsewhere, the symptoms are so often complicated with those of lar- daceous disease, that these may be regarded as almost necessary to the later stages of the complaint. The urine becomes pale, it displays more albumin than the pus could account for, the legs become dropsical, and the patient sinks, with vomiting and diarrhoea, or, as I have seen in more than one instance, dies with the ordinary signs of cerebral urae- mia. Among the accidents which occur in the course of the disease are ir- regular modes of exit for the matter developed within the kidney; when this is of tuberculous origin it far less often escapes otherwise than by the ureter than when dependent on stone, but it does so sometimes. Among the cases from St. George's Hospital to which I have referred, is one in which the front of a tuberculous right kidney presented a sloughy aperture which communicated with a large abscess, which lay behind the peritoneum in the lumbar region, between the kidney and the ascending colon and the duodenum. In another instance, a hole simi- larly formed in the left kidney had given rise to an abscess circumscribed by adhesions within the peritoneal cavity. A third case was a somewhat remarkable example of a psoas abscess of renal origin. A young man had a psoas abscess which discharged in the usual situation for a year, and of which he died without any suspicion that the abscess Avas not spinal. It proved to have its source in the left kidney, which was ex- tensively excavated by tuberculous disease; but strange to say, there was also found, though upon the other side, an incipient psoas abscess, con- nected, as is usual, with diseased vertebrae. This had penetrated about two inches into the muscle. The urine usually shows traces of albumin even before the tubercle has proceeded to softening. I have l)efore me records of the state of the urine in six cases in which the kidneys were found after death to contain unsoftened tubercle; in four albumin was detected; in one a little blood as well. There are as yet no other changes, but as soon as the organ be- gins to excavate, pus appears, tliough it is seldom so 'Maudable," not so sharp in microscopic outline, nor separating so cleanly from tiie super- natant urine as when pyelitis is the result of stone. Blood is observable in a minority of cases, it is seldom in large amount. In the course of thirty-nine cases from St. George's and the Hospital for Sick Children in which the state of the urine is recorded, hgematuria was noticed in nine. In three of these it was connected with much disease of the bladder, and })resumably of vesical origin. In one it was associated with marked lar- daceous disease. In the remaining cases the discharge of blood was ap- 92 TUBERCLE. parently dependent on the tuberculous condition of the kidney or its outlet. In no instance was the discharge profuse, though it was in some obstinate, especially where connected with vesical disease. As the dis- ease progresses, the urine is apt to become ammoniacal and variously putrid and offensive, to be mingled with ropy mucus, and to deposit triple phosphate, often as the results of vesical disease; but it may be al- kaline and even ammoniacal in consequence of disease limited to the kid- neys. Both may be so much damaged that only plain alkaline urine of low specific gravity is secreted, and this may become more or less decom- posed by partial retention in the pelvis, and thus be passed ammoniacal, as in a case recently under my care, even though there be no such bladder disease as to account for the alteration within this cavity. Often with the advance of the disorder the urine becomes highly albuminous, and displays hyaline casts as the consequence of the superaddition of larda- ceous change, by which the secretion of the hitherto unaffected kidney becomes modified. The occasional impoverishment of the urine, with a specific gravity as low perhaps as 1.006, is occasionally a marked result of double tuberculous disease of the kidney, even though there be no larda- ceons change, or this be only inciiMent and trifling. The time that elapses between the commencement and the close of renal tuberculosis is difficult to limit; many cases are cut short by pul- monary phthisis, and many by meningitis; taking those in which the be- ginning has been marked and the end mainly renal, it would seem that the range extends from about four months to as many years. In those instances in which the outset was marked, and apparently occasioned by a blow or fall, the duration of the disease was respectively four months, three years, and four years. A renal psoas abscess was open for a year before death; an abscess of the same origin in another case which discharged from the thigh was open also for a year; the organic disease necessarily of longer date. In three instances in which the pres- ence of the disease was declared only by the more ordinary symptoms, these were noted for periods before death of seven weeks, eight months, and four years respectively. In the case with the briefest reconl, how- ever, one kidney was reduced to a mere shell, so that the disorder had existed for a much longer time than the symptoms appear to have been observed. Instances are met with in which one kidney has been destroyed by suppuration apparently tubercular, and the disease has been limited, has become quiescent and practically harmless. Some of tliese cases, how- ever, are of doubtful nature; the absence of tubercle elsewhere, whicli is almost necessary to recovery, may raise a doubt as to whether the suppu- ration may not have been of other than tubercular origin. It is suffi- ciently obvious that destruction of a kidney by calculous pyelitis or some other form of supi)uration is a less dangerous process than when a dis- seminating growtii is the agent; but there is no reason to doubt that tu- bercular disease of the kidney, as of the lung, may sometimes be restricted and be outlived, though the frequency with which other organs partici- pate, as shown at page 85, is a discouraging fact in its natural history. The treatment of renal tuberculosis involves, first, that of the consti- tutional condition, and may be much that called for if the consumption were pulmonary instead of renal — nourishing diet, sea-air, iron, quinine, and the general anti-tuberculous regimen. The tendency of the urine to alkalinity, and, when alkaline, to putrescence, with possible results in the way of septic absorption, may be met by the use of the mineral acids> TUBERCLE. 93 quinine, and perchloride of iron. I have sometimes found distinct ad- vantage, when the urine has been offensive, from the use of creasote by the mouth, though I think that such antiseptic treatment is not so often called for as when urine is locked up in the pelvis in consequence of stone. The bladder-symjitoms, which are often pressing, and may be regarded as generally necessary to the disease, may be palliated by pa- reira, with hyoscyamus or belladonna and opium, or by these sedatives as suppositories. It is scarcely necessary to dwell upon the surgical considerations. I have known a distended and tuberculous kidney to be punctured with the aspirator with relief. With regard to the excision, it must be presumed that so dangerous an operation would not be justifiable, were not permanent cure likely to ensue upon its immediate success. It has been shown (p. 86) that both kidneys are affected by tubercular disease about as often as one alone; and further, that, given advanced renal disease of this nature, there is only about one case in seven in which the formation is not shared by other organs. These facts would appear enough to discourage, and probably to prohibit, the operation. It was performed fatally by Peters, in a case referred to in the table in Chajiter XIV. Lucas' removed a supposed tuberculous kidney with success, but as the organ was described only as containing abscess-cavities, there must remain doubt as to the nature of the disease. Baker^ removed with present success, from a child of seven, a kidney which proved to be tuberculous: six months afterwards the urine still contained pus. Dr. Goodhart' and Mr. Golding Bird record the unsuccessful excision of a scrofulous kidney from a man of the age of twenty-seven, who had a temperature which ranged from 100 to 104. The operation proved tedious and difficult, and the patient died four hours afterwards. The tubercular disease proved to be con- fined to the kidney, which had been removed, excepting that it involved the ureter and to a slight extent the bladder. Dr. Cole^ of Bath has re- corded an interesting instance in which a tubercular kidney would have been extirpated, had not the patient begun to die on the day before that fixed for the operation. It was found that the kidney not in question had been so completely destroyed by antecedent disease of the same na- ture, that the removal of the organ to which the symptoms referred would have taken away all that remained of the secreting tissue. ' Trans. International Med. Congress, vol. ii. p. 271. 2 Trans. International Med. Congress, 1881, vol. ii. p. 262. ' Clinical Transactions, vol. xv. p. 139. *Brit. Med. Journ. Aug. 5th, 1882. CHAPTER IX. HYDRONEPHROSIS AND PYONEPHROSIS. Whek the cavity of the kidney is extended by aqueous fluid, the con- dition is described as hydronephrosis; when by purulent fluid, as pyone- phrosis. Hydronephrosis, hydrops renum, or dropsy of the kidney, is a condition to which much practical interest attaches, since it is apt to present itself as an abdominal cyst of which the nature may be mistaken, and with regard to which questions of operation may present themselves, whether it be recognized as renal, or regarded as ovarian, or as ascites. Hydronephrosis may be congenital or acquired, of either kidney or of both, constant, variable, or intermittent. It is difficult to draw a line which shall always hold good between hydronephrosis and dilatation, for hydronephrosis is only extreme dila- tation. For the most part hydronephrosis affects one kidney only, and arises in obstruction of the ureter; the accumulation is now cut off more or less completely from the vesical cavity, is not relieved by the empty- ing of it, and consists not so much of urine as of an aqueous fluid which bears only a remote resemblance to it. The distention is here persistent as well as extreme, and the distinctions between this condition and the more passing kinds of dilatation are sufficiently marked. They hold good no less when both kidneys are affected, as they sometimes are, from similar or accidentally concurrent stop])ages of both ureters. But the name is also applied to extreme dilatation of the urinary cavities from obstructions in the urethra or bladder, in which the distending fluid is urine not at all or but little altered; in such circumstances it may be a somewhat arbitrary matter to decide whether hydronephrosis or dilatation shall be the term employed. The following account of hydro- and pyonephrosis is based in part upon an analysis of sixty-nine cases completed hy pof^t-morfcm examina- tion, which I have brought together from various publications, the de- scriptions of preparations which I have had opportunitions of examining in several museums, and my own practice. 1 may say that twenty-two of the whole number are derived from the records of St. George's and the Hospital for Sick Children, and are for the most part unpublished. In collating i)ublished cases I have been greatly indebted to the paper ol Mr. Henry Morris, in the fifty-ninth volume of the " Medico- Chirurgi- cal Transactions." My records contain forty-three cases of single, six- teen of double, hydronephrosis, and ten of i)yonephrosis. This may rep- resent the relative frequency of these conditions. It is not practicable to separate the consideration of pyonephrosis from that of hydronephrosis HYDRONEPHROSIS AND PYONEPHROSIS. 95 flince the two conditions are usually but different phases of the same disease. Hydronephrosis is distributed between the sexes, like most renal dis- eases, with a slight preponderance towards the male side. Of sixty-one cases of hydro- and pyonephrosis, certified hj posf-mo7'tem examination, of which I have records to the point, thirty-two belonged to the male and twenty-nine to the female sex. This is of interest in relation to the origin of the renal in uterine dis- ease, which would seem not frequent enough, in comparison with other causes, to give preponderance to the female sex. With regard to age, none is exempt. Of 51 of the above-mentioned cases, in which the age is stated, death occurred at birth, or within a few liours of it, in 3; during the first year of life in 5; between the ages of 1 and 10 in 10; between 11 and 20 in 5; between 21 and 30 in 6; between 31 and 40 in 8; between 41 and 50 in 9; between 51 and 60 in 2; between ■U and 70 in 1; between 71 and 80 in 2. Thus death from this cause is especially frequent during the first ten years of life, as the result of congenital lesions; as an acquired disease, largely due to stone, it pro- duces its fatal issue with increasing frequency up to 50, beyond which age it is seldom delayed. Of the cases in which hydro- or pyonephrosis affected one kidney only, the side is stated in 45; 25 left, 20 right. It is probable that this difference is accidental; I do not find that stone, apart from hydroneph- rosis, exhibits any decided preference for one side. For the causes of hydro- and pyonephosis I might refer to the chapter on Diseases of the Ureter as comprising their greater number; but as all could not be here included it is needful to take them into separate consideration. For the production of the great dilatation to wiiich these names are given it is generally needful that the exit of the ex])anding cavity or cavities should be obstructed, but not completely and finally. Cases are known to occur, like one recorded by Eayer (vol. iii. p. 488), in which the ureter Avas from the first impervious and incom- l)lete, but as a rule such absolute and permanent stoppages are attended with atrophy of the kidney, its extensive dilatation commonly being due to an obstruction which is either incomplete or intermitting. It is certain that a larger number of cases of hydro- and pyonephro- sis are due to stone than to any other cause; as compared with this all other causes are, separately, of slight frequency, though they appear numerous when taken together. Many of the causes which have been assigned to the disease — obliquities, twists, and valvular openings of the ureter, may, with as much jirobability, be placed among its cou- ■iquences. In the collection of cases to which I nave referred, comprising sixty- nine /jo.s^-wior^e?^ examinations of hydro- and pyonephrosis, the causes of Mie dilatation, or in other words the nature of the obstruction, is thus Lated: — •96 HYDRONEPHROSIS AND PYONEPHROSIS. Causes of Single Hydro- and Pyonephrosis. Hydro- neph- rosis 43 cases Pyo- neph- rosis 10 cases Total of both 53 cases Calculus in aflfected kidney ov ureter 11 2 1 G 17 Calculus in unaffected kidney, cause of obstixiction not further ascertained, presumably a stricture left by a stone. Villous growth from pelvis of kidney 2 1 Congenital impei'viousness of ureter 1 1 .. 1 1 . - 1 Compression of ureter by swollen lymphatic gland 1 " •' cancer of pancreas " " band of peritoneal adhesion " " abnormal branch of renal artery. . . Stricture of ureter the result of a kick 1 1 1 i 1 5 1 6 1 9 •• 'i 1 *2 1 1 1 1 Ureter degenerated into solid cord 1 " of small calibre 1 Sudden bend in ureter 1 Valvular structure or arrangement, or obliquity of position, in connection with renal origin of ureter Valvular structure in connection with vesical exit of ureter.. Stricture of ureter of unexplained nature 5 1 6 Villous tumor of bladder affecting orifices of ureters Cause not satisfactorily ascertained 1 11 43 10 53 Causes of Double Hydronex)hrosis — 16 cases. Calculi in both kidneys , . . . . Calculus in one kidney or ureter, stricture in other ureter, possibly of calculous origin, .... Corkscrew twist in both ureter, Abnormal arrangement of renal artery compressing one ureter congenital narrowing of the other, Stone in bladder, ..... Stricture at neck of bladder, .... Congenital stricture or imperfection of urethra. Stricture of urethra, not congenital, . Congenital obstruction aj^pai-ently in urethra, but not clearly ascertained, ...... Diabetes insipidus, ..... Cause not ascertained, ..... 2 1 1 2 1 2 1 3 1 1 16 It is at once seen that the causes of the single and of the double affec- tions are for the most part different. The dilatation when one-sided is invariably due to obstruction of the ureter or its orifices; when bilateral it is in some cases due to simultaneous obstruction of both ureters, but more often to hindrance in the exits common to both kidneys, the blad- der and urethra. Taking one-sided dilatation first, it is seen that of 42 cases in which the nature of the obstruction was ascertained this was clearly due in 17 cases to stone in the kidney or ureter, while in 2 others calculus in the unaffected kidney suggested the probability that there had once been a stoppage of the same nature on the side which was the scat of the ob- struction. A small stone may lodge for a time in the ureter, and then pass out, leaving an abrasion, which will eventuate in a cicatrix and a stricture. It is possible that some of the cases in which only an unex- HYDRONEPHROSIS AND PYONEPHROSIS. 97 plained stricture of the ureter has been found may have had such an origin. Causes of compression of tiie ureter external to itself, tumors, enlarged glands, and bands of adhesion find place, but it is to be noted that disease of the uterine organs is not frequent in this relation. Cancer of the uterus is apt to involve both ureters rather than one only, and then appears seldom to cause the larger degrees of dilatation which are now under discussion. Suppression of urine would seem to be a more common result of such lesions than hydronephrosis. The tra- versing of tlie upper part of the ureter by an abnormal branch of the ■onal artery is generally accepted as a cause, however infrequent, of its obstruction. It might have been supposed that the relaxation of the artery during diastole would have afforded sufficient exit. Another class of causes is still more problematical. A comparatively large number of cases are attributed to obliquities, sudden bends, and valvular arrangements of the ureter at its origin. It is obvious that if the pelvis be dilated more on one side of the origin of the ureter than the other (and such irregularity often happens) the origin of that tube may be subjected to lateral compression or made to slant, so that the meni- brane on one side may overhang and perhaps occlude the orifice; but it may be suggested that in many or most of these cases the distortion of the orifice is in the first place the result of dilatation of the pelvis, though it may be a means of increasing it. Great extension of the pelvis must necessarily change the position and relations of its duct. In the case, for example, of congenital hydronephrosis 'reported l)y :\Ir. Glass (" Phil. Trans.," 1746), where the cyst held thirty gallons, the ureter, which was not otherwise obstructed, was abruptly bent and opened obliquely into it. It is clear that much displacement of the ureter was inevitable as a result of the distention; we are left in doubt as to its original cause, save that it was not a permanent and complete organic stricture. One case is referred to from St. George's Hospital, in which the obstruction, which was of intra-uterine origin, was a loose fold of mucous membrane in the ureter within the vesical wall; this presents itself as a first cause with more probability than the valvular arrange- ments which are so often found at the junction of the ureter and the dis- tended pelvis. Much dilatation has been known, as in a case reported by Mr. Morris,* to follow upon vesical growths involving the orifices of one or both ureters. In Mr. Morris's case there were growths in connection with both orifices; one kidney was dilated, the other atrophied. Lastly, injuries of the ureter by violence from without — in one case by a kick from a horse,' in another by a fall at leap-frog — were followed by obstruction and ac- cumulation, whether of aqueous or purulent matter. Double hydronephrosis depended upon obstructions in or about the bladder or urethra in a proportion of nine instances out of fifteen, in which the seat of the difficulty was approximately ascertained. In the majority of these cases the obstruction was congenital and involved the urethra. An instance has been recorded in which the obstruction was apparently a membranous obstruction at the vesical end of the urethra. This was broken down with a sound, after which urine was passed freely, and the swelling disappeared. The child, three days old at the time of the operation, had passed no urine since birth. ^ > Med. Chir. Trans, vol. lix. p. 233. * See chapter on Diseases of tlie Ureter. * Lamotte, quoted by Morris, Aled. Chir. Trans, vol. ix. 7 98 HYDRONEPHROSIS AND PYONEPHROSIS. A peculiar obstruction has been described by Dr. Hare as tlie cause of double hydroncplirosis, which, like many of the hiterai and valvuUir ori- fices so common witli tlie uuilateral condition, may not improbably be its result. Each ureter was coiled, at a little distance from its origin, " like a turn and a half of a corkscrew brought closely together," the coils being adherent to the dilated pelvis, and held together by the tissues around, upon the detachment of which by dissection the channel gave ready exit to the accumulation above, which before could not pass, even when the kidney was subjected to i)ressure. It is to be suggested that the coiled condition may have resulted from some process in the course of disease, whereby the extremities of each ureter have been unnaturally a[)proxi- mated; each duct would thus have a su[)erfluity of length which must be disposed of in curves of coils, or otherwise than as a straight line. Hypo- thetically, the ureters might be rendered longer than their course by de- l^ression of their orifices, such as might arise from enlargement of the l)elves, by elevation of their exits from distention or displacement of the bladder, or by elongation of the ureters themselves as the consequence of dilatation. The conditions, whatever they were, which preceded the twists were in the end obscured by their results; these circumvolutions, like the bends and valvular entrances so often described, though probably not the originators of the distention, were at least causes of its increase. One case of double hydronephrosis is ascribed to pressure upon one ureter by an abnoryial branch of the renal artery, while the duct on the other side was congenitally narrowed. Diabetes insipidus, by means probably of the profuse secretion of urine which it entails, causes extreme dilata- tion of both kidneys, which may be called hydronephrosis, if dilatation due to Urethral or vesical obstruction be so termed. When hydronephrosis arises before birth, the swelling may be enough to cause difficult labor. The child may be stillborn or perish in early infancy, or the cause may, particularly if one kidney only be affected, operate gradually and declare itself only in advanced life. Disease of the uterus or ovaries is a frequent cause of the lesser de- grees of hydronephrosis, which are usually described as dilatation. Dr. Koberts, in collating the causes of fifty-two cases of hydrone|)hrosis, as- signs six to encroachment upon the ureters of the disease of the uterus, ovaries, or pelvic organs. Cancer of the uterus, starting equidistant from both ureters, is apt to involve both, if either, and seldom gives rise to enough swelling to cause a tumor palpable during life. Mr. Morris ob- serves that at the Middlesex Hospital, where the cancer wards sui)ply a large number of cases of cancer of the pelvic organs, and where scarcely a week passes without the presentation in the dead-house of some degree of hydronephrosis from this cause, yet that none of the present surgeons remember to have detected an abdominal swelling of this nature during life. The comparative rapidity of malignant disease, and the fact that both sides are so often involved, does not give the opportunity for ex- treme expansion which is found with more chronic conditions, and where one kidney is left to perform the function of both. Displacements, also, of the uterus may cause obstruction of the ureters and accumulation in the kidneys, though perhaps not enough to give rise to tumors tangible clinically. Retroflexion of the uterus has been shown to bend and so ob- struct the ureters as they pass by its side, and prolapse to displace the bladder and compress the ureteral exits. The obstruction which gives rise to hydronephrosis is, as already stated, usually incomplete. Instances are known in which the pelvis of HYDRONEPHROSIS AND PYONEPHROSIS. 99 the kidney has heen without exit from the first, and the child born with hydronephrotic distention, as in a case quoted by Rayer, from Billard ; but more often in such circumstances the kidney is simply atrophied. Occasionally in older subjects great dilatation has been found to be due to a stone, which after death at least appears completely to block the in- fundibulum; but such obstacles have necessarily been of slow formation and the stopj^age long imperfect. As regards the course of the ureter, a . -^^^^.^I'^n of a kidney dilated in consequence of the impaction of calculi. The expansion of the intunilibulnm and calyces, the latter of which open like diverticula into the pelvis, is well shown . ine calculi, which were of uric acid, have not been preserved. . (From a preparation at the Loudon rlospitai.) perhaps narrow, but not impervious, stricture in connection witli stone is a more common cause of hydronephrosis than the impassable lodgment of stone itself. The rule is, that if the adult kidney become suddenly and completely occluded, the consequent dilatation is not excessive. Wlien the ureter is stopped two processes ensue — dilatation and atrophy, when the stoppage is incomplete the former predominates, when complete 100 HYDRONEPHROSIS AND PYONEPHROSIS. the latter. The urine is secreted with so little force that the point of accumulation is soon reached which i^uts an end to it. The ghmd will now secrete only as much as is removed by absorption and leakage. The absorption is insignificant; if there be no leakage the secretion will be A kidney which lias become converted into a dehcate transhicent cyst, nothing apparently re- maining but the cai)sule, tlie pelvic lining, and some septa, which indicate the original structure of the organ. The ureter liangs down similarly stretched and attenuated. The kidney is but little enlarged externally, however extended within. There is no record of the nature of the obstruc- tion—it may have been stone. (From a preparation at the Middlesex Hospital.) virtually at an end, and the organ become effete from disuse ; if there be leakage the secretion will go on pari passu, the activity of the gland HYDRONEPHROSIS AND PYONEPHROSIS. 101 be maintained, and with it a slight but constant pressure upon the cavity. Reviewing the causes of hydronephrosis — meaning by this dila- tation enough to be palable during life — it is clear that the majority in- volve only partial or intermitting stoppyge: stricture rather tlian oblitera- tion, injuries caused by stones more often than their impassable fixture, valvular entrances and exits, obliquities, twists, and external pressure, whether by arteries or growths. Given the required obstruction — necessarily incomplete, should both sides be involved, as deatli by suppression would prevent any chronic changes — and a sufficiency of secreting tissue, distention, and dilatation of the pelvis may ensue which, according to its contents, is hydro- or pyonephrosis. Pyonephrosis is hydronephrosis ^j/?^? pyelitis. The mam- millary processes are replaced by depressions, and the cones by excavations, which increase until they are separated from each other only by plates of condensed fibrous tissue, while the contact of the [)elvic membrane with the capsule is prevented possibly only by remnants of renal tissue,, scarcely recognizable except with the microscope. As the swelling in- creases it loses more and more of its renal character, retaining, however,, in most cases something of the renal outline, and still having abbreviated partitions, or radial folds on its inner surface. The organ in extreme cases will expand into a thin ovoid cyst, wliichy as far as regards the outside, is to be recognized as renal only by its re- lations to the ureter and. the colon, which latter is usually inseparable- from its surface. If the inside of such a cyst be examined, it is possible that all septa, may have disappeared, but a record of the renal structure be still preserved in a peculiar delineation, for it may be little more, which marks the places where the mamillary processes pierced the pelvic membrane. The lining of the cyst may present an arrangement of round holes, which look as if they had been punched, through whicli protrude thin laminae, which are the attenuated and extended cones. The effect is that of a "slashed doublet," the lining showing through the cuts. The dimensions of such a cyst may be great, or even gigantic. In a boy of eight at the Hospital for Sick Children, the longer and shorter diameter of an ovoid cyst of this nature were nine and eight inches, and its contents eighty-three ounces. This, though large for so small a sub- ject, is enormously exceeded in the adult. I have elsewhere (p. 55) referred to a largely dilateil kidney, which had given lodgment to an accumulation of colloid materia,l: the kidney, which still retained its shape, measured eleven inches by six, and far larger examples could be cited, the only limit being the ca[)acity of the trunk. The largest instance on record is probably one which I havft already referred to, and whicli has been quoted by Dr. Roberts, from the report of Mr. Glass in the " PIiiloso])hical Transactions" for 1747. A woman, who had been dropsical from birth, died at the age of twenty-two; her belly then had the circumference of six feet four inches, and measured four feet and half an inch from the ensiform cartilage to the pubes. The swelling was produced by a cyst, which represented the right kiddey, and held thirty gallons all but a pint of liquid, limpid as urine, but lightly tinged of a coffee color. The ure- ter opened into this cyst without recognized obstruction. The distention of hydronephrosis is usually general to the pelvis, but instances occur in which it is limited to a portion of its wall, and others in which a cyst from the outside has become connected with the renal cavity. As an instance of partial or local dilatation, there is a prepara- tion at St. George's Hospital which exhibits a great expansion, limited to 102 HYDRONEPHROSIS AND PYONEPHROSIS. the top of the ureter and its funnel-shaped entrance, the pelvis itself being elsewhere but little affected. This superadded cavity, which may have held half a pint, stretches inward from the kidney, and must have ex- tended during life across the vertebral column. The contents of the cavities whicli have been described are watery or purulent, as their names imply. AVithin the term hydronephrosis there is a considerable variety. If the dilatation, as often in double hydro- nephrosis, be common to all the urinary cavities, their contents will be urine, little changed, save that the specific gravity may be low, as with urine secreted against pressure, and it may have become ammoniacal. Ill Dr. Little's case, where botli kidneys were distended from a congeni- tal obstruction below the bladder, tlie fluid withdrawn by tapping had a urinous smell, and contained urea and uric acid, but had a specific grav- ity of only 1.004. It is sufficiently obvious that, when hydronephrosis depends upon stoppage below the bladder, as in most cases of congenital origin, the collected fluid is necessarily urinous, since it contains the "whole renal secretion. When the dilatation is of one kidney only, the destruction or metamorphosis of the organ may be carried further than is consistent witli life where both are involved; but even in the most ex- treme of these cases, if the cyst be actually a dilatation of the kidney, the fluid gives evidence of urinary constituents, unless much clianged by de- composition, or replaced by suppuration or colloid. Tiie fluid found in unilateral dilatation is usually clear, either aqueous or albuminous, uri- nous in appearance and smell, and giving evidence of urea and uric acid to chemical tests. It has sometimes been dark in color, probably from blood; the liquid in Mr. Glass's case was limpid as urine, but of a coffee color. In otiier cases, it has been ammoniacal and offensive. In Dr. Hillicr's case, the fluid withdrawn from the cyst during life was foe- tid, highly albuminous, and contained urea; that removed after death was clear, pale, urinous in smell; it contained a mere trace of albumin, and had a specific gravity of 1.002.' Mr. Cooper Rose has described a case of liydronepiirosis which was tapped, witii tlie result of a permanent fistula and tlie habitual issue^ of a foetid discharge, in which none of the ele- ments of urine could be detected. In ]\Ir. Caesar Hawkins's case, else- wiiere referred to (p. 119), where tlie cyst was virtually external to the kidney, however closely connected with it, the absence of special urinary constituents Avas ascertained by Dr. Prout; and it may, perliaps, gener- ally be inferred that, if aqueous or simply serous fluid, not obviously pu- trid, be found to be free from urea, it is not from a hydronephrosis. If the cavity be altered by suppuration, the contents may be either such as Hiave been described, more or less mingled with pus, or may be sim[)ly purulent, the pus possibly not differing appreciably from pus formed in other situation. A truly hydronephrotic cavity may become filled with a gelatinous material, having all the cliaracters of colloid cancer, as in the case already referred to, and in another of the same kind which has since been ])ublislied by Damreicher. Cholesterin has been found in tiie fluid of hydronephrosis.^ The symptoms of hydronephrosis, when it is congenital and double, are — to place them in the order in which they present themselves — possi- bly difficult labor, abdominal tumor, absence of urine, and death, unless ' Med.-Chir. Trans, vols, xviii. and lii. ■' Ibid. vol. li. « Dr. Coghill, Edm. Med. Journ. Feb., 1875, p. 747. HYDRONEPHROSIS AND PYONEPHROSIS. 103 the urethra can be made pervious within perhaps two days of birth. If the obstruction be incomplete, in which case it may long escape notice, the disease may not cause death until much later. Instances have been published by Broadbent, Faber, and Little, in which distention of both kidneys with their ducts, of congenital origin, proved fatal at the ages respectively of three months, 5| and 6^ years. The case fatal at the age of 5| was so suddenly, after a fall; with that of 6|, death was preceded by convulsions and coma. The chief symptom in all was abdominal swelling; one which was subsequently tapped was at first thought to be ascites. When hydronephrosis presents itself later, its course is ruled by that of the disease upon which it is dependent; if unremoved or irremovable stone in the bladder, it is early fatal; if on diabetes insipidus, it but lit- tle interferes with life. When double hydronephrosis ensues as a result of calculi in both kidneys, as in a case reported by Rayer, or of obstruc- tion in both ureters, as is not uncommon, death may occur by uraemia, with or without total suppression of urine. In a case published by Dr. Roberts, in which one ureter was compressed by a branch of the renal artery, the other narrowed by an old stricture, death was ])receded by sixty hours of suppression. It is not necessary to describe the swellings of double hydronephrosis, save as cysts in the renal positions and with renal characters which have been sufficiently dwelt upon in the general consideration of renal tumors. Double tumors seldom attain the dimen- sions of single dilatation; they are often of unequal size; one often evi- dent during life, the other not so. In one of Rayer's cases the right kid- ney formed a sac eigl)t inches by five, the lefc a small membranous sao not discoverable until after death. In others, particularly where the ob- struction has been m the urethra, both have been voluminous. Tlie more or less persistent swellings of double, as of single liydronephrosis (ex- cluding, that is to say, distentions like those of diabetes insipidus, which are habitually relieved with micturition), so frequently intermit, either spontaneously or under pressure or friction, as to be importantly charac- terized by their thus becoming relieved by urinary discliarge. Out of the sixty-nine cases of hydro- and pyonephrosis, upon which this account is chiefly based, subsidence of the tumor occurred spontaneously in twelve cases, under friction in two. In one of the instances the discharge was by the rectum, in the rest ascertainably or presumably by the urinary chan- nels. This occurrence is more frequent with hydro- than with ])yoneph- rosis; in the cases of the latter, it took place but once. It is relatively more frequent with double than with single hydronephrosis; among the sixteen cases of double hydronephrosis this phenomenon presented itself either once or repeatedly in six patients; among the forty-three of single hydronephrosis, it occurred in seven. This habit of renal accumulation, to which especial attention has been drawn by Mr. Morris in the paper already referred to, is obviously to be associated with the incompleteness of the stoppage which usually give rise to the disorder. To revert to double hydronephrosis, the general symptoms, apart from the swellings, are various; and, excepting the forms of uraemia and constipation from pressure on the descending colon, may be called acci- dental. Febrile disturbances, or signs of prostration described as febrile, have been noted in some cases; in others the more definite results of •urEemia, vomiting, convulsion, and coma. Pain in the back and other immediate signs of urinary disturbance sometimes present themselves, and also thirst and frequency of micturition, as the results of the state 10-i HYDRONEPHROSIS AND PYONEPHROSIS. of renal secretion whicli belongs to the dilated condition of the glands. The urine wlien it finds exit is usually pale, copious, of low specific gravity, and often with a trace of albumin. It has been found to contain blood and epithelium of pelvic characters. It is liable to occasional sup- pression and sudden, often large, increase from the overcoming of a ureteral obstruction. It is not necessary to refer to the urine of single hydronephrosis, which, except at the times of intermittent discharge should these occur, is solely supplied by the undilated kidney, and is healthy if this be so. It may be albuminous, bloody, or purulent, as the result of disease in the practically solitary organ. When hydronephrosis is limited to one kidney, the cystic transforma- tion of the organ and consequent abdominal swelling may be greater, as already stated, than is consistent with life where both are involved. The greatest on record is Mr, Glass's, already referred to, where the abdomen measured six feet four inches in circumference, the cyst held thirty gallons, the heart was pushed up to the clavicle, and the lungs reduced by compression to the size of those of a new-born child. The patient was described as a tall, well-proportioned woman. Slie died at the age of twenty-two. Smaller, but still considerable, degrees of abdominal swell- ing from single hydronephrosis are matters of familiar experience ; and in many cases have involved botli sides of the abdomen. I estimate that, in about one-fourth of the cases of single hydronephrosis, the swelling, as observed during life, has ceased to be limited to the lateral half of the body, while, in perhaps a tliird of these, it has come to occupy the greater part of the belly. Wiien the cyst has transgressed the limits character- istic of renal tumors, tiie dilatation has become great, tlie walls attenu- ated, and the fluidity of the contents obvious. In tiiese circumstances it has been mistaken for ascites, and often for ovarian dropsy. In Dr. Hillier's ' case at the Hospital for Sick Children, tlie swelling was at first thought to be of this nature, so large, so symmetrical was it, and so superficially did it fluctuate ; its nature was first suggested by the char- acter of the fluid withdrawn, which, though albuminous, was urinous in smell, and contained urea und uric acid. The ovarian error is more fre- quent and more important. I have before me records of seventeen cases of single hydronephrosis in females: in eight of these the tumor was thought to be ovarian, in five ovariotomy was jn-oposed, and in four attempted.^ To refer to pyonephrosis in this connection, though somewliat out of order, this error of diagnosis is somewhat less frequent: with five female subjects it occurred but twice.^ Wlien once such a mistake is recognized as one to be guarded against, it should cease to be possible. The de- pression of the uterus witli the renal cyst, as compared with its elevation with the ovarian, should suggest farther inquiry, part of wiiich should be by puncture and examination of the fluid for urinary constituents. A renal indication second to none in reliability, but not always present, is the abrupt variation of the tumor in size witii or without noticeable dis- charge with the urine. But I need not recapitulate the distinctions elsewhere stated between renal and ovarian tumors. Another error of diagnosis has occurred in the mistaking of a right hydroueplirosis for ' Med.-Chir. Trans, vols, xlviii. and lii. " I need make no individual reference to these, as most of them are referred to in Mr. Morris's jiaper, my obligations to which I have already acknowledged. Sea Med.-Chir. Trans, vol. lix. 3 Cooper Rose, Med.-Chir. Trans, vol. li. p. 167. HYDRONEPHROSIS AND PYONEPHROSIS. 105 hydatid of the liver, and the tumor in this belief ' been repeatedly tapped and injected with idione. The distinctions between hepatic and renal tumors have likewise found mention elsewhere. One of tlie most important cliaracters of renal dilatation, whether hydro- or i)yonephrotic, is intermission by discharge into the urine, whether spontaneously or nnder pressure or friction. It has been already shown that these expansions usually result from incomplete closure ; the consequence is, that when a certain degree of fulness and of tension is attained, or a valvular obstruction is so stretched as no longer to act, there is an escape, partial or complete, of the accumulation. The addi- tion to the urine in these circumstances may attract notice, as im[)arting to it some unusual character; but more often a simple increase is ob- served, or the urinary change wholly eludes observation. The inter- mitting habit of these tumors has already been noticed in connection with double hydronephrosis. The accumulation of hydronephrosis when on the left side has been known, like accumulations of pus, to enter the descending colon, and tlius escape by the rectum.* Slightly to sketch the remaining symptoms of single hydronephrosis, it is first to be noted that, so long as the other kidney be healthy, there may be none apart from tlie tumefaction, and this may not be such as to attract notice. There is at St. Gl-eorge's Hospital a kidney dilated, as the result of stone, into a cyst, which must have held nearly a gallon, and reached from the pelvis to the diaphragm. This was taken from tlie body of an aged clergyman, of whom it was said that he had never had a day's illness, nor any symptom to draw attention to the tumor, until two or three days before his death. He had been a great walker, and was well known in his neighborhood by a peculiarity of gait, as if from spinal curvature. Tlie symptoms which in other cases have presented themselves have been occasionally, but rarely, pain in the lumbar region and retraction of the testicle as if from stone, though no stone was present. Tlie more serious results of uraemia do not occur so long as the other kidney is healthy, though repeated vomiting, whether arising in this or otherwise, has been known, as also has an urinous smell from the skin, the result of absorption from the cyst and cutaneous excretion. Hydronephrosis may cause death by discharge through the bowel, as in a case already re- ferred to, or by rupture in the peritoneum, with consequent peritonitis and collapse,^ But the greatest dangers which hydronephrosis entails are in the surgical procedures which it suggests, chiefly by its deceptive resemblance to ovarian disease. In the collection of cases I liave referred to are four in which death was caused by attempted ovariotomy ; four in which it followed upon tapping, which, in two instances, was performed in the belief that the cyst was ovarian. If hydronephrosis of one kidney be accompanied with disease of the other,* as in an instance in which the dilatation on one side, the result of calculus, was conjoined with obstruction by calculus of the opposite ureter, fatal suppression of urine may ensue; but that tlie disease is not one of rapid or large mortality is evident from the fact that about one- third of the patients that present themselves die of causes unconnected • Dr. Fai-re, Lancet, 1861, vol. ii. p. 472. ' Gintrac, Sydenham Societies Retrospect, 1867 and 1868, p. 175. ^ Mr. J. Thompson, Path. Trans, vol. xiii. p. 128. ■• Rayer, vol. iii. p. 490. lOG HYDKONEPHROSIS AND PYONEPHROSIS. with it. The annexed abstract ^ives the causes of death in twenty-eight cases in which they were explicitly stated. Causes of Death in twenty-eight cases of Single Hydronephrosis. Imperforate anus, 1 Suppression of urine, ......... 1 Ura?mia, 1 Yoniitinj;, ........... 1 Diarrhoea, 1 Wasting, 1 Dyspnoja, etc., from pressure of cj'st, ...... 1 Peritonitis from perforation of cyst, 1 Discharge of cyst into rectum, ....... 1 Attempted ovariotomy, ......... 4 Results of tapping, 4 Suppuration in kidney after operation in bladder, ... 1 Accidental injurj' unconnected with renal state, ... 3 Disease unconnected with renal state, ...... 7 28 The range of duration of single hydronephrosis is, as must have been already inferred, nearly as wide as that of human life. Of eight cases in whieh the disorder was apparently congenital, death occurred at birth in one; during the first year in four; in one at the age of eight; in one at twenty-two; in one at thirty-two. Of twelve cases in which the disorder was acquired subsequent to birth, the time between the first recorded symptom and death, often an obviously insufficient expression of the duration of the disease, was in one case "a few days; " in two a year; in four between one year and four years; in two between four years and ten; in one ''many" years; in one thirty-two years; in one forty-two years. Pyonephrosis is dilatation plus inflammation of the pelvis; hydrone- phrosis, dilatation without inflammation. The dilatation may come first, and the inflammation afterwards, as in the ordinary occurrence of a hydronephrotic cavity becoming the seat of suppuration, either as the result of tapi)ing or spontaneously, in which case hydronephrosis and pyonephrosis are but the earlier and later stages of tlie same disease. Or the inflammation may precede or accompany the dilatation, as when a stone sets up pyelitis, and subsequently, or at the same time, obstructs the exit. In this case we have pyonephrosis ab initio, independently of hydronephrosis. The symptoms of pyonephrosis are more urgent, its course more rapid, and death more often its direct result, than is the case with hydrone- i:)hrosis. It is due in a larger proportion of cases to calculus (see p. 96), a loose body within the urinary cavity being suited to cause irritation as well as obstruction. With pyonephrosis the symptoms of suppuration, whether with the discharge of pus or of its retention, are superadded to tiiose of iiydro- nephrosis. Lardaceous disease is common as a result of the chronic dis- cbarge, while in other cases the patients have become hectic and sunk without this adjunct. In other instances there have been rigors, ^vith the intermittent fever of septic or purulent absorption, not, however, going so far as the establishment of pyaemia or secondary abscesses. The suppurative process sometimes extends beyond tlie kidney and penetrates the bowel, usually the descending colon, the affected kidney being the left; and it has been known to extend backwards and cause erosion of HYDRONEPHROSIS AND PYONEPHROSIS. 107 the spine, as in an instance within my own experience, where a large col- lection of pus in connection with a calculus was in contact with the de- nuded transverse processes of the second and third lumbar vertebrae. No paraplegic symptoms were noted, but it was obvious that, with a little further extension the cord would have been involved. Further particu- lars as to the extension of suppuration of renal origin will be found in the chapter on *' Perinephritis." In treating hydronephrosis it is necessary to bear in mind its slow pro- gress and small mortality. Produced, as the secretion is, with less force than that of ovarian cysts, it is more easily arrested by the pressure it naturally encounters; the tendency to increase is smaller, and the need for interference less imperative. The spontaneous occurrence of discharge by the ureter so frequently noted, and the almost invariable fact that with hydronephrosis this channel is only imperfectly closed, afford much en- couragement to the use of friction and pressure. As long ago as the year 1837,' it was put on record that a tumor in the abdomen of an infant, afterwards found to have been formed chiefly by a great dilatation of the ureter, altered in size when rubbed, the bladder at the same time swelling under the hand. Dr. Broadbent* related at the Pathological Society the case of a large double hydronephrosis of congenital origin which completely subsided, with profuse discharge of urine, under friction with the ointment of iodide of potassium, and judiciously infers that the result was due rather to the friction than the ointment. Dr. Eoberts completely emptied a unilateral cyst of this nature in a child by diligent manipulation every •other morning with a lubricating ointment; and it is an obvious sug- gestion that re-accumulation might be prevented by a suitable pad secured by a bandage or truss. When the cyst has become so large, as in Mr. Glass's case, as to encroach upon the organs of respiration, or otherwise cause dangerous pressure, or, as in one recorded by Mr. Thompson, to be painful when distended, it may be necessary to draw off the fluid. Most •of the cases in which this has been done have been anterior to the aspi- rator, and the results less satisfactory than would probably now be the case. I have before me the particulars of fourteen cases in which a renal •cyst, holding an aqueous or purulent fluid, was tapped once or repeatedly: in six a fatal result was immediately due to this operation, in four by way ■of escape and peritonitis; in one case death occurred only after fifteen years' discharge through a fistulous opening tlius established; in seven, the operation was unattended with injurious results. Tapping Avas exe- cuted often on a false hypothesis: in one instance, as Avas suj)posed, for ascites; in one for hydatid of the liver; in four for ovarian disease. I presume, however, that, when the organic site of the disease is clear, the ureter closed, and the accumulation purulent, it would be riglit to relieve it from the loin, notwithstanding the results which have attended abdo- minal tapping. The proper course would probably be to aspirate from behind, post-peri toneally, after having found the matter by tentative puncture with a capillary tube. Dr. Coghill ta]>ped^ a hydronephrotic cyst from the loin behind the peritoneum, with the discharge of over four pints of aqueous fluid. The patient, as I learn from Dr. Coghill, ' Mr. Thurnam, Land. Med. Oaz. vol. xx. (1837) p. 717. Quoted by Mr Morris Med.-Chir. Trans, vol. lix. ' « Path. Trans, vol. xvi. p. 164. ^ Edin. Med. Journ. Feb., 1875, p. 747. 108 HYDRONEPHROSIS AND PYONEPHROSIS. was apparently cured by the operation, for she is now (1882) alive and well. The question next arises as to excision of the cyst, whether hydro- or pyonephrotic. This has been performed in a considerable number of cases, some of which were known to be renal, many supposed to be ovarian. We are indebted to Mr. Harker ' for valuable tabular statements, which represent the published experience on tliis subject up to March, 1881. Mr. Barker has collected fourteen instances in which renal cysts or dilatations have been removed: eiglit by abdominal section, with five deaths, and three recoveries; six from the loin, with four deaths and two recoveries.* In five of the cases of abdominal section the tumor was thought to be ovarian; three cases were operated on know- ingly as hydronephrosis, all by abdominal section, with one death; three were operated on knowingly as pyonephrosis, all by lumbar section, with two deaths. Thus it would appear, so far, that the mortality attending the removal of diagnosed renal cysts is fifty per cent. The condition found in the fourteen cases referred to was described as hydronephrosis in three, with one of which sarcoma Avas conjoined; as pyonephrosis in two. There were seven in which dilatation and sacculation were found, but which cannot be definitely ascribed to one category or the other, though it is probable, from the frequency of calculus among them, that most would have fallen under the description of pyonephrosis. Four cases were of renal cysts of uncertain character. As might be expected, the incision of renal cysts presents itself as more successful wlien performed intentionally than by mistake; but, in any circumstances, the operation involves too much risk to be recom- mended unless more than ordinary danger be involved in the progi'ess of the disease. Hydronephrosis, chronic and comparatively harmless as it is, can scarcely justify such hazards as are properly incurred in dealing with an ovarian cyst; and as compared with ovariotomy, it is probable that the dangers of removing a large reiuil cyst through tlie abdomen will always be the greater. But when the collection is purulent, from stone or otherwise, danger may threaten, whether by exhaustion or ex- tension, which may warrant the operation, thougli, as far as we yet know, those are greater than are incurred when aqueous distention is in question. I have recently been informed by my colleague, Dr. Barlow, of a successful excision, in a case of pyonephrosis under his care, performed by Mr. Cowper. The patient, a girl of sixteen, in good general health, had lumbar pain, passed highly purulent urine, with much frequency, and displayed a tumor in the right renal region, Avhich was traversed by bowel. Nephrectomy was performed tlirough the loin, with the removal of a thin-walled suppurating cyst which represented the kidney. There was no sign of tubercle or caseation about it, nor any evidence as to the cause of the dilatation. The patient had perfectly recovered by the fol- lowing August. ' Med.-Chir. Trans, vols. Ixiii. and Ixiv. * See cases by Czerny, Thornton, Couper, Barker, and Lange. See paper by Barker, MecL-Chir. Trans, vol. Ixiv. CHAPTER X. CYSTIC DISEASE OF THE KIDNEY. Cysts as closed cavities witliin the renal substance are sufficiently dis- tinct from the cystiform dilatation of the hollow organ to which the term hydronephrosis is given. And it must be needless to refer to the essen- tial differences between the cysts in question, which are for the most part transformations of the proper elements of the organ and those of parasitic origin, which will find consideration elsewhere. For practical purposes renal cysts may be thus classed: 1. Minute cysts which occur as part of some other form of renal disease, more especially the interstitial, and occasionally present them- selves in kidneys ostensibly healthy. 2. Large and numerous cysts which give rise to great increase of size of the affected organs; these mav be congenital or acquired after birth. 3. Large cysts which are solitary, or only accompanied by a few others, usually of minute size. These may be similar in nature to those pre- viously mentioned, or may be connected witii malignant or other dis- ease. 4. To these must be added cysts which may be termed i)arane2ihric, which involve or impinge upon the kidney from the outside. The Large Cystic Kidney as a Disease of Extra-uterine Life. I do not now propose to deal with the renal cysts, usually of small aize, though often in considerable numbers, which present themselves as the concomitants of other renal changes, to which they play only a sec- ondary part; these have found mention in connection with the types of renal disease to which they belong: I refer at present only to the large cystic kidney, in which the vesiculation transcends all other changes, and produces such increase of bulk that the organs may fairly be considered as abdominal tumors. The kidneys are transformed into collections of cysts so completely, in well-marked cases, that it is diflBcult to discern with the naked eye any remnants of the proper tissue, though with the microscope this is always to be abundantly found, however its ordinary semblance may be destroyed by extension and distortion. Tiie increase of bulk is usually great, though the renal shape is more or less preserved, as if the addition of substance were distributed with some uniformity. Such kidneys often measure ten inches in length, and weigh two or three pounds each. Two at St. George's Hospital, described by Dr. Whipham in the twenty-first volume of the '' Pathological Transactions," weighed eighty- one and three-quarter ounces, another pair from a patient under the late Dr. Page weighed six pounds ten ounces, while the maximum of 110 CYSTIC DISEASE OF THE KIDNEY. balk was reached in a case placed on record by Dr. Hare,' in which the 'H\ t 7J ^iiiiii'' Large cystic kidney, one of a pair which weighed eighty-one and three-quarter ounces, referred to on preceding page. (From a patient in St. George's Hospital, under Dr. Wadham, reported by Dr. Whipham.) " Path. Trans." vol. xxi. p. 245. ' This remarkable case is recorded by Dr. Hare in the Path. Trans, for 1850- 51. By a printer's error it is stated that " some of the cysts contained hydatids." I have Dr. Hare's authority for stating that for some should be read none. The case is therefore unequivocal, and is of great interest. CYSTIC DISEASE OF THE KIDNEY. Ill left kidney weighed sixteen pounds and measni-ed fifteen 'and a quarter inches in "length, while the right was enlarged, but only to double its natural size. The cortical substance, and to a less extent the cones, are Tcplaccd by cysts which vary in size from the smallest distinguishable by the naked eye — while smaller still ai-e shown by the microscope — to the bulk of wal- nuts as is common, or much beyond this. In Dr. Hare's case, the larg- est cavity held more than half a pint. The cysts protrnde from the surface as circular bosses, raising the capsule, which, together with the cyst-wall, is so trans^iarent that the variously colored contents can be seen from without. The external appearance roughly resembles that of a water-worn mass of conglomerate or pudding-stone, the prominent pebbles representing the cysts. On section, the globular or ovoid cavities are seen to be crowded to- gether and altered in shape by apposition, nothing be- ing easily recognizable of the renal tissue, except here and there the remnant of a cone. These structures, however, as already stated, are not exem pt f rom the mor- bid transformation, though less alfocted than the cor- tex. Within them cysts are often to be seen, though smaller and less numerous than elsewhere. The cysts, wherever found, appear to be lined with a translucent membrane, which is smootli, excejit that in the larger cavities it may display shal- low folds or creases. Their contents are various in color and kind ; they are generally pale or deep-yellow, and highly albuminous ; often viscid, treacly, or even col- loid; they are sometimes purplish, variously blood-tinged, purulent, or caseous; epithelial cells and renal tubes have been found in tlicm, some- times uric acid, cholesterin, or triple phosphate. The pelvis and ureter are commonly free from dilatation, though this alteration to a sliglit extent has in some cases been recorded. I have occasionally noticed that the pelvis has been stretched with the dimensions of the organ, but under- gone no increase of capacity. Both kidneys are usually affected. I find that among twenty-six cases of which the morbid appearances are fully recorded, there was only one in which the disease was not obviously bilateral, though often more advanced on one side than the other. In the single exception,* many of the tubes of the apparently unaffected kidney were found to be de- Cyst from large cystic kidney, showing its epithelial lining. 1 Dr. Conway Evans, Path. Trans, vol. v. i>. 183. 112 CYSTIC DISEASE OF THE KIDNEY. nuded and dilated, changes which, as will be presently seen, are part of the cyst-forming process. I have made translucent sections of as many large cystic kidneys as I have been able to obtain, including fresii specimens, and others that have been preserved in spirit, some as taken from the body, and some after minute injection of the arteries; the results are as follows: The cysts are globular, ovoid, or somewhat irregular closed cavities which range u])- wards in size fi'om about the normal diameter of tubes to sizes which are beyond the comprehension of the microscope. They lie for the most part among the convoluted tubes, but occasionally among the straight, closely surrounded, wherever they be, by the proper structure of the organ. The boundaries of the cysts or cavities often appear to be formed only of exposed and condensed renal tissue, though in some instances Cyst in large cystic kidney filled with detached, crumpled, and denuded tubes. this is seen to be lined by a delicate layer of epithelium, a basement membrane beneath it being a matter rather of inference than demonstra- tion. The epithelial cells are of small size, but mostly solid figure, such as might have been derived with little alteration from the tubes. Occa- sionally they are flat. The thin, almost imaginary, walls of the cysts are in marked contrast with the thick coats of the neighljoring blood-vessels. The C3'Sts, as seen under the microscope and in section, are generally empty, especially those of large size, while the smaller are sometimes filled W'ith a translucent, structureless material, which hardens in spirit or chromic acid, so as to retain its place in thin sections. In three S])eci- mens I have found contents which were at first sight i)uzzling, but which I think can be accounted for without improbability. The cysts or cavi- ties I refer to, which are comparatively seldom met with, are of small CYSTIC DISEASE OF THE KIDNEY. 113 size, perhaps four or five times the diameter of a Malpighian body, and contain tubes detached from their surroundings, and either little altered or, as in the woodcut (p. 112), crumpled and denuded. I liave seen such tubes as in the illustration, comprised within a regular cyst, or in other cases sticking raggedly out of the walls of a broken cavity. The appear- ance suggests that tlie cavity in each case has resulted from a local de- struction of tissue rather than by mere distention of any existing struc- ture ; the frequent absence of lining membrane corroborates this view. Supposiiig a tube to burst in the process of distention, it might give rise to such appearances as have been described — a somewhat indefinite cavity would be formed, into which surrounding tubes might protrude or fall. Witii time the cavity might acquire, as in the woodcut, a regularly cystic outline. The tubes and Malpighian bodies lie, as has been intimated, in close apposition to the cysts ; the Malphighian bodies are often close to the cavity, and even protrude into it, as if some process of destruction had worn away the less resistant parts of the glandular structure ; but they are clearly normal in character and position, as if any association they miglit present with the cavities were accidental. The most noteworthy condition of the tubes about the cysts and in cystic kidneys elsewhere is irregular dilatation. This may be more or less general, so as to give to the section an almost honeycombed appearance, or limited to certain tubes, whether convoluted or straight, which are conspicuous by their solitary enlargement, and are often densely plugged with epithelium or blood. These are often of such size — many times the common diameter of tubes — that, when seen in transverse section, it requires care to deter- mine whether they be tubes or cysts. A longitudinal view is of course conclusive, but Avhen this cannot be obtained, it is often impossible to say whether one is looking at a tube or a cyst, so close may the resemblance be. There is often about the cysts and the kidney containing them much hypernucleation and fibrosis ; usually not general, as with the granular kidney, but scattered or partially distributed. The blood-vessels of the organ appear, both in injected and uninjected specimens, to be, like the Malpighian bodies, natural; they have no special relation to the cysts, though they often pursue an uninterrupted course riglit up to the edge of the cystic cavity, as if this were a mere broken hole, without any se])a- ration between the surrounding tissue and its cavity. Less frequently capillaries can be traced in circular arrangement around the slender cyst- wall. The cysts in question, unaccompanied as they are Avith any formation foreign to the kidney, are necessarily but an alteration of it, either by destruction of its tissue or transformation of its elements. I have shown reason to suppose that some at least are attended with destruction of tissue, but the majority are obviously the results of transformation. I have seen nothing to justify a view which has been advanced, that tiiey are excessive and peculiar overgrowths of the epithelia. I have never seen a cyst within a tube, however often they api)ear to replace tubes. Tiie choice lies between transformation of the tubes and of the Malpi- ghian bodies. With regard to the Malpighian bodies, it is beyond doubt that these are sometimes dilated as the result of interstitial disease, though not so far as I have been able to make out, to much beyond microscopic limits. In large-cysted kidneys, I have never been able to satisfy myself that any of the cvsts had this origin. The Mal- 8 114 CVSTIO DISEASE OF THE KIDNEY. pighian bodies are evidently unconnected with the cysts, though often in apposition to them, and display no change, save tiiat rarely a capsule may be a little dihited, as is so often seen in other forms of renal disease. The presence of cysts within the cones, where no Malpighian bodies are, is evidence that in this situation at least they have no such origin. There is a large cystic kidney at the College of Surgeons (1,902a), of which the cysts are stated in tlie catalogue to be formed by enlargement of the Malpighian capsules, within which the Malpighian tufts were seen. By the courtesy of Professor Flower I was enabled to examine this prepara- tion. The Malpighian bodies were generally natural ; the cysts clearly had no association with them except that of accidental contiguity; in some cases the Malpighian body lay in tlie wall of the cyst, clearly sepa- rated from its cavity by the undilated Malpighian capsule, virtually ex- ternal to the morbid process however near to it. It cannot be doubted that the cysts are, as a rule, altered tubes; whatever uncertainty there is, is only as to the manner in which the change has been wrought. The epithelial lining of the cysts, the tenuity of their walls and their resem- blance to the walls of tubes, the presence of the cysts wherever tubes are found, the frequent arrangement of these morbid formations in line, and their containing urinary constituents, together furnish apparently con- clusive evidence. The mode of their formation can scarcely be but by constriction, closure, and final obliteration of the tubes at certain points between which secretion continues, but cannot escape. The only appear- ances suggestive of obstruction wliich such kidneys present are ordinary tubal distention, not to be distinguished from that of ordinary tubal nephritis, and, what is more constantly present — indeed, it occurs Avith- out exception, as far as I have seen — inter tubal overgrowth, Avith conse- quent constriction of the tubes; if there be any other cause of obstruction it is either transient in its nature, or not such as to present itself to microscopic examination. To complete the pathology of the cystic kidney by reference to associ- ated changes, cysts, roughly speaking of a similar nature, have been found in the liver and spleen, though so infrequently that it may be doubted Avhether the connection is more than accidental. Special attention has been drawn to this concurrence in the '' Pathological 'J'ransactions," by Dr. Bristowe in the first place, and later by Drs. Wilks and Pye Smith, and four exam})les there recorded, in which the liver was cystic together Avith one or both kidneys, and one in Avhicli the spleen was atfected to- gether Avith the kidneys. Including these, there Avere among the total of thirty-three cases of the cystic kidney, five in Avhich the liver Avas thus affected, one in Avhich the spleen Avas affected; but it is not probable that cysts in other organs actually concur Avitli those in the kidney in nearly so large a proportion as this represents; for the cases of concurrence have been especially sought for and brought together. The origin of the cysts in the renal tubes, of which no doubt can be entertained, is enough to dissociate their nature from such as arise in organs which, like the spleen, have no secreting ducts, or, like the liver ducts, Avhich are so dissimilar to those of the kidney that they can scarcely be supposed to share the same diseases. The cysts in the liver have generally been small, seldom numerous; they have been supposed by Dr. Lionel Beale' to originate in a change in the hepatic cells, Avhich Dr. Pye Smith defines as vacuola- ' Dr. Lionel Beale, examination of case recorded by Dr. Bristowe, Path. Trans. vol. vii. p. 234. Dr. Pye Smith, Path. Trans, vol. xxxii. p. 112. i CYSTIC DISEASE OF THE KIDNEY. 115 tion. It is sufficiently clear that the C3'Sts do not depend on any new growths common to several organs, but are modifications of the organs themselves, probably different in each situation, and connected remotely, if at all. To complete as much of the morbid anatomy of the disease as may be considered apart from its progress and termination, the heart has in many cases been found to be hypertrophied, as with the granular kidney. In three instances which occurred at St, George's Hospital, this organ, which was enlarged chiefly in the left ventricle, and without the occur- rence of valvular disease, though in one of them the aorta was noted as atheromatous, weighed respectively twenty-three ounces, twenty-two and a quarter ounces, and nineteen ounces. The state of the heart, there- fore, is much what it would have been had the kidneys exhibited the ordinary form of granular degeneration instead of cystic transformation and enlargement. The whole morbid anatomy of the disease points to the inference that, although it is possible that in some cases the cystic change may be due to obstruction by tubal nephritis, yet, as a rule, it is due to a form, perhaps a peculiar form, of interstitial fibrosis. Evidences of this overgrowth are always abundantly present, and appear sufficient to account for the cystic conversion, while no distinction in kind, how- ever much in degree, is to be recognized between the small and scattered cysts, so common in the contracted granular kidney, and the gigantic and innumerable chambers which produce the cystic enlargement. The clinical outline Avliich follows is chiefly founded upon an analysis of thirty-three cases, ten of which have been obtained from the records of St. George's Hospital, two relating to patients of my own in that in- stitution. The rest were obtained from other hospitals and pathological collections, and various publications. The subjects of the enlarged cystic kidney are more often males than females, in the proportion of 21 to 7, judging from 28 cases which afford information in this particular. They are always adults (I am not now considering the congenital cystic kidney, fatal about or before birth): the ages at death varied in 21 cases from 20 to 98 years. In five in- stances death occurred between the ages of 20 and 29; in one between 30 and 39, in eleven between 40 and 49; in five between 50 and 98. It thus presents itself as an acquired chronic disease somewhat resembling in its incidence the granular kidney. The mortality between 40 and 49 is noteworthy in this light; and scarcely less so its early period of fatal activity between 20 and 30, which may correspond with those cases of early granular kidney which are due to scarlatina and the other affections of childhood. As with granular degeneration, the causes of cystic enlargement are obscure, and its beginning unmarked. Gout has not presented itself in the cases from which I have drawn. Tuberculosis, generally in the form of phthisis, was present in five cases of twenty-eight of which details arc given; not of ten enough to indicate any pathological association. In two cases the diseiise followed a blow or injury; in one it was attributed to cold. The disease, which is usually latent until an advanced stage is reached, not unfrequently remains so until revealed hy post-mortem examination; this was so in nine of twenty-five cases of which I have histories. When the disorder is declared, it is usually by symptoms which are so nearly those of the granular kidney that it is only by the presence of the renal tumors that a sure distinction can be m^de. The differences are chiefly 116 CYSTIC DISEASE OF THE KIDNEY. these: With the large cystic kidney there is almost no tendency to dropsy, while pain in the loins is more obtrusive, and hematuria more frequent and profuse, than with the more common form of disease. The latter distinction is strongly marked. Dropsy, whether superficially or in the serous cavities, appears to be generally absent. A patient under my own care was said to have had swelling of the legs, but when Isaw him there was none. The only recorded case I have met with in which oedema was mentioned, presumably as a result of this disease, was that of the gigantic cystic kidney recorded by Dr. Hare (see p. 110). In this it is probable that the swelling was due more to the mechanical effect of the tumor than to the constitutional influence of the disease. The oedema was most marked on the side to which the renal swelling was nearly limited. The urine furnishes the most marked evidence of the presence of the disease, though not of its kind. It has the characters which belong to the granular kidney. It may possibly be normal, as with the earlier forms of this disorder. Dr. Conway Evans has described an instance in which this secretion was natural, and the large cystic kidney found to exist. But there are few exceptions to the rule that, with the advanced disease, it has been found to be albuminous if examined, though in many cases the urine and the disease have alike escaped notice. The albumin has varied from a small amount up to about two-thirds. The urine has usually been pale, co))ious, of low specific gravity (in one instance down to 1.005), and has been found to contain casts, as in a case under my own observation, of the coarse granular variety. It is characterized in most cases by the frequent admixture of blood, often so copiously as to call for styptics. Of sixteen cases in which symptoms were present, hsematuria was prominent in eleven. In some it largely contributed to death by the exhaustion it caused; in others it gave trouble by the formation of coag- ula, which were passed with difficulty; and in one it helped to produce suppression by the blocking with coaguluni of one ureter. In a few in- stances small amounts of pus have been found. The pathognomonic feature of the disease is the double tumor, a sign generally unfound and unsought for, the observer being generally satisfied to regard the case as one of the granular kidnev. Among the general characters of renal tumors (p. 41) is to be found an outline from a case recorded by Bright. The laterally symmetrical, though often unequal, tumors are softer than solid renal growths, but do not fluctuate.' Dr. Hare's case, already referred to, gives an instance of the largest abdomi- nal swelling from this cause, as of the largest renal tumor. The palpable tumefaction reached from the thorax to an inch and a half below the spine of the ilium, and from the loin to within an inch of the median line. Tins bulky mass presented in the abdomen in the guise of two tumors on the same side, with bowel between; but since both could be moved together from the loins, it was decided, Avith the help of Dr. Brigiit, that there was but one, and that kidney. The kidney on the other side, it may be observed, was not affected so as to be appreciable from without. The general aspect of the patient, his sallowness, his cardiac hyper- trophy and his arterial tension, are, like the urine, all indicative of chronic renal disease, and deceptive as to its nature, unless, indeed, it be held, as may be the case, that the cystic and the granular kidney are varieties of the same essential condition. With the advance of the dis- ' See case recorded by Roberts, 3d edit. p. 512. CYSTIC DISEASE OF THE KIDNEY, 117 ease ursemiii often presents itself with gastric and cerebral disturbances, obstinate vomiting, convulsion, and coma. This is, indeed, the most frequent cause of deatii. I noticed in one instance that the body emitted not the ordinary odor of uraemia, such as is usually produced by disease of the substance of the kidney, but a truly urinous smelll, such as more often indicates retention of urine in a cavity, as with obstructive sup- pression, wiiich, however, did not exist. In an instance I have already alluded to, under my owii observation, nearly complete suppression ex- isted for two days before death, after which the lower part of the right ureter was found to be })lugged with a decolorized clot, tiie other ureter and the bladder being natural. Death by uraemia is sometimes antici- pated by exhaustion from iiaematuria, and not seldom by bronchitis, pneumonia, or congestion of the lungs, with sudden and severe dyspnoea. This termination occurred in two cases in St. George's Hospital, which have been placed on record by Dr. Whipham.' As with the granular kidney, cerebral hemorrhage has been known to occur in these cases; in a case recorded by Dr. Cliurch there was evidence of an attack of this nature three years before death. ^ It is difficult to estimate the duration of a disorder of which the be- ginning is usually so indefinite. It must necessarily be considerable. In a case at St. George's Hospital the outset was apparently due to a blow seven years before death; in another, at the same institution, lumbar pain appeared to mark its beginning five years before death. Dr. Bright's patient, from wliom the outlines were taken' which have been reproduced, was attacked with hematuria two years before death; Dr. Hare's nine months before death. . It is not necessary to refer to treatment further than to say that the uremic symptoms must be met in the ways detailed in connection with granular degenei'ation. Congenital Cystic Transformation of the Kidneys. The kidneys of the foetus sometimes undergo a cystic transformation similar to that which belongs to extra-uterine life, though it is sufficiently clear from the age at which the later disorder declares itself, that is not a continuation of a congenital condition, but an acquirement of advanc- ing years. The foBtal condition is of little interest to tlie physician, how- ever important to the i)athologist as showing typically and simply the results of obstruction. The disorder has not come within my experience, and I have nothing to adil to what is generally known. Tlie kidneys may have become swollen in utcro so as to equal or exceed the bulk of the healthy kidney of the adult, by a cystic transformation which closely resembles that which has been already described, and is due to absence or obstruction of the urinary exit. Th.e cysts have been found to con- tain urinary matters, and there is a concurrence of evidence and proba- bility that they generally consist of dilated and intersected tubes, as those of a later date have been shown to do. Sir W. Gull " who reported many years ago upon a typical example of a congenital change of this nature, inferred that the cysts were dilated Malpighian capsules, but it is not unlikely that with recent methods this excellent observer might have been * Path. Trans, vol. xxi. p. 244. » Ibid. vol. xix. p. 274. ^ Bright on Abdominal Tumors (Sydenham Society) p. 208. * Case reported by Dr. Lever, Path. Trans. 1848-49, p. 74. 118 CYSTIC DISEASE OF THE KIDNEY. led to a different result. The cystic transformation of foetal life is gene- rally associated with absence of the ureter or pelvis, or some malforma- tion which renders the escape of urine impossible. In the case examined by Gull, and reported by Lever, tliere was a total absence of ureters; and in otlier instances, other parts of the urinary channels have been oc- cluded or deficient. In certain cases Virchow found closure of the straight tubes a result, as he supposed, of the impaction of uric acid and iutra-uterine nephritis. In most cases there has been absence or im- perfection of the pelvis, ureters, or other of the larger exists, which has been often associated with malformations in other parts of the body. The absence of renal function in these cases may cause the death and premature exi)ulsion of the foetus; the abdominal tumor which arises may be such as to be a hindrance to birth, which can only be overcome by operation; or, should tiiis difficulty be overcome the child may per- ish shortly afterwards from respiratory embarrassment, due to the en- croachment of the abdominal swelling upon the thoracic cavity. Solitary Eenal Cysts. Otherwise healthy kidneys are often found, especially in persons of advancing years, to contain small solitary cysts, which project from the capsule and burst with miniature violence as this is being removed. These are apparently of the same nature as the multiple cysts which have re- ceived attention, due to the accidental occlusion of a single tube. Such cysts may occupy either the cortices or cones, may be absolutely single, or be accompanied with one or two others, as if to declare their alliance with the multiple cystic disease, and they may attain a considerable size, so as to come within the category of renal tumors. They usually have a thin wall, scarcely to be separated from the renal tissue, and have been found to contain urinous, albuminous, gelatinous, and bloody fluid, uri- nary salts and cholesterin. A cyst probably differing only in size from the small and multiple variety is to be seen at the College of Surgeons. It is thin-walled and membranous, of spherical form, and six inches in diameter. This protrudes from the outer surface of a somewhat en- larged kidney, Avhicli is granular, and exhibits a few more cysts, appar- ently of the same sort, but only a line or two in diameter. This must have formed an abdominal tumor of considerable prominence. Paranephric Cysts. There are some cysts, not always of the same kind, but which may be classed together as neither developed in the kidney tissue nor dilatations of its cavity, though they often open into it, but as involving the organ from the outside. The terms 2^c(ra}iephric, or pararenal, may be applied to these formations as to solid tumors similarly placed. Some of these cysts are congenital, others of later and perlia])s doubtful origin. The occasional connection of these cavities with that of the pelvis must make them clinically indistinguishable from hydronephrosis, however distinct in their nature. A preparation at St. George's Hospital displays a renal annex of this kind. A large cyst protruded from the back of the pelvis, which is generally out little dilated, and is scarcely unnatural except that its posterior wall opens into the cyst behind it. Tlie ureter which was unobstructed opened into the cyst, so CYSTIC DISEASE OF THE KIDNEY. 119 that this cavity lay in the course of the urine, between the pelvis and its duct. The cyst resembled in extent, and somewhat in shape, a distended stomach, and held above four pints of clear albuminous fluid. The abdominal tumor was first noticed when the patient, a woman of the age of thirty-seven, was brought into the hospital in consequence of having been knocked down in the street. She fell down, became unconscious, and died in a few liours from causes which the post-mortem imperfectly explained. She had emphysema and bronchitis. Some aqueous cysts present themselves in connection with tlie kidney, but clearly external in origin as well as jiosition. A remarkable preparation of this sort is to be seen at St. George's, and is de- scribed by Mr. Caesar Hawkins in the eighteenth volume of the " Medico-Chirur- gical Transactions." It had presented itself three months before death as a tumor in the right side of the abdomen of a boy six years of age. The cyst, which held five pints of transparent fluid, ascertained by Dr. Prout to be free from urinary constituents, lay beliind the kidney, which was closely attached to its wall, but had no essential connection with it. Tliere were, however, two small openings in the pelvis, apparently the result of ulceration, which made communication between the renal and the cystic cavi- ties. The ureter had no communication with the cavity of the cyst, but entered tlie kidney in the usual manner. Attached to the cyst wall was a itidimentary tliird kidney of the size of a walnut. A prolongation of the cyst passed under Pouparfs ligament, and through tlie femoral ring. Tlie formation was clearly of foetal origin. I have elsewhere alluded to a case (p. 48) in which' the the ap- pearance in the scrotum of a portion of a cystic growth of equivocal origin led to a just inference that it had originated not within, but outside, the kidney, the outlying portion having probably been brought down with the descending testicle, the embryonic tissues about which organ in its first situation being, as it seems, rather apt to undergo morbid development. CHAPTEE XL RENAL CALCULI IX GEXERAL AND PARTICULAR, WITH THEIR CAUSES. GeKERAL CoNSIDERATIOXS RELATIXa TO THEIR FORMATION AXD Distribution. Many secretions — urine, bile, saliva, and the secretions of the pro- state gland and tonsils — are apt to throw down witliin their channels or reservoirs certain of their elements which are superabnndant, or which, from other circnm stances, are no longer capable of solution. Of all se- cretions, the nrinary is the most apt to undertake this process. It is highly complex and highly variable. Furnishing, as it does, the main exit by which the blood discharges its superfluities of almost every kind, its several components change in amount with every change of system. According to the nature of the superfluities which it thus receives, the urine continually becomes loaded beyond its capacity of continuous solu- tion with various materials, which are in their Avay out precipitated in one part or another of the complicated urinary channels. Besides the numerous deposits which thus result from an excess in the urine of their components, there are others which owe their precipitation, not to any superabundance of their material, but to some change in the urine which renders it less than naturally capable of holding it in solution. The precipitation is most apt to occur in the pelvis of the kidney and in the bladder, in which cavities the urine may remain for a time in con- siderable bulk and in comparative quiescence. Calculi, especially if they be composed of uric acid, oxalate of lime, or cystine, generally take their first concrete form in the pelvis, though they sometimes escape notice until they have reached the bladder, become the centres of further con- cretion, and the source of vesical symptoms. Renal, though generally more simple than vesical, calculi, present a considerable variety of composition. Tlie following concretions have beea found in the human kidney, or presumably passed from it: f Uric acid. I The urates of soda and ammonia. I Oxalate of lime. Primary deposits -[ Sfiato/tae; Cystine or cystic oxide. Xanthine or uric oxide. Indigo (?) i ]\Iixed phosphates (fusible calculus). Secondary deposits ^. Phospliate of ammonia and magnesia. ( Carbonate of lime. Those classed as primary deposits, or at least the first six of them — RENAL CALCULI. 12L for of xanthine and incligo we know but little — are thrown down in the kidney independently of any preceding; local change. When renal cal- culi consist of one ingredient only, they are always composed of one of these substances. When renal calculi consist of more than one material, one of these substance invariably forms the nucleus. The three secondary deposits occur only in kidneys which have been the seat of previous disease; they are continually deposited upon stones of some other sort, as the result of the pathological changes they have set up. They occur as layers upon the primary calculi, never as inde- pendent concretions in healthy kidneys. In order to give a general idea of the relative frequency and mode of combination of the different kinds of calculous substances — a point of great practical importance — I have compiled the following table, wiiich gives the composition of ninety-one analyzed renal calculi belonging to the thirteen pathological museums of London. Considering from what scat- tered sources the hospitals of the metropolis attract ])atients and specimens, it may be held that the collection represents not merely the local tenden- cies of London, should there be such in relation to this question, but comprises the jiroduce of a wide field of disease, and jierhaps portrays not very unfairly the general constitution of English renal stones. The table has been compiled with much care, the results of personal inspection having been in the case of each of the hos])itals corrobo- rated or coi'rected by the gentleman in charge of the museum,' It may be assumed that tlie errors of the table are only of omission. There is no I'eason to doubt in any instance the existence of the calcu- lous substances in the position assigned to them. But, on the other hand, it is by no means unlikely that many of the concretions may have con- tained matter which escaped observation, so that calculi represented as simple might, to a more minute analysis, have declared themselves com- pound. Hence it must be taken that the table rather under- than over- states the complexity of renal stones. The calculi were in most cases obtained from the body after death, though one or two examples have been included of calculi voided by the urethra immediately after a nephralgia attack. The table gives the composition of ninety-one renal calculi. Of these fifty-two are simple; thirty-nine compound. Of the compound stones, twenty-two are composed of two ingredients; ten fo three; seven of four. As regards the simple calculi, uric acid is their most frequent mate- rial, forming rather more than a tliird of the number. Oxalate of lime comes next. Mixed and triple phosphates occur not seldom in the guise of sinii)le calculi, though it is probable that, in some cases at least, a nu- cleus of a different substance would have come into view had the section fallen more happily. The list does not comprise any example of the pure phosphate-of- lime calculus, the concretions of which are described as phosphate of lime, from the circumstances under which they were found, almost cer- tainly (see note 1, p. 122) consisting of the mixed phosphates. Carbo- ' I have to acknowledge my obligations to Dr. Green at the Charing Cross Hospital, Dr. Moxon at Guy's, Dr. Kelly at King's College, Mr. McCarthy at the London Hospital, Dr, Cayley at the Middlesex, Dr. Gee at St. Bartholomew's, Dr, Payne at St. Mary's, and R. J. Lee at the Westminster, all of whom liave given me assistance in this matter. To Mr. Carter at University College I am indebted in an especial manner, since he undertook, with a view to this inquiry, the analy- sis of seven calculi which had not previously been examined. 122 RENAL CALCULI. Table slioioing the Xumher and Comjjosition of the Renal Calculi in the {March, Composition of Stone. C Uric acid S c I Mixed iirates c -2 j Oxalate of lime. ..... •^ "^ ) Phospliate of lime (?) ^ %.'] Phosphate of ammonia and magnesia. 'tt S I Mixed phosphates. . c^ g I Carbonate of lime . . ; '-'= LCystin f ( Uric acid + urates) Uric acid + oxalate of lime ( Uric acid + oxalate of lime Uric acid + mixed i^hosphates (Oxalate of lime + urates) - Oxalate of lime + phosphate of lime (Oxalate of lime +2ihosphate of lime) Oxalate of lime + mixed phosphates {Oxalate of lime + carbonate of lime) {Pliosphate of lime + mixed 2ihosphates) Mixed phosphates + phosphate of ammonia and magnesia ( Uric acid + nrates + oxalate of lime) Urates + oxalate + uric acid Urates + (phosphate of lime + urates + oxalate of lime) (Oxalate of lime + urates) + phosphates {Oxalate of lime + phosphate of lime + phosphate of ammonia and magnesia) (Oxalate of lime -t jyhosphate of lime) + carbonate of lime (Oxalate of lime + carbonate of lime + uric acid) .... [ Phosphate of lime + carbonate of lime + urates fUric acid + (urate of lime + urates -r phosphates) ( Uric acid + urates + phosphates + oxalate of lime) Urates + oxalate of lime + (mixed phosphates + carbonate of lime) Urates + uric acid + (oxalate of lime + phosphate of lime) ( Urates + uric acid -^ oxalate of lime) + mixed phosphates Oxalate of lime -i- (phosphate of lime + urates + phosphate of am- monia and magnesia) (Phospliate of lime + phosphate of ammonia and magnesia f car- bona'te of lime) -f- oxalate 21 3 11 3 2 9 1 2 7 1 3 1 2 1 1 2 1 1 1 'Jl Wliere not expressed to tlie contrari% the components of the calculus are placed in their order of position, ]irocepdiii{; from the centre to the ciicnniference. Uonipoiieuts which are printed in italics and lirackeied are either not regularly superimposed, or are insufficiently described as to their relative position. Calculi in both kidneys, or several calculi in one kidney, if of the same kind , count only as one. ' The two specimens described as phosphate of lime, in Guj^'s Museum, were taken from otherwise diseased kidneys, and may be looked upon as certainly of KENAL CALCULI. 123 Pathological Museums of London, which have heoi chemically examined. 1871.) Number in each Museum. College of Physicians. c o s o IS u £ o Guy's Hospital. King's College Hos pital. 5 te K B •a tEl ii ■3 •a g ai'a ■5. w C 02 3 ■5, K te 3a 3 to s H o5 m it ression, in all of which the subjects were of the male sex and of ages be- tween forty and sixty-seven. Tlie late Mr. Nuneley, of Leeds, recorded in the "Pathological Transactions," vol. xi. p. 145, an instance of su])- pression in a woman, whose age was thirty-three, calculi being found after death in both kidneys, but in both sex and age this occurrence was somewhat exceptional. I may mention as unusual in age and sex the case of a girl of seventeen, under my care as a hospital patient, in whom total ' Essays and Orations, p. 31. 174- ON CERTAIN RESULTS OF RENAL CALCULI. sui»[)re3sion of urine for sixty-seven hours was relieved upon the passage of u ([luintity of uric acid. I have never ascertained tlie existence of calculous su[)pression in childhood, though a ease is mentioned in the chapter on suppression in which it was jiresumed to liave existed. The course of the disease may be sufficiently gathered from the fore- going instances. An elderly, but apparently healthy man, who perhaps has at some former time had symptoms of gravel, fiiuls, to his surprise, that he no longer needs to pass water. The cessation may take place in connection with an attack of sharp pain, indicative of a moving stone, or it may occur without warning. For a time t)ie patient seems little the worse. He is either entirely free from local uneasiness, or he has merely a dull pain or sense of weight in the loins, which does not trouble him much. His appetite is good, liis general sensations are those of health, and at first little notice may be taken of the sensation. Presently the unusual nature of the occurrence, rather than any feeling of illness, causes him to seek medical advice. A catheter is ]iassed, and the bladder found to be empty. The urine may remain totally absent, or small quantities from time, or now and then something approaching the amount of a natural urination, may be dis- charged. TJie urine, sometimes albuminous, is pale, of low specific gravity, and wanting in urea. According to the father of medicine,* "persons affected Avith calculus have very limpid urine." This is par- ticularly the case when the renal outlet is obstructed. It has been else- where explained that there is a direct relation between poverty of urine and obstruction of the renal outlet. The longer uraemia is postponed, the greater the chance that the stone, should it be " viable," may com- plete its ]ierilous course and allow the kidney to resume its functions. This it will do with extraordinary activity on removal of the obstacle. Should the obstruction fail to be removed, symptoms of uragmia will gradually appear, and ultimately prove fatal, the period at which this result happens being very variable, depending much upon whether the suppression be complete or incomplete. In tlie case presumably of cal- culous obstruction related by Sir H. Halford, of which he says that the others he saw were exact copies, the jiatient died in a state of stu- pefaction on the fourth day. The lady whom I saw with Mr. Tatham, in whom the obstruction was complete, died on the fifth day; the man seen with Mr. Keen, in whom it was likewise complete, died at the end of the sixth. Dr. Koberts relates a case in which death occurred on the sixth day, of complete suppression, but from the a<|ueous character of the urine there was reason to believe that some obstruction had existed for a longer period. In two other examples which the same physician was able to pursue to post-mortem examination, death occurred on the tenth day of suppression, which in each case was so far incomplete that in one fifty-four ounces (divided over three days), and in the other two ounces, of urine were ])assed. Dr. Bagshawe's patient died likewise on the tenth day, and in liim also the period of suppression was interrupted by the passage on one occasion of a small quantity of urine. Eichardson died on the eleventh day; with him the sujipression was so far inclom- pete that small quantities of urine, generally two or three ounces, were passed on seven of the eleven days. The woman under the late Mr. Nunneley survived twelve days of suppression, uninterrupted so far as was known; while the Hampshire farmer, under Mr. Paget, endured for ' Hippocrate?, On Airs, Waters, and Places, chap. ix. ON CERTAIX RESULTS OF RENAL CALCULI. 175- twenty-two days suppression, which was intersected by the passage dur- ing one night, near the middle of the period, of about a pint of urine. It thus appears tiiat, poor as the secretion is wliich is yielded against pres- sure, and small as it may be in amount, it generally may be reckoned, upon to prolong life. It is possible that in many cases of incomplete obstruction more urine has escaped than has been observed. The results of obstruction may, however, ensue, though a considerable quantity of the pale urine in question has been voided. Dr. Roberts mentions a case almost certainly of calculous blocking, fatal on tlie fifteenth day by uraemia, in which a daily average of two pints of urine — pale and of a specific gravity of 1006 — was discharged throughout. The explanatioi\ of the fact lies in the small proportion of excrenientitious matter which the urine in these circumstances contains. Unless the obstruction be overcome, the constitutional signs of uraemia will inevitably appear sooner or later, though they are seldom prominent until within a short time, a few days at most, of death. Once evident their course is rapid. The functions of the stomach are among the first to suffer, as shown by loss of ai)petite, nausea, and occa- sional rather than continued vomiting. Sometimes there is much flatulence. Failure of muscular power early occurs and increases with the uraemia. Lassitude and debility are succeeded by embarrassment of breathing, which becomes hurried or slow, panting, and laborious, prob- ably chiefly in consequence of weakness of the muscles of respiration. Finally the heart shares the change, the pulse becomes weak, then slow, irregular, or intermittent, and at last in a large proportion of cases death occurs from asthenia, the ventricles after death being found to be totally uncontracted. The asthenic state of the heart may determine the manner of dissolution, which often takes place suddenly, perhaps upon a change of posture, or while the patient is sitting uj), without any premonitory disturbance of breathing or of the mental faculties, death being immediately due to an abrupt failure of the powers of circulation. Before muscular failure has reached its climax there are other results of blood-poisoning, the most constant of which are muscular twitchings, which occur sometimes almost all over the body. These appear to be generally, though not always, present in advanced uraemia from this cause. General convulsion occurs with comparative infrequency. The tongue, first moist and tremulous, becomes coated, then brown and dry. The functions of the bowels are but little affected. Constipation is some- times present early in the attack. There is seldom diarrhoea unless due to medicine. Latterly the motions are often dark and peculiarly offen- sive. The skin is clammy and moist, sometimes there is much sweating, seldom of the distinctly urinous character occasionally observed in other diseases of the urinary organs, more especially with retention. The skin is noticeably cool, aiul to the thermometer slightly sub-normal (9G' or 97°). There is a remarkable absence of dropsy. Notwithstanding that five or six days may have passed but not a drop of urine, or two or three weeks with only as many urinations, the only oidema observed, and even that is exceptional, may be a slight puffiness about the face. The patient is sometimes drowsy, in other cases want of sleep is experienced, he is often restless and sleeps fitfully, with sudden star tings, and semi- convulsive disturbance. Low delirium sometimes occurs, but, as a rule, is not a prominent symptom. The pupils are contracted towards the end, sometimes to mere points. In some cases coma supervenes at last. but far less often than in uraemia from other causes. In suppression. 176 OK CERTAIN RESULTS OF RENAL CALCULI. from calculus, the tendency to asthenia is always marked, and generally ^ives its character to the closing scene. The preceding account has been of necessity founded upon cases which have received the elucidation of a post-mortem examination, but it is not to be supposed ti)at the disorder is always fatal, though the mechanical disablement of both kidneys must always involve mortal peril. Insanity axd Epilepsy ix Coxxection with Rexal Calculi. The numerous and important nervous relations of tlie kidney have Toeen elsewhere adverted to, and it has been sliown that neuralgia, some- times of extreme severity, is apt to affect certain branches of the lumbar plexus in connection with the irritation of a renal stone. Remote ner- vous disturbances, of the kind ordinarily called reflex, may also have their origin in the same irritant. Epilepsy is known to occur occasion- 4illy in connection with renal calculi, more especially when their move- ment, as in entering or traversing the ureter, gives rise to severe pain. It would also seem that there is a concurrence, too frequent to be acci- 2 3 1 T 2 5 Abdominal nephrectomv Particulars of 22 Operations for Stone existing in the Kidney, referred to in Tables I. and TIL Operation Number of eases Stone removed by lumbar incision, without previous sinus Stone removed by lumbar incision, sinus previously ex isting - ... Lumbar incision, but stone, which was in ureter, not reached Lumbar incision. No stone found at operation, though minute calculi existed. Large stone on opposite side Lithotrity through puncture in loin Lumbar nephrectomy, in many cases succeeding upon at- tempted lithotomy Nephrectomy through abdomen without incision in loin. . 23 Recov- ered 13 Died I have annexed in a condensed form the particulars of thirty-five cases in whicli operations have in recent times been performed for stone in the kidney, omitting several of which the result is uncertain or not fully stated ; tlie catalogue, even if not complete, may fairly represent present experience. First, as to tiie existence of the disease whicli it was designed to remove, it a^ipears that in thirteen of these cases no stone was found, a proportion of erroneous diagnosis wliicli is certain to diminish now that attention is called to this subject. It can scarcely be accepted as a persistent rule that in a third of the instances in wliich a renal stone is confidently diagnosed, no such concretion exists. Did the difficulty of diagnosis amount to this, the feasibility of any operation for its removal with or without the kidney would scarcely need further dis- ' One of these cases is also counted in Table I., as lithotomy had been at- tempted at an earlier date. '^ Two of these cases are also counted in Table IL, as lithotomy had been at- tempted at an earlier date. o:h the tkeatment of stone in the kidney. 193 ciission. But, as in many novel enterprises, the early adventurers fell into errors, which may serve as warnings against their repetition. The incision into and the removal of the healthy kidney presents itself in this light. With such facts before us as the tables present, we may at least insist that no operation for the relief of renal calculus be undertaken on the evidence of pain or general symptoms, unless corroborated by the dis- charge of blood or pus, or at least, as in Mr. Butlin's case, of crystals and albumin. The doubt likely to occur in future, is not between disease and no disease, but between stone and tubercle. The distinctions have been detailed elsewhere (pp. 89, 1G4:). With tubercle there is usually a characteristic look, family liistory and temperature, and often disease possibly incipient in the lungs. The pain is not acute, nor does it widely extend, nor is it aggravated by movement or in paroxysms. Hasmaturia is the exception, cystitis the rule. With stone, these statements may be reversed. By way of insuring the diagnosis, a calculus has been struck with a needle inserted behind; this could scarcely be reckoned upon un- less, as in a case in which Mr. Barker thus detected a stone, it presented a large surface. Manual explorations by the rectum may sometimes be of use, and an instance has been referred to in which the grating of stones in the kidney was felt through the abdominal wall. It has been supposed that single stones could be detected by palpation through the integuments, particularly in children and under chloroform, but though a lump may be thus discovered in the renal position, its nature may be doubtful. A stone diagnosed by this means has, within my knowledge, turned out to be tubercle. As a rule, the diagnosis of stones in the kid- ney rests not on any one certain indication, but on the concurrence of a number each of which and all together may be mistaken. A some- what careful balancing of evidence is often needed, Avhich in the cases before us does not appear always to have found place. A doubt as to the existence of a stone must, as a rule, negative any operation for it, notwithstanding that it is clear that the kidney can be cut into from be- hind, whether tentatively or otherwise, without great danger, supposing that nothing else is attempted. Putting aside all operations founded upon erroneous diagnosis, and considering only those undertaken for the removal of existent calculi, we have the following results: — The kidney has been opened from the loin for tlie purpose of remov- ing a stone from it, in sixteen cases, in fourteen of which the operation was limited to lithotomy or lithotrity, and is accordingly detailed in Table I.; in two nephrectomy was executed upon the failure of the less formidable procedure, and the instances therefore referred to in Table III. Of the sixteen operations, eight were immediately successful; eight unsuccessful ; six fatal. Of the unsuccessful operations, two were, as stated, followed by nephrectomy, once with a favorable, once with a fatal issue. In one of the cases of successful lithotomy there was a previous sinus; in seven, none. One instance is included in which tiic stone was crushed, and then removed through a puncture rather than an incision. In two of the cases counted as successful, a sinus was left at date of the report, one of which did not communicate with the kidney; in the rest healing was complete. Among the unsuccessful cases was one in which the stone was not on the side of the operation, one in which it was in- accessibly placed in the ureter. The removal of the kiJney, together with the stone, presents itself as a much more dangerous operation than simple extraction of the stone, 13 194 ox THE TREATMENT OF STONE IN THE KIDNEY. and probably will not be resorted to out upon failure of the smaller pro- ject. The causes of death after renal lithotomy are not stated in every fatal case, but it is to be remarked that extravasation of urine finds no place among them. Of four cases where the manner of death is stated it oc- curred from sinking in tliree instances; from pytemia in one. Among the results of nephrectomy for existing stone we find similar dangers; shock or sinking in three cases ; pyaemia in one. Peritonitis presented itself as a cause of death in one instance, in which a tuberculous kidney Avas exi)lored for stone, but did not occur as the result of any operation in which calculus was correctly diagnosed. Suppression of urine occurred in one case of fatal nephrectomy in which no stone was found. Grave as the recorded results are, thej^ are encouraging and are daily becoming more so; we owe a debt of gratitude to those surgeons whose enterprise has placed renal calculus in the list of curable diseases. Mistakes of diagnosis can scarcely be so frequent in the future as in the past, and the attempt to remove bodily a kidney from which a stone could not be extracted, or in wliich it could not be found, is an addition to the mor-- tality which may be avoided. It appears that a kidney may be laid open from or exposed behind without special danger, and with a death rate represented, so long as no evisceration be attempted, by six deaths in twenty-two cases. It is to be expected that with further experience the operative process will improve, and to be hoped that in future surgical enterprise may be more successfully guided by medical judgment. The system is tolerant of renal calculi more so than of vesical ; with pain slight, and danger remote or hypothetical, no such operation as in question can be justifiable. But in some cases the pain is so great as to warrant much risk in search of cure, and in others the tendency of the disease is such that, should an operation kill, it will only anticipate by a little the action of nature. In such circumstances it maybe right to cut for stone in the kidney, accepting the teaching of experience mainly in two respects — not to do so when the diagnosis is doubtful, and, in doing it, to do as little as possible. Another rule wliich may be laid down, is not to cut for stone if the renal discharge intermits and accumulates, since this habit would indicate obstruction in the ureter, a condition which no operation would be likely to remove. A discouraging considera- tion is the possibility that, if the stone be of long standing and ])re- sumably phosphatic, it may be of such a size or branched in such a manner as to make its removal during life clearly impracticable. The frequency with which stone affects both kidneys (about one case in five) can scarcely be held to militate against the operation. The danger of it may be somewhat more if there be any obstruction of the unconcerned kidney; but in this case there is the greater need that the risk should be incurred, since it is an attempt to remove a condition which is one of mortal, though, perhaps, not immediate peril. Solvent Treatment of Kenal Stones. "When an imperfect and much dreaded process of lithotomy was the only method of removing stones in substance from the bladder, lithon- thryptics, as they were called, were sought eagerly and not without suc- cess, though the composition of urinary calculi was then unknown, and the search was guided solely by empirical considerations. Alkalies were early used for this j^urpose. Basil Valentine used a fixed alkaline salt in ON THE TREATMENT OF STONE IN THE KIDNEY. 195 calculous disorders, and Sennertus in similar circumstances is said to have em|)lo3'ed cream of tartar. The searcli received a later direction from Joanna Stephens. Her nostrums for the solution of stone having be- come notorious, Parliament, acting by the advice of a scientific com- mittee Avlio put her ren;iedy to the test of clinical experiment, bought her secret in the year 1739 for £5,000, and made it public as follows for the benefit of mankind.' " My medicines are a powder, a decoction, and j)ills. The powder consists of eggshells and snails, both calcined. The decoction is made by boiling some herbs (together with a ball wliich con- sists of soap, swine's cresses burnt to blacivuess, and honey) in water. Tiie pills consist of snails calcined, wild carrot seeds, burdock seeds, ashen keyes, hips and hawes, all burnt to blackness, soap and honey." Tlie powder was given in drachm doses; the decoction by half-pints. The pills, which were luirchased by quarts, were swallowed at the rate of fifty or sixty a day, in weight about two ounces.* Calcined eggshells and soap had been long esteemed as lithonthryp- tics, as also had most of the vegetable ingredients of her charred and nauseous mass. The essentials of the mixture were lime and soap, or, in other words, lime and potash, since in considering the remote action of the soap we may put aside the oil and have regard only to the alkaline bases, which Avith Alicant or Castile soap are lime and potash. Thus a powerful alkaline remedy was given in large doses with the effect, as we learn from the case published by Dr. Parsons, of making the urine alkaline and keeping it so for months. Mrs. Stevens' alkalies did not cure, but it is evident from the published cases that they often much alleviated, and even when they apparently did the reverse they did not fail to encourage the patient by engendering phosphatic sand and grit, which he fondly attributed to disintegration of the stone. After the death of a man (Mr. Gardner) whose supposed cure had helped to make the fame of the medicine and the fortune of the proprietor, no less than nine stones were found in his bladder. These had become sacculated in such a manner as to elude the experienced sound of Cheselden.' In spite, however, of this solution, rather of the doubt than the stone, soap, lime, and alkalies continued to be introduced in all shapes, both by the mouth and by the urethra, in calculous affections of every kind. There is still to be seen in tlie College of Surgeons a large saponaceous mass, which had accumulated in the bladder as the result of this misdi- rection of a valuable external ai)plication. Subsequently, when, owing in great measure to the researches of Wollaston, the nature of urinary calculi began to be understood, alkalies by themselves came to be exten- sively used. Dr. Marcet, in the year 1819, pointed out that the alkalies, which he recommended as bicarbonates, could exert a solvent action only u])on lithic acid, while phosphatic concretions might be aggravated or originated by their use. He, however, despaired of materially lessening large concretions of any kind in this manner, having regard to the small surface tliey exposed in relation to their bulk, and limited the use of alka- lies to the correction of the uric acid diathesis, the prevention of the in- crease of existing calculi and the formation of fresh ones, and to such sol- vent action upon small stones and gravel as might round their edges, ' Extracted by Sir Henry Thompson from the Oeiitlenian's Magazine, June, 1739, vol. ix. p. 298. '' See Parsons Lithonthryptics. London, 1754. Case of Mr. Gai-dener. ^ Parsons, loc. cit. , p. 2;J6. 196 ON THE TREATMENT OF STONE IN THE KIDNEY. and enable them to make easy exit. For practical purposes the problem still stands much as he left it.' The solution of urinary calculi was subsequently investigated, at the instance of the Academy of Sciences, by Gay Lussac and Pelouze, with reference to the researches of d'Etoilles upon the subject. The results ^ were published in the year 18-42. Experiments were made upon different sorts of calculi and with various reputed solvents, of which the alkaline carbonates received most consideration. Stones were exposed, even for a year, to solutions containing from 1 to 2 per cent of the carbonates of potash or soda. None were dissolved; some were not even diminished in bulk. They had lost from a quarter to half their original weight. In another experiment fragments were ex^iosed for three months to a stream of water holding in solution one-twentieth of its weight of car- bonate of soda. The fragments did not generally lose volume, but be- came friable, and lost from ten to sixty per cent of weight. After such experiments, and others upon the living body, in which alkaline carbonates were given as medicine, and passed as injections into the bladder, the Commission reported that, without denying the possi- bility of the cure of stone by solution in certain cases, they were of opin- ion that unless the calculi were small they were not likely to be destroyed by agents acting indirectly, as baths or potions, and that as to solvents applied directly by injection, though they acted more powerfully, yet the process was attended with difficulty and danger, not counterbalanced, as in lithotrity, by the prospect of speedy cure. Finally, the Commission suggested that the plan might be of use in conjunction with lithotrity, where a large surface was exposed by fracture to the action of the solvent. Front,' writing in 1843, spoke hopefully of the solution of stone by medicine, but did not materially add to the previous knowledge of the subject. He. believed healthy urine to have in itself a certain amount of solvent power over concretions of lithic acid. Medicinally, in the treat- ment of such stones he recommended Vichy Avater, or the alkaline bicar- bonates, giving the preference to potash, which he advised in quantities of from one to two drachms a day, with an equal quantity of tartarated soda. He used these salts in solutions containing an excess of carbonic acid, in which shape he attributed them to a peculiar disintegrating power. He thought that by such means ''an impression might be made " on calculi in the kidney or bladder, but admits that the method is long, tedious, and uncertain. He restricts the use of solvents by injection to the employment of acids in the jihosphatic diathesis. More recently the subject has been resuscitated by the researches of Dr. William Roberts,^ which enable us to direct the old remedies with new precision; though it must still be admitted that the dissipation of stones of bulk by agents which have to traverse the general circulation is a matter of hope rather than experience. After this indication of the steps by which it has been reached, our present knowledge of the subject may be easily disjilayed, so far as it bears upon the subject of this treatise. Phosphatic stones are soluble in dilute acids. Uric acid, the urates, ' Marcet on Calculoxis Disorders, 1819, p. 152. ^ Coinptes Rendus, vol. xiv. p. 429. ^ On Stomach and Renal Diseases, 3d edit. p. 424 et seq. * Transactions Med. Chir. Society, 1865. " On Urinary and Renal Dis- eases," edit. 2, p. 290. ox THE TREATMENT OF STONE IX THE KIDNEY. 197 "and cystine are soluble in dilute alkalies. Oxalate of lime is not soluble in anything Avhicli the tissues can tolerate, and may be at once excluded from consideration. With regard to acid solvents, as there is no way of causing the urine to be secreted so acid as to act upon stones, they can only be ap- plied by the urethra and to the vesical cavity. Stones in the kidney are out of their reach. The coats of the bladder will endure a solution of nitric acid strong enough to produce the slow dissolution of phosphatic calculi, and I have seen this means resorted to, though vainly, in the treatment of a concretion of this character which was considered, justly, as it turned out, too large to be dealt with by either cutting or crushing. The case must be quite exceptional in which this tedious and uncertain method can be preferred to the recognized surgical expedients. It w^ould jseem to have its use, as long ago suggested, rather as an adjunct to lithot- rity than as a substitute for it. In a case mentioned by Dr. Roberts,' the fragments left after the operation Avere dissolved, and the formation of fresh phosphatic matter, to Avhich there was a great tendency, was prevented by the injection every day, or every other day, of a solution of two drachms of dilute nitric acid to a pint of water. The treatment of Tesical stones, however, to which only this method applies, is foreign to the design of this work. With regard to stones which remain in the kidney, the question re- duces itself, in the present state of our knowledge, to the solvent action of urine, alkalized by the mouth. Solvents can reach renal calculi only by secretion, and those only which are alkaline can be thus conveyed. The stones which we can ho])e to affect in this way are uric acid, the urates, and cystine; uric acid as the most common, must be chiefly con- sidered. The belief in the efficacy of lime-water as a solvent for calculi, which prevailed in the last century, with the evidence which was adduced, at least of relief by it, together with the present commendations to the same end, of calcareous waters, make it of interest to look somewhat narrowly at the powers of solution which this earth possesses, and can impart to the urine.* Lime-water out of the body will dissolve uric acid and disintegrate calculi mainly consisting of it, and lead to their destruction more readily, at least, than any of the alkaline carbonates. A piece of uric acid calcu- lus soaked in lime-water, which was frequently renewed, became so fri- able in three weeks as to break at a touch, while in six weeks it had crumbled so neai'ly to powder that no fragments remained but such as would have readily escaped by tlie urethra. Similar portions of the fiame stone scarcely lost percei)tibly in solutions of carbonate of i)otash and of ammonia; while in carbonate of soda and in carbonate of ammo- nia they underwent a slight increase of weight. Next to lime-water, the greatest disintegration in this experiment was effected by pure water. Thus, if lime-water could traverse the system as such, and reach the bladder with its jiroperties intact, it would clearly be an efficaceous and safe lithonthr3'ptic as far as uric acid is concerned. But it is sufficiently clear that lime given by tiie mouth cannot reappear in the urine either as the calcic oxide, or even as the carbonate. ' On Urinary and Renal Disease, 2d edit., p. 313. ^ Essay on the Virtue of Linie-Water and Soap in the Cure of the Stone. By Robert Whytt, M.D. Edinburgh, 17(31. Alston's Materia Medica, 1770. 198 ON THE TREATMENT OF STONE IN THE KIDNEY. The calcic oxide must necessarily form salts in the blood, and thus lose the activity which belonged to it before; while the earth can- not emerge in the urine as a carbonate by reason of the insolubility of that compound. It can reach the urine only as a salt, presum- ably a phosphate to which we have no reason to attribute any such solvent power as the alkaline earth possesses. But although lime cannot enter the urine in a free state, or as carbonate, it yet has the power of making the urine alkaline, and upon this depends any action it may liave upon uric acid. The urine may be made alkaline by lime- water, by the Liquor Calcis Saccharatus, or, more conveniently, by the acetate of lime, which is decomposed in the body, and has much the same ultimate effect as a corresponding quantity of lime-water. The amount of this water needed to make the urine alkaline is, of course, very large, as were the doses given of old — two quarts a day, for example. With the addition of the saccharate the same effect can be accomplished without preposterous dosage. Of the acetate I have found from 'Z to 12 drachms daily, according to age and circumstance, effective in making ordinarily acid urine alkaline. Lime thus given probably leaves the system largely by the bowels, but somewhat with the urine. It may sometimes be noted, however, that the urine becomes alkaline before it disphiys any increased precipitate with liquor potass*, or, in other words, before any of the lime so admin- istered has reached it. The alkalescence is due to the potash and soda which the lime has displaced. If the urine, therefore, in such a case has any solvent power, it owes it to these alkalies, not to the lime. In- deed, it is clear, from the reasons I have stated, that the lithonthryptic properties of this caustic earth cannot survive transit by the blood, in which phosphoric acid abounds ; but nevertheless it makes the urine alkaline, and thus a solvent of uric acid, whatever the immediate cause of the alkalescence be. But if lime is to make the urine alkaline by the agency of potash and soda, it only does indirectly and with concomitant risk what can be done directly and safely. Lime promotes the forma- tion of the oxalates in acid urine, of the phosphates in alkaline. The alkalies may, indeed, increase the deposition of the phospluites, but not of the oxalate. Lime, therefore, as a solvent of uric acid by the mouth is inferior to the alkalies. If the question were the solution of uric acid by injection into the bladder, lime would be more effective than any- thing but liquor potassge, than which it might prove to be better borne. But with lithotrity possible, injection need not be consitlered. It is scarcely needful to add a corollary touching the use of calcareous waters, such as those of Contrexeville, which have been vaunted as sol- vents or expellers of gravel. Contrexeville is a slightly alkaline calcareous water. It contains sulphate of lime in chief (in a proportion of about 1.2 in a thousand parts) with smaller quantities of the carbonates of lime, magnesia, and soda, and other salts. This is drunk at the rate of twenty or thirty glasses a day, with the obvious results of diuresis and sometimes purgation, and the reputed effects of bringing away gravel and relieving gout and vesical catarrh. It may well be believed that scanty urine may be made abundant, over acid urine not so, that gravel may be washed from tiie pelvis and tubes, and that the salutary conse- quences of irrigation may be wrought in a system loaded with the ]n-o- ducts of inactivity and excess ; but whether all this would not be better done by some non-calcareous water is a question to be asked. I do not know whether stone is especially common among the natives of Contrexe- ON THE TREATMENT OE STONE IN THE KIDNEY. 199 ville, bat we know enough of the endemic influence of calcareous water in our own country, to make us cautious in the use of it wliere a calculous proclivity exists. And it has been already sliown that lime-salts taken by the mouth impart no solvent ])ower to the urine which may not be equally given by other means. Lithia is more promising than lime in respect of the solubility of its carbonate, which appears to reach the urine and act there according to its kind. I shall postpone what I have to say of this earth until after the consideration of potash, with which it may with convenience be compared. Soda must be at once discarded. Urate of soda is a difficultly soluble substance of greater bulk than the uric acid of which it was formed, so that salts of soda may, under certain circumstances, lead to the increase of uric acid calculi rather than their decrease. I found that a fragment of a stone of this nature had added one- seventh to its weight in a week, by a rough incrustation which a solution of carbonate of soda had imparted to it. Hence, soda must be put aside, and with it the numerous waters, with Vichy at their head, which owe their alkalinity to it. A word may be said in passing as to the action of ammonia. Though this alkali is not secreted by the kidneys when given by the mouth, yet its carbonate is so often present in the urine as a product of decomposi- tion, that its action upon stones is not without interest. Ammonia and its carbonate have in water an effect upon uric acid which is comparable to that exerted by the fixed alkalies and their carbonates — forming an urate which may be either dissolved or left as an incrustation — but in urine ammonia, whether free or as carbonate — the carbonate only need be considered — produces such a deposition of the triple or mixed phosphates that any stone which may be present is both increased thereby and pro- tected from any solution that might otherwise be possible. Neverthe- less, it may be supposed that if an uric acid stone or part of it be kept clear by friction, a certain amount of solution may in course of time be produced by the ammoniacal products to which itself has given rise, and thus may probably be explained the signs of spontaneous solution which are sometimes to be discerned upon the calculi. Dr. Eoberts came to the conclusion that salts of potash were more effective as solvents of uric acid calculi than those of soda or lithia, and that of carbonate of potash in particular, the solvent power was up to a certain point increased by dilution, the maximum action upon the uric acid belonging to a solution of sixty grains to the imperial pint. With increasing strength the solution was arrested by an incrustation of biurate of pota.sh,' insoluble in all but very dilute solutions, which pro- tected the stone from further action. AVith solutions containing from forty to sixty grains to the pint, tiiere was scarcely any accumulation of this material, as it was removed as fast as formed; with eighty grains there was a loose, with 120 grains, a tenacious coat. Having ascertained the material and the strength of solutions which have'the greatest })ower of dissolving uric acid out of the body, the next step is to impart to the urine within it the needful amount of tiie need- ful substance. The salts which the alkalies form with the vegetable acids appear in the urine as carbonates, a fact which as regards citrate of potash Avas originally pointed out by Sir Gilbert Blane. AVith potash, for example, the urine will equally contain its carbonate whether the ' See Dr. Robei-ts on the solvent power of strong and weak solutions of the alka- line carbonates on uric acid and calculi. Report of British Association for 1%Q\, p. 90. 200 ON THE TREATMENT OF STONE IN THE KIDNEY. alkali be given in a caustic state, as bicarbonate, or as tartrate, acetate, or citrate. Of these preparations the citrate a])pears to create tlie least disturbance. It may indeed be given in quantity sufficient to keep the urine alkaline for an almost unlimited time without injuriously affecting the stomach or bowels, without causing vesical irritation, Avithout causing the patient to lose weiglit or strength, or hurting the health in any man- ner. A man whom I treated unsuccessfully for a presumed uric acid stone in his kidney took a drachm of citrate of potash every four hours for nearly five months, during which time his urine was constantly alkaline. Under the treatment he gained slightly in weight, lost an appearance of anaemia which he had at its commencement, and improved in general health. Sligiit nocturnal frequency of micturition was the only undesir- able consequence which was noticed. From this and many similar ex- periences, including those afforded by the alkaline treatment of acute rheumatism, it is certain that most persons can take the citrate of potash and other neutral salts of the alkalies in considerable doses, and for a considerable time, without liarm. I must here say a Avord about lithia, which as a lithonthryptic is more encouraging to the chemist than the physician. Dr. Garrod, as is Avell known, has been led to the belief that this earth is a more active solvent for uric acid than potash, Avhile Dr. Eoberts has come to the contrary conclusion. I have made many experiments, in which fragments of uric acid stones have been exposed under the same circumstances to the action of carbonate of lithia and carbonate of potash, and I have found as a constant result that outside the body the earth has dissolved more than tlie alkali. Among others I may briefly relate three. Of the first the subject was a small stone, nine-tenths of which consisted of uric acid and urates, one-tenth of phosphates. Three similar portions, each weighing .377gramme, were suspended each in six pints of liquid, one in distilled water, one in a solution of carbonate of potash, a drachm to each pint of distilled water, one in a solution of carbonate of lithia of the same strength. After nineteen days of the month of June the stone in water was found to weigh .365 gramme, that in potash .254, much encrusted, that in lithia .091, clean and so friable as to crumble at a touch. The Avater had taken aAvay a thirty-first, the potash a third, the lithia three-fourths. Another experiment dealt with two similar por- tions of a large stone of almost pure uric acid, each of Avhich Aveighed 2.775 grammes. One of these Avas suspended in a solution of carbonate of potash in distilled Avater, half a drachm to 10 ounces, the other in a similar solution of carbonate of lithia. Both were kept in a Avater oven at a mean temperature of 100° Fahr. ; the solutions Avere changed every day but the stones not touched. After four days and nights, the piece in lithia had become so attenuated that the experiment Avas discontinued lest there should be nothing to shoAv; what remained Aveighed .404 gramme, six-se\'enths having gone; what Avas left was uncoated and ex- tremely friable. The piece in potash Avas covered Avith a brittle Avhite crust including Avhicii it Aveighed 2.053, having lost a little over a quarter of its Aveight. In the last experiment to which I need refer, tAvo portions of the same stone as in the preceding were treated similarly in all respects except that they were brushed tAvice a day so as to remoA'e any crust which might form, as might be presumed to be done Avithin the body by movement. Each piece Aveighed at starting .728 gramme. After tliree days and nights the stone in lithia had been reduced to .042, and in potash to .225. The inferior result from the potash thus appears to be ON THE TREATMENT OF STONE IN THE KIDNEY. 201 due not only to the protecting effect of the crust which forms more abun- dantly with this agent, but to the superior solvent power of the lithia upon uric acid. Accepting this conclusion as constant out of the body, we come to the most unsatisfactory part of the question. The salts of litliia, whether carbonate or citrate, are not tolerated in anything like the quantities in which potash can be generally given with impunity, and cannot be suita- bly employed so as to keep the urine constantly alkaline. Whatever value lithia may have in doses short of this result, it appears that enough to accomplish it generally produces disagreeable consequences — headache, sickness, trembling, and dimness of sight. I have given for short periods as much as half a drachm of the citrate or carbonate every four hours, with the effect of rendering the urine quickly and decidedly alkaline; could we continue the drug in anything like these quantities we might find the solution of caculi within the body practicable, but it is sufficiently clear that such doses cannot be long borne, and indeed it would appear that in ordinary circumstances the alkalinity necessary to the solution of calculi cannot be long maintained by lithia with- out such constitutional disturbance as would call for its discontinu- ance. It must be borne in mind that there are those to whom alkalies of any kind are i'»eculiarly inimical. The class is small but easy of recognition. The disturbances which belong to it, as elsewhere detailed, though often having a superficial resemblance to those in which alkalies are of use, present essential differences to them. The individuals referred to are of nervous temperament, and have one form of what has been called the phosphatic diathesis. The urine, which may be naturally or over acid, but perhaps more often is wanting in acidity, is pale, copious, and gives a bulky precipitate with liquor potassae in consequence of the excess of earthy, chiefly of lime, salts which it contains. Oxalate of lime and the crystal- line phosphate are of frequent occurrence as spontaneous deposits, and if calculi are found they are apt to be of the oxalate or some other earthy salt. Uric acid is seldom thrown down. Lithates, if they occur, are pale, not red. These characters of the urine are conjoined with a sensi- tive, mobile, and often intellectual character. There is bodily as well as mental activity, and an aspect tending to i)allor, or at least not rubicund. Such persons are tremulous, neuralgic, and liable to slight and partial ana3sthesia, especially as numbness in the legs. The tongue is apt to be tremulous, and as if boiled, anasmic, uniformly coated, and wliat is called oedematous. All these conditions are aggravated by mental dis- turbance, under which the amount of lime in the urine is at once in- creased, possibly as an evident crystalline deposit. With these persons gout take an asthenic shape; if they have rheumatic fever it is not with the acute symptoms and acid overi)lus common to others, or with the same liability to cardiac complications. Thus their diseases do not sug- gest alkalies, and should such drugs be inadvertently administered their inappropriateness is shown by early alkalinity of urine, the aggravation of any neuralgic symptoms that may exist, the tongue at the same time turning more white, sodden, and shaky, and by increasing malaise and nervous prostration. Persons in general, however, and especially those who deposit uric acid, endure alkalies well enough to allow of their free and protracted use. By such means considerable vesical stones have been so acted upon as to show, after their removal from the bladder, evident signs of solution; small ones have, it is believed, been entirely dissolved 202 ON THE TKEA.TMENT CF STONE IN THE KIDNEY. or reduced to viable size. With stones in the kidney, this amount of success, small as it is, appears to have been seldom attained,' though Dr. Ralfe has recently related an instance in which one came away in an at- tenuated state, owing as was thought to alkalies and soft water. Stones in the pelvis are probably less effectively exposed to the action of the urine tiian in the bladder. Renal calculi are washed, vesical are soaked. The bladder usually contains urine in which the stones lie more or less completely and constantly exposed to its influence. The pelvis is gener- ally empty, or nearly so, the urine leaving it, except under constrained positions of the body or morbid obstruction, almost as fast as it enters, so that calculi here lodged are only acted upon, and that transiently, by as much of the secretion as trickles over their surface. The solvent plan must, as has been shown, be practically limited to concretions composed almost entirely of uric acid or urates, or the two together. With this in view it becomes of importance that we should know the numerical chance that the stone is of material thus soluble. The table (page 122) which has been already explained, was compiled with this object. Thence it appears that of ninety-one renal calculi in the museums of London, twenty-one were wholly composed of uric acid, three of urates, seven of uric acid and urates together, and two of cystine. These, thirty-three in number, comprise all, even theoretically, assailable by alkaline solvents. For practical pur- poses we may exclude the rare cystine stones, the solution of which has as yet received little attention, and regard as amenable to the alkaline treatment, only those calculi which consist of uric acid and the urates. These, as it is seen, comprise almost exactly a third of the whole number. It must be borne in mind, however, that the calculi enumerated were with few exceptions taken from the body after death. They had, therefore, had the utmost time to gather phosphates and re- move themselves from the class of soluble stones. It is probable that, at an earlier period, a few of them may have consisted wholly of uric acid and been possible subjects for solution. But it is evident from the fact that the compound calculi have more often a nucleus of oxalate of lime than of uric acid, that the number at any time soluble by alkalies never could have amounted to one-half. It may be observed that thirty-nine of the ninety-one calculi whicii contained either a phosphatic deposit or carbonate of lime, had necessarily been associated at some period of their growtii with alkaline urine, and were therefore not only insoluble in alkalies but were liable to derive fresh accretion from alkalization. It will be readily inferred that the causes of renal calculi amenable to alka- line treatment are proportionately few. The stone must be of pure uric acid, or at least must contain no admixture but urates. It must also be of small size. If the urine be alkaline, it may be presumed that a phos- l^hatic crust exists, and all such cases must be discarded. If the stone be of long standing, a similar condition must be suspected, notwithstanding that the urine retains its acidity, and a similar encasement must also be apprehended, should the urine contain much pus or mucus of renal origin. If oxahite of lime habitually exist in the urine, it may be pre- sumed also to occur in the stone, and must also contra-indicate solvent remedies. In the absence of all these prohibitions, perhaps the least hopeless subjects are children. Uric acid concretions occur especially at an early 1 Path. Trans., vol. xxxiii. p. 20G. ON THE TREATMENT OF STONE IN TilE KIDNEY. 203 age, and when crystals are habitually passed it is often easy to arrive with some confidence at a belief that there exists a small renal stone of this nature. With children the stone, necessarily recent, is probably small and simple. Given a suitable case, citrate of potash must be accepted as the best material for charging the urine with the desired carbonate; the dose to impart the greatest solvent effect is for the adult, as Dr. Roberts has shown, from 40 to 60 grains every three hours, in three or four ounces of water. Two conditions may arrest the solvent process. If the urine become ammoniacal the treatment must be discontinued, as then the mixed pliosphates will be apt to be deposited as an insoluble crust. It is beyond question that by this state of urine stones have often been increased and multiplied. Secondly, it is needful to guard against a too great alkalinity of urine from fixed alkali, since, as has been shown, under this influence the stone may become incrusted with the in- soluble alkaline biurate. Thus dangers of two kinds lie in the direction of over-alkalinity. It is safer to give too little alkali than too much. It is a matter of common experience that the symptoms caused by the passage of uric acid gravel receive marked and speedy relief from alka- line solutions, but I have never been successful in removing by such means the signs of a stationary renal concretion. In cases where un- mistakable symptoms of stone in the kidney have been associated with highly acid urine and the habitual passage of uric acid gravel, so that the nature of the concretion was scarcely more doubtful than its position, I have kept the urine alkaline with potash for periods varying from two to five months. Under such treatment, without injury to the general health, the local symptoms have mitigated, but they have never disap- peared. The benefit has declared itself in a diminution of pain, with in- creased tolerance of rough locomotion and improved power of walking. A lady whose walks had been restricted to a mile a day by pain in the loin, leg, and foot, attributed to a concretion of uric acid in the left kid- ney, became, under alkalies, able to walk four miles with no more in- convenience, and she subsequently endured much rough travelling with little annoyance, which it was thought she could not have done previous to the treatment. Beyond such alleviation of symptoms my success in the solution of calculi has not gone. To sum up, the solution of stones whether in the bladder or kidney, is not yet within the range of practical medicine. Lithia is not well borne; potash out of the body in the most favorable circumstances acts slowly; within the body, there is the uncertainty as to the nature of the stone, and the suitability of alkaline treatment. When in the bladder, any such tedious and worse than uncertain method can never be opposed to the operation of lithotrity, though when it is impracticable, or as an adjunct to it, acid injections may find the use which has been assigned to them. As to the kidney, enough has been said to show that no methods which have as yet been tried are substantially effective; if the solution of calculi is ever to be accomplished it must be from a new departure. OHAPTEE XY. MISPLACEMENT, DISPLACEMENT, AND MOBILITY OF THE KIDNEY. MiSPLACEMEJS'T. Before considering the movable kidney, which may either be con- genital or acquired, a word may be said about congenital misplacement of the organ so far as this condition is capable of clinical recognition or has practical importance. The common horseshoe fusion of the two kidneys hardly comes within this description, but one kidney has often been found to be misplaced downwards, either upon the lower part of yertebral column on its own or the oj)posite side, often upon the sacro- iliac promontory or the sacro-iliac synchondrosis. The organ has been found in one of the iliac fosste, or partially or entirely within the j)elvis. It appears that the development of the renal structures commences in front of the bifurcation of the aorta, and that the ordinary misplace- ment of one of these organs is due to its retention in or near its original situation. The misplaced organ usually presents itself as a post-mortem surprise, though its situation is often such that it could not fail to have been felt as an abdominal tumor had there been any symptoms which suggested palpation of the abdomen. The kidney thus out of place has indeed been so recognized, and in one instance extirpated in circumstances which will be presently referred to. A gentleman, aged 45,' whose case is related by Mr. Durham, had an attack of fever, during convalescence from which a swelling was noticed in tlie hypogas- tric organ, somewhat to the left of the median line ; it Avas oval, elastic and fixed, not nodulated, nor did it present any distinct elevations or depressions. j\Ianipulation caused disagreeable sensations, but not acute pain. No conclusion Avas arrived at as to the nature of the tumor. Five years later it was exposed, ^;o.s^ mortem, and found to be the left kidney, which was situated over the sacro-iliac synchondrosis and extended some- what on to the promontory of the sacrum, and also by its lower part into the true pelvis. The colon formed no sigmoid flexure in the left iliac fossa but passed across the median line, and the commencement of the rectum was on the right side of the sacrum. The kidney was partially divided into three lobes. Four ureters left it, which shortly united into one ; there was no distinct liilum, and consequently not the characteris- tic kidney shape. The organ received three arteries, the largest from the aorta near the bifurcation, a branch from the right common iliac, and one from the left internal iliac. The supra-renal capsule was in its normal position. 'Paper bv Mr. Durham "On Misplacement and Mobility of the Kidneys " Guy's Hospital Reports, 186U, p. 408. MISPLACEMENT AND MOBILITY OF THE KIDNEY. 205 The misplaced kidney has been known to form an impediment to labor, as in one instance quoted by Rayer, in which it was found after death deeply situated on the inner side of the psoas muscle. ' Two chil- dren had been borne ; with the delivery of each a tumor was recognized on the left side of the pelvis, which became painful with each contrac- tion of the uterus and retarded the passage of the head. Congenital misplacement of the kidney is in a considerable majority of instances of the left, and in the male sex ; acquired dislocation or mobility chiefly alfects females, as will presently be seen, and the right side. Displacement and Mobility. The kidney is apt to be displaced or to become movable as the result either of acquired or congenital states. It is sometimes completely sur- rounded by peritoneum, the folds of which meet behind, like those of the mesentery, forming what has been termed a mesonepliron, which may allow so much liberty of movement that the organ may be immediately beneath the abdominal wall or elsewhere, far from its proper position. In other circumstances the kidney becomes loosened in its bed, so as to be capable of being moved within it, but within which its movements are limited. It is ordinarily covered by the peritoneum, but not embraced by it, nor, putting aside a long anchorage from the hilum, is the organ fixed in the interval in which it lies otherwise tlian by the cohesion of the areolar tissue around it. A temporary increase in the size of the gland can easily expand the inclosure which it occupies, so that this, when the enlargement has subsided, is too wide for the structure within ; or any force brought to bear upon the organ may cause it to split its encase- ment in one direction ot another, and thus come to occupy a cavity which is too large for it, and within the limits of which it can move. In the first of these circumstances the kidney may float ; in the second, without floating, may become movable. The movable and the floating kidney may be distinct in origin and nature, the movable kidney an ac- quired, the floating a congenital state, or they may be merely difiierent degrees of the same condition : the peritoneum may become loose enough to enfold the kidney and meet behind it, much as though the mesone- phron had been an original structure. The displacements of the kidney thus described have no tendency in themselves to cause death, and are far more often met with during life than afterwards ; nevertheless they have been exposed with sufficient frequency to give a pathological foundation to our clinical knowledge. I believe that acquired mobility of the kidney is more common tlian it is generally supposed to be. I have notes of eleven cases of it Avhich I have seen during the last five years. The movable kidney is usually found in women, and on the right side. Eoberts estimated that of 70 cases Gl occurred in women, 9 in men ; Ebstein, that of 96 cases 82 were in females, 14 in males. To these I may add 12 cases of my own, as yet unpublished, of Avliich the subjects were females in 10 cases, males in 2. As to age, the disorder is exceedingly rare in childhood ; the earliest instance I have seen was in a girl of 10, in which mobility was associated with, probably, congenital displacement. Instances have been recorded at the ages of 8, 7, and G ' Rayer, loc. cit. vol. iii. p. 774. 206 MISPLACEMENT AND MOBILITY OF THE KIDNEY. years. In a large majority of case^ the peculiarity presents itself in early adult and middle life, coincidently with the j^eriod of child-bear- ing, and the frequency of accidental violence. It has been said that the subjects of the movable kidney are always thin, a statement by no means consistent with my own experience. I have seen it most often in women with large, loose abdomens, often in- clined to corpulency. With regard to the side affected Ebstein — to quote his enumeration as the latest and largest — found that of 91 cases, the right kidney was affected in 05, the left in 14, both in 1^. Among the 12 instances re- ferred to, 10 belonged to the right kidney, 2 to the left. The condition is usually acquired after birth, though sometimes the result of a congenital peculiarity of the peritoneum. Mr. Durham' re- ports a case in which this membrane presented an abnormal arrange- ment which was associated with malposition of the colon. In this in- stance the affected kidney, which was the left, could Ije made, after death, to ya&s from its proper position into the left iliac fossa, and also across the spine, somewhat to its right side. It once happened to me to observe in the course of the post-mortem examination of a person in whom no renal symptoms had attracted at- tention that the layers of peritoneum met behind one kidney, forming a complete mesonephron about an inch and a half long, to the extent of which the organ enjoyed free play. This arrangement, of which several similar examples have been recorded, was probably congenital. As to the acquired conditions, the organ has been known to have been dis- placed downwards, in connection with a hernia which involved the caecum, possibly dragged down by the descending bowel. Usually the state found is mere looseness of the peritoneal covering by which, to- gether with the structures which enter the liilum, the kidney is held in place. The amount of mobility varies much; the gland usually slipping down for an inch or two under pressure or change of posture, some- times moving, as in a case referred to in the "Pathological Transac- tions," ^ within a circle having a diameter of eight or nine inches. The kidney itself has in most cases been found to be healthy, though some- times its condition and environment show changes which account for its' peculiarity, and sometimes alterations which are subsequent, and possi- bly consequent, upon it. A deticiency of the circumrenal fat has been often noticed, and the mobility of the organ found to follow upon rapid emaciation. An instance in which the organ had probably thus become loosened in its bed by losing its packing has been reported by Dr. Jago,3 and others of the same sort have been recorded. Mobility of the kidney has been associated with p3'elitis, as in an in- stance within my own experience to which I shall presently refer. Dr. Sawyer' relates the case of a woman W'ho died at the age of thirty-five Avith svmptoms of a right movable kidney and pyelitis. She had had seven children, and for six years had had pain and frequency in passing urine. Latterly the urine had contained much pus, evidently ' Durham, Ony's Hospital Reports, 1860, vol. vi. p. 413. ' Report of Committee on Displaced, Movable, or Floating Kidneys, Path. Trans, vol. xxvii. p. 467. 3 Medical Times, September, 1872, p. 329. ■* Paper on " Floating Kidney," by J. Sawj^er, M.B., Birmingham Medical Re- view, 1872, vol. i. p. 120. See also report by Dr. Hickenbotham, Brit. Med. Journ. December 24th. 1870. MISPLACEMENT AND MOBILITY OF THE KIDNEY. 207 of renal origin. She died of acute peritonitis. The right kidney which lay between the umbilicus and the anterior superior spine of the ilium was riddled witli abscesses, and the ureter dilated and thickened. We have no evidence of the cause of the pyelitis in this case, or whether it preceded or followed the mobility, but the fact of the association is of interest. The same concurrence is to be seen with hydronephrosis, as in one instance related by M. Fritz.' A woman of the age of thirty-three, who had long had pains in the right iliac fossa, w^as found to i)resent an oval tumor in tliis region which had the character of hydronephrosis. The tumor, which extended from the lumbar to the umbilical region, was movable in all directions. After a time a calculus was passed, and the tumor much diminished, still remaining movable. Another instance of a similar association is related in the same paper from the experience of M. Urag. A woman wdio was the subject of bronchitis was found to present a reniform tumor in the abdomen below the anterior border of tlie right lobe of the liver. This moved with re- spiration, and could be displaced towards the median line, towards the right lumbar region and slightly downwards. Manipulation caused con- siderable pain. After death it was found that the tumor was the right kidney, Avhich was attached by old adhesions to the liver, the gall-blad- der, and the transverse colon. The organ was hydronephrotic, the ureter being occluded, inconsequence of ^'engorgement" of the posterior wall of the uterus. In the latter case the condition was complicated by the adhesions which occurred in the course of the disease ; but in both it is probable that the essential cause of the mobility was the alternation of bulk which the condition of hydronephrosis generally involves. Whether a-soeiated with pyelitis or hydronephrosis, there is not in- frequently a history of calculus or gravel in connection with the movable kidney — accidents which particularly tend, to cause the variation of bulk which are so ajit to loosen its attachments. To complete the morbid anatomy of the condition before further dis- cussing its mode of origin, the kidney, though usually healthy, has been found to have become affected in various ways, either consequently upon its mobility or independently of it. The most common change is peri- nephritis, as indicated by peritoneal thickening, and occasionally by adhesions to the neighboring organs— especially the liver. The fre- quency of pyelitis in this relation suggests that the inflammatory state may occur not only antecedently, but also as a consequence of the mobil- ity by means of the constriction of the renal outlet which the shifting must often involve. The displaced or movable kidney is not thereby exempted from other chances of disease. It has been found to be granu- lar, as in an instance related by Dr. Coats. ° The causes of the condition are in great part explained by its morbid anatomy. Loss of bulk, whether in or about the kidney, whether the escape of an accumulation from the pelvis Avhereby the kidney shrinks so as no longer to fill its bed, or loss of the surrounding fat so that its bed becomes too large for it, has been sufliiciently dwelt upon in con- nection with its origin. It remains to add what is needed to make the tale complete. The kidney appears to be often displaced by external pressure or violence. The leading facts in the distribution of the pecu- ' Paper by M. Fritz on " Floating Kidneys," Archives Generales de Medecine, 1859. A'ol. ii. p. 168. Path. Trans., vol. xxvii. p. 469. 208 MISPLACEMENT AND MOBILITY OF THE KIDNEY larity. its frequency with women, and on the right side, may point to intiuence of pregnancy, of tight lacing, and of the pressure of the liver. It has been observed that movable kidneys are most often found in wo- men who have borne children, and that after delivery the abdominal muscles are lax, and the viscera comparatively unsupported. Of twelve cases of movable kidney under my own observation, the subjects of nine were women who had had children, though one of these attributed her disorder not to pregnancy but to severe and repeated exertion in lifting a sick husband, and another to a fall upon tl>e right lumbar region. Fig. 1.— Misplaced left kidney with two Fig. :i.— Movable right kidney in a man. faecal masses . Fig. .3.— Movable right kidney in a woman. Fig. 4.— ^lovable riijlit kidney in a woman One of my patients became aware of the mischief upon recovering from chloroform, Avhich had been given during labor ; another at- tributed it to violence used in the extraction of the placenta by an in- ebriated accoucheur. The condition had been somewhat doubtfully attributed in the same sexto a hyper.Tmic swelling of the organ supposed to occur at each menstrual period and subside with it. Tight lacing by which the liver is pressed down upon the right kidney has been assigned as a cause of its becoming loosened and displaced; and the same result has been with more certainty traced to strains and falls and other violent MISPLACEMENT AND MOBILITY OF THE KIDNEY. 209 injuries. It has been said, though my own personal experience scarcely bears out the statement, that movable kidneys are proportionately more often met with among women of the working class than amongst those in easy circumstances, with whom tight lacing is more common. A gentleman under my care, whose case will be further referred to, attributes the peculiarity which affects the right kidney to repeated falls in hunting. An instance is related ' in which the left kidney became thus movable inconsequence of a fall upon the ice, and another in wliich both became so after a fall from a horse. A laborer ^ over whose loins a cart passed was found by Dr. Yeo to present afterwards the signs of movable kidney. With regard to the clinical aspect of movable and displaced kidneys, the latter, so far as congenital malposition is concerned, need no further notice than has already been given them. Movable or floating kidneys, however, have much importance from this point of view. They are to be Fig. 5.— Right kidney extensively movable. Fig. 6.— Right kidney extensively movable. recognized by the presentation of a tumor of renal size and shape in a position not 1)elonging to the kidney, from which, under pressure, it withdraws itself in the direction of the proper renal region. The pecu- liar slipping of the movable kidney under the influences of pressure and position, at once distinguishes it from every other abdominal tumor; it moves like the testicle in the scrotum or a pea in its pod. The organ emerges from the depths of the liypochondrium, commonly the right, to present itself as a tumor tangible from the front or lateral aspect of the abdomen. The position of the tumor has a wide range: it nuiy not de- scend further than as if the lower end of the kidney protruded from under the edge of the ribs, or the organ may pass as low as the umbili- cus or even into the iliac fossa, and occupy almost any i)art of the S})ace between the lateral limit of the trunk and the median line, which boundary, indeed, is sometimes partially crossed by the erratic mass. 14 ' Roberts, loc. cit. 3d edition, p. 014. ^Brit. Med. Journ., June 6th, 18y4, p. 744. 210 MISPLACEMENT AND MOBILITV OF THE KIDNEY. The lump suddenly presents itself from under the ribs from the effect of bodily movement — the patient possibly turning on the side on which the movable kidney is not — or of deep inspiration, perhaps undertaken with the purpose of displaying the condition. The rounded and reniform mass may then be more or less grasped, and made by directed pressure to hastily withdraw itself in the direction whence it came, gliding at once out of reach, giving to the fingers a sensation as if it were slippery. When the organ descends, its absence can be detected from the lumbar region by hollowness and comparative resonance. The displaced kidney may be near the surface, though usually not so superficial but that bowel resonance can be detected over it. The pulsation of the renal artery has been felt, though the mass is seldom sufficiently suj^erficial to allow of this. Sometimes it is very deep, only to be reached by somewhat forci- ble palpation, and even may be distinctly recognizable only when the abdominal resistance is overcome with chloroform. Pressure on the or- gan usually gives rise to a sickening sensation. The shifting may be quite or nearly without discomfort, or may be attended with much pain and intestinal or nervous disturbance, symp- toms which are probably largely due to the tension or forced flexure of the nerves which enter the hilum. The pain is often described as of a dragging character. It chiefly accompanies displacement of the organs, though in some cases always present more or less. It is aggravated by movement and relieved by lying down. It stretches from the lumbar region to the tumor, which is apt to become tender, and often shoots in various directions, into the testicle or labium and down the thigh. I have known a patient so suf- fering to have severe pains of a neuralgic character in parts of the body not locally connected Avith the affected part. The pain of the movable kidney has been observed, as with a patient of my own, to become aggravated at the monthly periods, and the dis- placed organ thought to swell. A peculiarity of the disorder is the oc- currence at irregular intervals, and often without any obvious cause, of severe attacks of pain Avith constitutional disturbance, not unlike fits of renal colic. The displaced organ swells and becomes exquisitely tender, and cannot be replaced. There is intense pain in its neighborhood, to- gether with shivering, sickness, and prostration. "With a lady under my care, the attacks recurred about every five or six days, each lasting ten or twelve hours. -The jmin was described as ver}' severe, passing through the abdomen under the liver to the spine. These were attended with vomiting and extreme prostration. They subsided under the influences of morphia and rest in bed. These seizures have been thought to depend upon retention of urine in the pelvis, owing to some twist or compression of the renal outlet, but the evidence of this is incomplete, and indeed with the remarkable toleration of obstructive suppression when it affects only one kidney, we can scarcely assign the severe and sudden symptoms wliicli have been described to this origin. It has been supposed with more probability that a sharp bend or twist of the renal vein, with consequent congestion and swelling of the organ, is more particularly concerned in the production of these paroxysms; at the same time it must be allowed that their symptoms, apart from the swelling, tlie pain, vomiting, and prostration, show at least that the nerves are closely implicated in the passing disorder, even if not its primary cause in some mechanical man- ner connected Avith dislocation. MISPLACEMENT AND MOBILITY OF THE KIDNEY. 211 Vesical irritation and frequency have occasionally' been noticed. A gentleman, who applied to me with a movable kidney, had, at the time of its appearance, symptoms which were attributed to cystitis. When I saw him some weeks afterwards, I found that the urine was phosphatic, but free from pus; I presumed that the irritation might have been purely of nervous origin. Various forms of bowel disturbance are frequently noticed in connection with the condition. A gentleman under my no- tice who had a movable right kidney, found that occasional diarrhoea was the chief trouble it caused. Tlie diarrhoea was connected in sensa- tion with the movable organ, and was always brought on wlien, by in- creased bodily movement or mental excitement, the pain in it was made worse. In a case mentioned by Dr. Roberts, also of a movable right kidney in a man, there was much irritability of the bowels, associated with dragging pain in the situation of the kidney and ascending colon. Constipation and faecal accumulation have also been found. A girl of 10 years old under my care had a misplaced kidney, which lay near the surface of the belly to the left of the umbilicus. She had at the same time a number of superficial lumps in the abdomen, which were re- moved by purgatives, and no doubt were f«cal. An instance is recorded by Dr. Johnson^ in which accumulation of the same nature had simi- larly resulted. A displaced right kidney has been known, as in an instance recorded by Girard,3 to compress the vena cava and cause a3dema of the right lower limb. Jaundice has been produced by the compression of the common bile-duct by a dislocated kidney, which was in contact with the transverse fissure of the liver* and adherent to the duodenum. The kidney may be diseased independently of its displacement, but, putting this aside, the only urinary changes proper to this condition are such as give evidence of pyelitis. When this complication is not present the urine is natural. Evidences of pyelitis, possibly only microscopic, scales of epithelium, presumably from the pelvis, and perhaps a few pus-globules, are found more often than not with such cases, while in some the urine is abundantly purulent, showing a high degree of the same inflammatory state. It is clear from what has been already stated that some conditions associated Avith pyelitis may precede and cause the mobility, but it is no less probable that the necessary distortion of the pelvic outlet may in some cases prevent the free escape of urine, and thus produce results due to its retention. The diagnosis of the condition presents little difficulty ; the peculiar mobility is pathognomonic. A movable kidney has been mistaken for the spleen, and frequently for a morbid growth within the abdomen. Women who have had them have been known to persist that their move- ments were those of a foetus i)i utero. As the disease has little tendency either to shorten life or to get well, its duration is absolutely indefinite. Among 11 cases under my own ob- servation, where the date of beginning was noted, was 1 in which the condition had lasted for thirteen years, 1 for six, 3 for five. Dr. Jago " * jritz, Archives Generales de Medecine, 1859, vol. xiv. p. 171. ^ Med. Times, October, 1859, p. 426. ^ Journal Hebdomadaire des Proqres des Sciences Medicales, 1836, vol. iv. p. 445. * Brit. Med. Journ., January 29th, 1876. 5 Med. Times, September, 1872, p. 328. 212 MISPLACEMENT AND MOBILITY OF THE KIDNEY. mentions one instance in wliicli it had been present for twenty-three years. Death usually occurs from some cause unconnected with the state of the kidney, though where it has been associated with pyelitis a fatal issue has been brought about by this complication. A woman' under the care of Dr. Hickenbotham, whose case has already been referred to, had a floating right kidney, together with pyelitis, as evinced by the passing of pus, blood, and phosphates with the urine. Fourteen days before her death she was seized with pain in the movable kidney, which she had not had before, followed by symptoms of peritonitis. It was found that, in addition to general inflammation of the peritoneum, the right kidney was riddled with abscesses, and its ureter dilated and thickened. The peritonitis had probably been produced by the renal suppuration, that by the pyelitis. No cause apjjears for the j^yelitis be- sides the displacement. The medical treatment of the condition essentially consists in the replacement of the organ, its retention in its proper position, and the relief of the pain to which its displacement gives rise. A simjile and often sufficient measure of relief is the recumbent posture. The avoid- ance of riding on horseback, and all rough exercises and modes of loco- motion, and straining at stool, is no less obvious. A woman, whose case is mentioned by Dr. Hare,^ lost her symptoms almost entirely under the influence, as was thought, of two successive pregnancies, the enlarged uterus supplying the needed upward pressure. Artificial sup2:)ort by means of a belt or truss has often been used with advantage.- For a lady who suffered from severe and frequent paroxysms of pain, con- nected with a movable right kidney, I had a truss constructed with a powerful spring, of which one end rested od the spine, the other pressed a conical pad, with a spiral spring, deep into the right hypochondrium. This instrument proved so effective that whereas the attacks formerly recurred every five or six days, after its application the lady passed six months with only one, which had been brought on by exceptional exer- tion. The objection to a truss is the inconvenience of the necessary pressure. A less uncomfortable measure, but one which is found in some cases to suffice, is a broad elastic belt, fitted to the shape, with a firm pad upon the hypochondrium. I have at present five ]')atients who wear with advantage renal supports, three trusses, two bandages. Dr. De Mussy arranged, with benefit, that a lady, whose right kidney had become loose, should have an action of the bowels every evening, and before rising in the morning — that is, before the organ had become displaced by movement — should slip upwards over the lower extremities an elastic bandage, to which a horse-hair pad was so fixed as to press in front of the affected lumbar region. The urgent paroxysms of pain and vomiting which are sometimes attributed to strangulation of the ureter, but which are more probably due to stretching or twisting of the nerves or veins, are to be treated with absolute rest and morphia, the replacement of the organ when this can be accomplished without violence, and such measures as leeching and fomentation, should symptoms of local peritonitis present them- selves. The attacks usually appear to be of brief duration. ' Paper by Dr. Sawyer, Birmingham Med. Review, vol. i. p. 130. "^ Med. Times, January, 1853, p. 112. MISPLACEMENT AND MOBILITY OF THE KIDNEY. 213 Importance must be attributed to the regulation of the bowels; while the anjemic, hyijochondriaeal, and neuralgic conditions so common with the disorder call for ferruginous medicines and others of the tonic class. Pyelitis, gravel, or phosphuria may call for appropriate modifica- tions of the treatment should these complications present themselves. Regarding the movable kidney, as we must, not so much as a danger as an inconvenience, and an inconvenience which can be mitigated almost to nothing by safe and jjainless measures, it can seldom be justifiable to risk life in search of cure. Nevertheless, kidneys in this state have been removed often enough to enable us to measure with some accuracy the death-rate of the operation.' Martin, of Berlin, states that he has excised a floating kidney in seven cases, with the result of four cures and three deaths. He always cut from the front throilgh the peritoneal cavity. The operation was once performed by Meckel,- also from the front, with a fatal result, and by Smith, of New Orleans, from the loin, with a favorable one. Thus with nine excisions there were four deaths. Dr. Harris, of Philadelphia, in a recent collection of one hundred cases of extirpation of the kidney, includes sixteen in which floating kidneys were thus treated.' Putting aside one in which the re- moved organ was the seat of sarcoma, and the result fatal, there were five deaths to ten recoveries, surgical enterprise having thus provided a considerable mortality for a disorder which of itself has little or none. A startling case is reported by Dr. Polk, of New York, in which a pain- ful tumor in the left iliac fossa, which was supposed to be what it ulti- mately proved, a misplaced left kidney, was removed from a young woman in whom, as has been ascertained, the vagina and uterus were absent.* The patient survived the operation for eleven days. It was afterwards found that the kidney of which she had been thus dejirived was her only one. No trace could be found of any structure correspond- ing with or belonging to the right kidney. It is to be observed that the left kidney is more often the subject of congenital misplacement than the right, which fact, together with the other congenital defects which were found, might have suggested some uncertainty as to the rest of the organism. My personal experience of the excision of movable kidneys amounts to my having successfully advised against it in several in- stances. There are conditions of suffering in which life may be i3roperly endangered in search of cure. That belonging to the movable kidney may be one, but we have to ask whether there are not safer means of relief ? As an apparently less formidable operation the movable organ, or rather its capsule, has been fixed by sutures to a wound in the loin, upon the healing of which it has been found that the kidney has been soldered to the side by granulations and cicatricial tissue, so as to be no longer movable. The present experience of this operation, nephroraphy, as it has been termed, is small ; it has been performed some seven times without death, and generally with benefit. ' It would appear that sur- ' Trans, of the International Med. Congress, vol. ii. p. 278. ^ Paper by Mr. Barker, Med.-Chir. Trans, vols. Ixiii. and Ixiv. ^ " Tabular record of 100 cases of extirpation of the kidneys," by R. P. Harris, M.D., American Journ. of Med. Science, July, 1882. * "Case of extirpation of a displaced kidney," by W. M. Polk, M.D., New York Med. Journ. February 17th. 1883. ' Centralblatt filr Chirurgie, July 23d, 1881, and July 22d. 1882. Cases by Hahn, Esmarch, and Kiister. Paper by R. W. Wier, M.D., New Yoi'k Med. Journ. Feb. 214: MISPLACEMENT AND MOBILITY' OF THE KIDNEY. gical enterprise in regard to the movable kidney is more promising in the direction of fixation than removal ; further than this it would not become me to express an opinion. 17th, 1883. Case by D. Newman. M.D., of Glasgow, BiHt. Med. Journ. April 28th, 1883, p. 831. CHAPTER XYL URINAEY PARAPLEGIA. Certai^t renal diseases are liable to produce paraplegia. Malignant growths beginning in the kidney may encroach upon the vertebrae and eat into the spinal canal with results as strongly pronounced in the way of paralysis as are found to follow fracture or dislocation. Whether pus, which has broken out of the kidney ever penetrates the inter- vertebral foramina I do not know; it seems not impossible, but I have not yet found an instance. Advancing still further into the region of hypothesis we come to the doctrine of Reflex Urinary Paraplegia, which Avas conceived by Stanley, christened by Graves, and adopted by Brown-Sequard. The theory of Stanley was that an irritation com- mencing in the kidney was conveyed by the nerves to the cord, which itself underwent no change, but transmitted the irritation to the lower limbs, to the impairment of their nervous function. The theory later took more definite shape, and met Avith much, and for a time with general, acceptance. The mode of operation was thought to be clearly made out by reasoning and experiment, and under the great authority of Brown- Sequard became a part of medical belief. Anaemia of the cord was be- lieved to be the essential change, this being brought about by a spasm of its blood-vessels, and this by an irritation carried to their nerves from the part, whether kidney or bladder, which was primarily at fault. If a nervous centre, it was urged, be deprived of blood, its function is ab- rogated, as hemiplegia may result from the tying of a carotid, or para- plegia from ligature or compression of the aorta. So the cord, if deprived of blood, though only by vascular spasm, may feasibly be sup- posed to cease to act as a channel of nervous influence. This theory is so generally accepted, at the same time that its application to the kidney and the existence of urinary paraplegia as of reflex origin have been so gravely questioned, that it is necessary to look somewhat narrowly at the facts which bear upon this part of the question. Dr., now Sir W. Gull, in a judiciously sceptical paper,' showed that in some of the cases which had been accepted as of reflex paraplegia the paralysis was not real, while in others it was not reflex, but more probably connected with organic disease of the cord, and later still Dr. Weir Mitchell in a no less masterly criticism* not only enforced the incredulity which since Gull's paper had begun to attach itself to the interpetration which Stanley and Graves had put upon their cases, but also threw doubts upon the whole theory of reflex jjaralysis. It was urged that it was highly improbable that a ' " On paralysis of tlie lower extremities consequent upon disease of the bladder and kidneys," by W. Gull, M.D., Guijs Hospital Reports, 1861, vol. vii. p. 313. ' " Paralysis from peripheral irritation," by S. Weir Mitchell, M.D., New York Med. Journ., 1866, vol. ii. p. 321. 216 URINARY PARAPLEGIA. vasal spasm conld he steadily maintained for months or year? without any intervals of relaxation; while supposing it to be so maintained with com]ileteness enough to abolish function by want of blood it was incon- ceivable that a tissue so mobile as the nervou^ should not become softened or show otherwise in textural change some result of the prolonged starva- tion to which it had been subjected. Softening of the brain rapidly fol- lows embolic obstruction, and no less so when the blood has been cut off bv ligature, as of the carotid, presuming that the collateral circulation is not efficient for vicarious duty. The questions to be answered are two — first, whether there is any Buch thing as urinary paraplegia ; whether in any way, by nerves or vessels, by any reflexion, conveyance, or extension of disease apart from the encroachment of a growth, paraplegia is brought about as a con- sequence of disease of the urinary organs; — and secondly, Avhether if paraplegia does arise from this cause, whether it comes on without material change in the cord by the mere suspension of function which is implied by the term reflex. To find replies I Avill briefly review some of the evidence which has been adduced. Mr. Stanley, in the paper wherein the theory of urinary jaaralysis was first propounded, related seven cases as examples.' In five of these the supposed cause of the paraplegia was that disseminated suppuration of the kidney which, as we now know, is so consistently a result of it. Disease of the cord, paralysis of the bladder, jDutrefaction of urine, and scattered renal suppuration as the result of absorption, is a morbid se- quence which is well made out and presents itself but too often. It is at least a suspicious circumstance that the particular form of renal disease which is credited with having produced spinal j)aralysis is precisely that which spinal paralysis so regularly produces. It is to be presumed, in the absence of any conclusive evidence to the contrary, that what Stanley supposed to be the cause was in reality the effect, and his deduction, so far as it is based on cases of this nature, cor- respondingly mistaken. That it was so must be clear to any one who reads the cases. Four of these present much the same outlines: a man jjerhaps has an injury to the spine or he has pain there, or without either he becomes unable to move his legs or pass his water. He dies with the kidney of disseminate suppuration, but with no disease of the spinal cord which is evident to the naked eye. Presuming one of the many changes to exist in the cord which are effective for its destruction, though not for its disfigurement, the sequence becomes intelligible and consistent with our daily experience. With the naked eye only almost any change confined to the cord short of diffluence might escape notice. It is there- fore impossible to infer that the cords in these cases were healthy or the paralytic symptoms and the renal lesion otherwise than dependent upon spinal disease. The argument as api)lied to these of Stanley's cases is equally suited to a large number of similar ones related by other authors, and it may be stated as a general conclusion that when the kidney of scattered suppuration is concurrent Avith paraplegia, the dis- ease of the kidney is not the cause but the consequence. Among the other conditions regarded by Stanley as the cause of para- plegia Avithout disease of the cord is dilatation of the kidney. This was exemplified by a case supplied by Burrows of a man who for two years ' "On irritation of tlie spinal cord and its nerves in connection with diseaseof the kidneys,"' by E. Stanley, Aled.-Chir. Trans., 1833, vol. xviii. p. 260. URINARY PARAPLEGIA. 217 had had severe pain in the spine and incontinence of urine, whose kid- neys Avere found after death with dihited and inflamed pelves and mottled structure. The spinal cord displayed no further evidence of disease than much vascularity of the lumhar pia mater and an excess of fluid within the sheath. During life there had been much tenderness about the sixth dorsal vertebra, difficulty of breathing, and the involuntary passage of urine and faeces. Presuming the vascularity and excess of fluid to indi- cate disease of the cord, as we cannot doubt that they did, notwith- standing that in the absence of microscopic examination no other evi- dence of disease was discovered, the whole case is clear. The condition of kidneys is precisely that which must necessarily result from long continued paralysis of the bladder with retention of urine, and it needs no further argument to justify the obvious conclusion that the renal disorder was the result, not the cause of the spinal. Two cases are related in which complete motor paralysis, involving the lower extremities and the sphincter together with loss of sensation ensued upon gonorrhoea; one was fatal in sixteen hours, the other in about a fortnight, with sloughing. In the more rapid case the kidneys were found to be merely congested, in the other they contained abscesses. In the more rapid case the cord was congested, in the other it appeared natural. It is scarcely possible to doubt that in both these cases myelitis was present though not disclosed to the naked eye. The comjaleteness of the paralysis and the sloughing are characteristic of disease of the cord of definite and acute kind, while we have the light of several cases minutely examined by Sir W. Gull in which paraplegia ensuant as in these instances ujjon gonorrhoea was found to depend upon distinct inflammatory change in the cord, apjjreciable Avitli the microscope, and in one instance not otherwise.' Sir W. Gull infers that paraplegia after gonorrhoea is produced by means of an infection, whether purulent or specific, which is conveyed to the cord after the manner in Avhicli the swelling of the Joints and the other secondary results of gonorrhoea are produced: and I think we need not hesitate to accept this con- clusion.'^ Thus it may be argued that of Stanley's cases from which the theory of urinary paraplegia was originally constructed there is not one which, according to our present knowledge, is to be explained on that principle. It is to be presumed that in every one there was disease of the cord, either as a primary lesion or as the consequence of gonorrhoea, to which as constantly the renal changes were secondary.^ Many other instances of supposed reflex paraplegia following upon gonorrhoea, some of which have ended fatally and some in recovei-y, are scattered through medical literature, but in the absence of minule ex- amination of the cord it may at least be said that none are conclusive. Dr. Graves's cases, published soon after Stanley's, are equally equivocal Avith his; some, indeed, more so, if that is ])ossible:^ in one a tumor, the size of "half a very small hazel-nut," Avas found external to the sheath of the cord, and it is not unreasonable to sup2)ose that this may liaA^e ' ' ' Cases of paraplegia associated with gonorrhoea and stricture of the ure- thra," by W. Gull, M.D., Med. Chir. Trans. 1856, vol. xxxix. p. lO'). ^ Med. Chir. Tran.s. vol. xxxix. p. 199. ^ See case quoted by Rayer, loc. cit. a'oI. iii. p. 174, also by Graves, Clin. Lec- tures, vol. i. p. 554. •• Graves, Clin. Lectures, 2d edition, vol. i. p. 563. 218 UKINARY PARAPLEGIA. had some share in producing the paralysis which existed of the legs and bladder, M, Leroy d'Etiolles has published a large number of cases of supposed urinary and reflex paraplegia, many of which were of gonorrhceal origin, and may probably be explained by implication of the cord in the manner already suggested. Others are cases in which the Aveakness of the legs, as justly remarked b}' Sir \V. Gull, appears to be not more definite than as part of general debility,' which the lower extremities, as having to support the weight of the body, usually express more distinctly than the upper. This is notably suggested in the instance of a man who died with an abscess in the neighborhood of the bladder, consequent upon urethritis, together with disseminated renal suppuration. He had a trembling gait, and dulness of sensation, which appeared to be general. He had diarrhcea, and soon sank into the state of prostration which characterizes purulent absorjition. Similar remarks will apply to a man with stricture and perineal abscess, who had weakness of the legs with some obtuseness of sensa- tion, coincidently with a febrile attack which caused much pros- tration. Of the cases related by this author those in which the reflex theory is best borne out are some in which enlargement of the prostate, or stric- ture of the urethra independently of gonorrhoea, were followed by loss of power in the lower limbs, which in some instances was restored after the discharge of an abscess, the use of the catheter, or some other surgi- cal procedure. The parajilegia seems, as a rule, not to have gone beyond enfeeblement of the limbs, though the circumstiince that this was in some cases more marked in one leg than the other is a point in favor of its being more than mere weakness. In one case spasmodic and con- vulsive movements (of the lower extremities?) occurred at the time of emission of urine. In this instance some loss of sensation was noted in the lower limbs, while the motor power in the two was unequally impaired. The patient recovered after the evacuation of a prostatic abscess. It is scarcely to be doubted that in this and in a few similar instances there was some degree of real paraplegia, as a result of disease of the bladder or prostate, and therefore properly to be called urinary; but to call it reflex, or in other words to assert it to be independent of disease of the cord, is to go not only beyond evidence but beyond probability. It is to be observed, as pointed out by Sir W. Gull,- that where para- plegia has ensued there has always been suppurative inflammation, mostly as a circumscribed abscess in or about the urinary organs, and the inference is obvious that by the veins or otherwise there has been some extension of the inflammatory process to the cord. Myelitis after gonorrhoea is a sequence which may be considered as beyond doubt; and it is at least probable that a similar result may now and then ensue after other kinds of suppurative disease. It is to be observed that with many of these cases there have been rigors or other febrile symptoms consistent with purulent absorption. A case directly to the point is quoted by Sir W. Gull.' A man, long the subject of stricture, with retention of urine, ' Case of Potemain, pour le Docteur R. Leroy d'EtiolIes, TraiU des Para- plegics, p. 'i'i. * Gmj's Hospital Reports, vol. vii. p. 328. ' " Cases of paraplegia associated with gonorrhoea and stricture of the ure- thra," Med. Chir. Trans. 1856, vol. xxxix. p. 198. URINARY PARAPLEGIA. 219 underwent, together with other measures, daily dilatation of the urethra; in the course of them he became feverish and rather suddenly para- plegic. A slough formed on the sacrum, the evacuations passed invol- untarily, and he died one month after the outset of the spinal symjDtoms. *'A small quantity of pus was found lying on the outside of the sheath of the cord, opposite the bodies of the sixth, seventh, eighth, and ninth dorsal vertebrae, and one of the vertebral veins in the lumbar region was full of well-formed pus. The spinal fluid was densely coagulable. The arachnoid was thickened, and presented traces of recent inflammatory exudation. The dorsal portion of the cord was very distinctly and gener- ally softened. An old stricture existed at the commencement of the membranous portion of the urethra, and several false passages, one open- ing into an abscess behind the bladder, and two returning into the blad- der. The vesical veins in the neighborhood of the pelvic abscess were thickened and partially obstructed by recent lymph." In this instance the process is made clear; and it is not to be doubted that in others para- plegia has similarly been brought about by the conveyance by the veins of purulent or septic matter from the urinary to the spinal region. The veins inside the spinal canal communicate freely with those outside the vertebrae, and these with the vessels ascending from the pelvis and lower extremities. The veins of the vertebrae have no valves, so it is conceiv- able that blood may occasionally flow from without inwards, even though the current be commonly in the reverse direction. Apart from the cases where inflammatory or septic products may be supposed thus to have impinged upon the cord we find nothing to en- courage a belief in urinary paraplegia. It does not arise from stone, great as is the nervous irritation shown in other modes which stone, es- pecially in the kidney, produces. Other observers, mostly coeval, or but shortly after those I have re- ferred to, have published cases which at the time were explained on the reflex theory, but which now present themselves with sufficient clearness in another light. Mr. Spencer Wells published a lecture' on " Incom- plete Paralysis of the Lower Extremities connected with Disease of the Urinary Organs," but the condition he describes, as he himself would now readily admit, is one in which the bladder has simply participated in a more or less general loss of nervous power. There is no stricture or definite urinary disease, but merely a loss of expulsive power, to- gether with other signs of muscular failure. The description applies, indeed, with much accuracy to locomotor ataxy. This transposition of cause and effect is apparently not of uncommon occurrence in the annals of reflex paralysis. Loss of power in the bladder and retention without stricture may possibly be the first noticeable signs of structural disease of the cord; cystitis probably will quickly follow, and it may not be until afterwards, particularly if the patient be in bed, that the paralysis becomes evident in the lower extremities; this therefore may present itself as secondary in time, and ostensibly in cause, to the urinary dis- turbance. liecent observation has added nothing to the records of reflex para- plegia of urinary origin. I have long sought but hitherto failed to recognize the condition, and I find that other inquiries have met with the same want of success." ' Med. Times and Gazette, November 14th, 1857. ' Dr. Wilks, Diseases of the Nervous System, p. 231. 220 URINARY PARAPLEGIA. It is to be fairly concluded from the evidence -which has been brought forward that — Paraplegia may as a rare occurrence ensue upon certain inflammatory" disorders of the bladder and neighboring parts, more especially when these are of gonorrhcpal origin; it is then a result of the extension to the cord of an inflammatory condition by infection or otherwise, presents the symptoms of myelitis, and may be fatal, even rapidly so, a circum- stance inconsistent with tlie supposed character of reflex paralysis. We have no evidence that disease of the kidney extends to the spine by similar means. "When the suppurating or "^surgical" kidney con- curs with paraplegia, the renal condition is not the cause but the conse- quence of the paralysis; the same may be said with regard to renal dilata- tion and pyelitis. There is no evidence of, but, on the contrary, many reasons to doubt, the existence of a form of piaraplegia dependent on the state of the urinary organs but independent of structural change in the spinal cord. In many instances supposed to be of this nature the evidence of paraly- sis is defective, in others there is reason to believe that the nervous dis- order has actually preceded the urinary, though the urinary symptoms attracted notice as the first sign of spinal failure, while in no instance of paraplegia associated with urinary disease has the cord been asserted to be healthy save on examination which has been entirely insufficient and inconclusive. Thus, though it is to be admitted that within certain limits paraple- gia may be urinary, there is no e\'idence to show that in any circum- stances it is reflex. CHAPTER XVII. DISEASES OF THE URETERS AND LARGE BLOOD- VESSELS. Diseases of the Ureters. As of all tubes, diseases of the ureter tend to its obstruction, which whether complete and of both sides and rapidly fatal by suppression, or iilcomjDlete or one-sided so as to give rise to hydronephrosis, is of so great importance as a source of disease that it would be difficult to find any other part of the body where so small an extent of lesion is productive of such formidable results. The ureters have little liability to independent disease, though they may be congenitally defective in various ways, may be involved in surgical accidents, and are apt to be damaged by morbid products and share in morbid processes which take their rise elsewhere. An ureter appears sometimes to have been impervious from birth and shrunk to a cord, while the corresponding kidney has become atrophied, usually with cystiform dilatation of the jjelvis, while the other has been hypertrophied. There is a preparation at St. George's Hospital showing a congenital obstruction by means of a valvular fold of mucous membrane in the portion of the duct which passes through the wall of the bladder. The ureter behind this was dilated to the thickness of the colon and the kid- ney in a state of cystic degeneration. Sometimes the development of the kidney and its duct appears to have been arrested simultaneously, as in an instance under my own ob- servation in which a shrivelled kidney, weighing but 43 grains, was con- nected with a ureter which though partially pervious was much shrunk and terminated in filaments before reaching the bladder. In this in- stance, as in many such, there were no symptoms, but the importance of the condition is obvious as half-way towards suppression.' A similar result" has been described as due to malposition, the duct starting, not at the bottom of the infundibulum, but at its side, so as to be liable to obstruction from lateral pressure; but I must refer to the chapter on Hydronephrosis for reason to believe that many such malpo- sitions and valvular arrangements are the consequences of obstruction and dilatation, not their cause. Supernumerary renal arteries compress- ing the upper part of the ureter have in the same place found sufficient mention. The ureters are little exposed to violence from without and seldom suffer except by such injuries^ as are likely to produce fatal or at least ' St. George's Hospital Museum. Series xi. p. 7. » Julius Pollock, Path. Trans, vol. xvi. p. 181. » Path. Trans, vol. x. p. 209. 222 DISEASES OF THE URETERS AND LARGE BLOOD-VESSELS. obvious results. Constrictions of the ureter have been attributed to this cause sometimes on inconclusive evidence. An instance is elsewhere re- ferred to where stricture of the ureter/ and consequent pyonephrosis were traced to a kick from a horse. After rupture of the kidney by ex- ternal violence the pelvis has been known to become tilled with coagu- lum, and the ureter thus completely and permanently stopped. A kick from a horse on the right hypochondrium was followed by collapse and li£ematuria; the ha3maturia did not occur after the second day, and the patient recovered, to die eighteen months later with granular kidneys. It was then found that the kidney had been ruptured into the pelvis, - which, together with the ujiper part of the ureter, had become filled with coagulum, to the complete and permanent obstruction of the duct. Inflammation of the ureter is usually a result of the ascent of cystitis or of the descent of stone. In the former relation it has been suf- ficiently referred to in connection with pyelitis as the result of gout or gonorrhoea. Under inflammation the mucous membrane of one or both ureters, in part or wholly, may become swollen, congested to a purple color, and bathed with pus. A man in St. George's Hospital had con- tinued shooting pains in the lumbar region, pain in the abdomen, pus in the urine, and frequency of micturition, which symptoms were suc- ceeded by uncontrollable vomiting, prostration, and death. He had been sounded for stone but none found, nor was any discoverable after death. Both ureters were in the state referred to from near the bladder to within about three inches of each kidney. The bladder and pelvis were slightly vascular and contained small quantities of pus. No other lesion Avas found save slight recent endocarditis. The kidneys them- selves were healthy. There was no history of gonorrhoea, but whether set up by this cause or by calculi which had escaped, it appeared that the inflammation of the ureters was much concerned in the production of the symptoms. ° The ureter has been known to become lined with lymph under the inflammator}^ process, or, as in an instance recorded by Murchison,* to be coated, in common with the calyx of its kidney, with a loosely adherent membrane, resembling that of diphtheria, shreds of which were passed wath the urine during life. The kidney itself was studded with small abscesses. In this instance as in the last the inflam- mation was attributed to the passage of stone, but none found. The ureter has been known to become surrounded from the bladder to the kidney with suppurative inflammation of the cellular tissue which in- volved also the renal and vesical neighborhood; in the case I refer to some small calculi were found in the peritoneal cavity and the affection as- cribed to perforation by them, though its position was not discover- able at the time of the post-mortem examination. The local suppura- tion was succeeded by pyaimia. Injury, probably ulceration, caused by stone may be succeeded by stricture, or even complete occlusion, and' thus give rise to dilatation and atrophy of the kidney, possibly with pyelitis or hydronephrosis or taking a half share in suppression of urine. When not causing com- plete obstruction the irritation of stone at the top of the ureter will ' Pye Smith, Path. Trans, vol. xxiii. p. 159. ' St. George's Hospital Museum. Series xi. p. 4, Path. Trans, vol. xi. p. 140. 3 Path. Trans, vol. xix. p. 281. * Ibid. vol. X. p. 191. DISEASES OF THE URETERS AND LARGE BLOOD-VESSELS. 223 sometimes cause this i)art of it to become thickened aud imbedded in fat. It is not necessary to add to what has found phice elsewhere with re- gard to tubercular disease of the ureter: thickening and ulceration of its wall often with total and permanent obstruction of the channel is an ac- companiment, usually a result of tubercular disease of the kidney. Malignant growths are less common, as proper to the ureter, than tubercular, though this duct is oftin encroached uijon by cancer from without. Cancer confined to the ureter is, I believe, unknown, though it often participates in renal and vesical growths. Its walls from end to end ' have become thickly infiltrated with malignant matter contin- uously with a like formation in the bladder, and superficial patches of fungous growth have been found upon its mucous surface in connection with a renal growth as if descending germs had taken root." The Avair of the ureter has been known to become infiltrated in con- nection with the development of lymphadenoma elsewhere. Cancer of the bladder may encroach upon and stop the channel of the ureter as it passes through the vesical wall, and the same result may be produced by polypoid and other growths. I knew a case in which a small mucous polypus grew from the bladder in such a position as ex- actly to close tlie orifice of this duct and cause dilatation of it and of the kidney. Growths external to the urinary organs often involve the ureter; some such have been referred to in connection witli suppression of urine; tumors, especially when malignant, of the uterus, vagina, or ovary, may thus invade and close one or both ureters; an instance is re- lated by Dr. Burdon Sanderson^ of a fibro-cellular tumor which had sprung from the capsule or hilum of the kidney and imbedded the ureter in its mass, constricting the duct at its origin to the size of a crow-quill. Beside growths of various kinds the ureter has been compressed by fibrous bands, the result of inflammation of the uterus or in its neigh- borhood, or variously constricted in consequence of displacement of that organ. It is not necessary to remark further upon dilatation of the ureters, except that both may be dilated, together with the pelves, in consequence of chronic difficulty in emptying the bladder, and that with such stretch- ing the valvular passage through the vesical wall necessarily becomes in- effective, so that the contents of the upper chanels become contaminated by those of the lower, with results which are explained with the subject of renal suppuration. In connection with, and probably as a result of the dilatation from urethral obstruction, the ureters have been known to become prolajDsed into the bladder by reason apparently of the downward pressure exerted by the swollen and rigid cylinders into Avhich the flaccid and yielding tubes have became converted.'' The ureter has been known to become dilated to such an extent as to cause an abdominal tumor more or less resembling that of liydronephro- sis. An instance is mentioned at p. 101 in connection with that subject; another was reported by Mr. Estlin" and is referred to by Dr. Bright. A ' Path. Trans, vol. xviii. p. 158, case by Dr. Bastian. ^ Ibid. vol. i. p. 155, case by Mr. Simon. ' Dr. Coiipland, Path. Trans, vol. xxviii. p. 126. * Path. Traits, vol. xiv. p. 195. ' T. Smith, Patli. Trans, vol. xiv. p. 185. * The details are to be found in the London Medical Gazette, vol. ii. 1828, and ■vol. XX. 1837, references which we owe to Mr. Morris. 224 DISEASES OF THE URETERS AND LARGE BLOOD-VESSELS. man had a tumor *•' of an oblong form, situated in the right hj'poclion- drium, about the edge of the rectus muscle, extending nearly from the eleventh rib to the right side of the symphysis pubes, and being particu- larly prominent about the situation of the internal abdominal ring. It soniewhat distended the integuments, so as to be perceptible to the eye, and might be considered to be about threa inches in width." The swelling repeatedly subsided on the emptying of the bladder with a catheter. After the patient's death, which occurred under an attack of influenza, it was found that the tumor was the right ureter enormously dilated and thickened. The prostate gland was the seat of three semi-cartilaginous tumors, by which the orifice of the urethra was obstructed. The bladder was sacculated and contained a large number of phosphatic calculi which varied in size from that of a chestnut to that of a pea. It is not explained why one urethra was dilated and not the other; possibly a calculus may have determined the inequality. The ureter may be perforated by abscesses of the neighboring parts and the pus thus find exit with the urine. An ordinary psoas abscess may do this, as is testified by a preparation at King's College, as also may a pelvic abscess of puerperal origin. A patient of the Late Dr. Lee in St. George's Hospital discharged pus with the urine for three years after pelvic cellulitis of this nature. An abscess then opened upon the back, and death shortly followed. An irregular suppurating cavity was found below the left kidney, which opened upon the loin and also into the ureter which, at about its centre, was lost in the abscess. The kidney was dilated and atrophied. This case bears also upon the sub- ject of perinephritic abscess after labor. A frecal abscess was supposed by Dr. Ord to have entered the ureter; it had certainly entered some part of the urinary tract, as fffical matter was found in the urine; but the case does not rest on post-mortem evidence. ' Diseases of the Rexal Artery. The renal artery is liable to certain anatomical peculiarities and de- fects of development which it is not my purpose to refer to except so far as they are associated with renal disease or deficiency. The supposed origin of hydronephrosis in compression of the ureter by a supernume- rary vessel has been already mentioned. In many cases of congenital atrophy of one kidney the artery has been found to be incomplete or impervious, notwithstanding that tlie duct and vein have been open, as if the defect in the artery was the cause of the general defect of development or nutrition. The shrivelled and effete'' remnant of the organ has generally been found to consist mainly of fibrous tissue and even in some cases to present the granuhir exterior and cystic change of acquired fibrosis; not, it is to be pre- sumed, that there has been any morbid formation of the tissue wiiich thus appears in relative excess, but rather because the lack of nutrition has told Avith greater effect upon the mere vascular and mobile struc- tures than on that which is more passive and enduring. It has frequently been noticed that where one kidney has been thus destroyed the other has become the subject of inflammatory disease, due no doubt to the increased work thrown upon the sole organ. ' British Med. Journ. September 7th, 1878, p. ;J48. ' See cases reported in the Path. Trans, by Mr. Sydney Jones, vol. viii. p. 279: by Dr. Conway Evans, vol. xvii. p. 173; by Mr. Pick, vol. xix. p. 281. DISEASES (>F THE URETERS AND LARGE BLOOD-VESSELS. 225 Embolism and thrombosis have been considered elsewhere. An in- teresting case is related by Dr. Moxon,' in which a short embolic clot from a diseased heart had stopped up the renal artery close to its origin but not extended into the organ; tlie aortic end of the plug was covered with a smooth membrane, and we are led to infer that the affected artery was completely closed, though from the state of the kidney it is evident that its blood-supply was not totally cut off. Tlie chief interest is in the contrasted state of the two kidneys. The right, which remained in free connection -with the circulation, was the large white kidney of Bright; a result, probably, of the disease of the heart, which was much dilated, and of which the valves were thickened as the result of rheu- matism. The kidney from which the blood had been cut off' was prac- tically natural, excepting that it Avas of rather small size. Dr. Moxon observes upon the infrequency of unilateral Bright's disease, and sug- gests with probability that the smaller healthy organ had been saved by the accident which had deprived it of a large portion of its blood. The renal artery becomes the subject of atheroma, though perhaps scarcely so often as some other parts of the arterial system. The athe- roma has been such that the vessel has been nearly but not quite closed, with the result of fibrotic atrophy in the connected organ, which was found to weigh in a case of this sort recorded by Dr. Greenfield only an ounce and a half; or the closure has been made complete by coagulum,. with resultant changes of a more acute kind, comprising chiefly anaemia of tissue, fatty degeneration, and the accumulation of leucocytes in and about the vessels.^ The effect of complete closure of tlie renal artery is to stop the se- cretion of urine, with comjjlete suppression should both kidneys be si- multaneously affected. This point is further touched upon in connection with the subject of suppression; but I may here refer to a case in which both renal arteries were so compressed by an aneurism of the superior mesenteric that their aortic openings were reduced to mere slits. The patient had repeated convulsions, which were succeeded by coma and death. The urine was incompletely suppressed; a little which was ob- tained with a catheter was highly albuminous.^ Aneurism of the renal artery occurs both from embolism and as the result of atheroma. I have elsewhere related a case in which extra- vasation of blood about the kidney external to the pelvis was at- tributed to the bursting of an aneurism of embolic origin, and M. 01- livier* has given an instance, which probably must be regarded as exceptional, in Avhich discharge of blood with the urine repeated during the course of six years was found to be associated with atheromatous aneurisms of the renal artery and its branches. An aneurism as large as a filbert was found at the bifurcation of the renal artery, while on the further branches were smaller aneurismal dilatations, the bursting of which into the dilated pelvis had apparently given rise to the re peated haemorrhages. Pyelitic symptoms not unlike those of stone had ' Path. Trans, vol. xix. p. 267. " " Atheroma of the Renal Artery, leading to Occlusion of the Vessel and Degenerative Changes in the Kidney." Dr. Greenfield, Path. Trans, vol. xxvi. p. 135. ^ " Aneurism of Superior Mesenteric Artery compressing both Renal Arte- ries. Dr. Burney Yeo. Path. Trans, vol. xxviii. p. 95. •• " On an Undescribed Varietj^ of Pyelo-uephritis," by Auguste OUivier, Arch, de Physiologie, 1873, vol. v. p. 43. 15 226 DISEASES OK THE URETERS AND LARGE BLOOD-VESSELS. been produced by tbe irritation and obstruction caused by coagula in the pelvis. AVith regard to disease of the renal vein, it is not needful to say more than has already found mention under the heading of Throm- bosis. CHAPTER XVIII. EENAL PARASITES. The parasites which have been recognized beyond doubt in the human kidney are but four — the Ecliinococcus, ov Hydatid, the Bilharzia hcematobia, tlie Strongulus gigas, and the Filaria sanguinis hominis. The Pentastoma deniicidatum is stated to have been seen in the iiidney, and the Tetrastroma renale to have come from it. Beside these, the Dadylus aculeatas and the Filaria 2jiscium, under the title of Sjyiy'o^j- tera hominis, have been produced as urinary parasites, but tliere is every reason to believe that their appearance in this relation is the result of accident or fraud. The filaria will be considered in the next chapter in relation to chyluria. Hydatids. The only parasitic cyst which has attracted notice in the kidney is the Ecliinococcus or Hydatid: the cysticercus cellulosse is widely scat- tered throughout the body, and it is scarcely to be supposed that the kidney enjoys an exemption from its attacks, but I cannot find that cysts of this nature have been recognized in this situation. It is not necessary that I should recapitulate what is to be found in every text-book with regard to the genesis of the hydatid. This is the cj'stic stage of the minute taenia echinococcus, which in its phase as an intestinal worm belongs only to the dog and the wolf, though in its cystic or hydatid form it infests many animals, of which the human be- ing is one. It is curious that this tape-worm, which is one of the smallest of its race — it consists of but four segments and is altogether only of about the size of a millet seed — should engender, in the shape of the hydatid, the largest parasitic growth to which the human body affords residence. The eggs of the taenia pass with the fseces from the bowels of the animal, and are conveyed into human food with a frequency cor- responding with the intimacy which exists belsween man and '"the faith- ful dog which bears him company." In Iceland, where dogs are necessary and numerous — each jieas- ant has on an average six — and where men and animals are closely associ- ated with little distinction of persons, hydatids are said to be fatal to one- seventh of the population. The spread of the disease is assisted by the strictly homoeopathic practice of the Icelandic quacks, whose favorite remedy for internal administration is dog's dung, or, as it used to be called, Album Grajcum. It is easy to imagine, also, how the ova of the tjfinia may be conveyed by water into which dogs' excrement has passed, or may cling to various articles of diet or culinary utensils where clean- liness is unknown and dogs ubiquitous. The hydatid disease is known also to prevail largely in Silesia, where it has been attributed to the use of dog's flesh as food: tasnia, or their eggs, probably escape from the bowel in some of the butchering processes, and 228 RENAL PARAblTES. contaminate the edible portions of the animal. By such means some of the ova of the taenia, which are very numerous — about 5,000 in the last or only fertile Joint of the minute worm — are carried into the alimentary canal of the animal destined to lodge the hydatid, and thus enter ui)on a new phase of existence. The eggs each contain a minute six-hooked embryo, whose occupation appears to be that of fixing upon and boring through the structures in contact with which it finds itself. It is diffi- cult to suppose that the tissues are traversed by any effort or design on the part of the embryo; more probably its translation is accomplished by some such process as that by which needles travel from one part of the body to another. The movements of the parts of the body on each other must necessarily tend to produce the frequent displacement of the germ, while the hooks prevent its movement save in one direction. Should a vessel be penetrated by this process, the embryo is of coui.-e liable to be swept in its current, and implanted in one of the capillanes to which it leads. Should the situation reached by one means or an- other be suited for its development, the hydatid will here spring from the tape-worm germ. And should the flesh holding the hydatid become the food of a dog, its germs may reproduce the ttenia in the bowel of the animal, and thus carry on the eternal interchange between intestinal worms and cystic tumors. Thus it appears that two animals in succession, and those of the nobler species, are required to minister to the engendering of a tape- worm. It is a little puzzling why tsenia^ and hydatids should not flourish within the same creature: why should not the eggs which must almn- dantly escape from the tteni^e in dogs' bowels start on their travels' there and then, and develop into hydatids within the same animal ? They do not do so. On the contrary, the eggs must form the food of another individual, usually of a different species, so that the tape-worm is proper to certain animals, its cystic successor to other and different animals. The dynasty is continued only by the eating of the flesh which contains the cyst by the animal who inherits the tape-worm. Thus the worms commonly belong to flesh-feeders, the cysts possibly to animals wliicli live on vegetables. The germ which belongs to the hydatid can scarcely be introduced but with the eating of flesh, while the eggs of the worm, being detached as excrement, may cleave to anything. It is to be ob- served that at each transfer the egg, or the cystic germ, as it may be, is exposed to the process of digestion — usually a destructive, but in the case of tliese parasites a vivifying process. The proper hydatid cyst, supposing it to have been produced within a parenchymatous organ, is surrounded externally by a concentric layer of tough fibrous tissue, which is derived from the organ itself. Within this comes the parasitic formation, the wall of which has been divided into two portions, described as the ectocyst and the endocyst. The outer portion, or ectocyst, is thick, elastic, and laminated, but otherwise homo- geneous. It is this portion of the cyst which is so readily recognizable as hydatid membrane. The inner layer, or endocyst, is excessively tliin and delicately cellular; it appears to represent the germinal membrane or essentially vital part of the animal, and to supply the surface by which the characteristic fluid is secreted. From this membrane grow, and push inwardly, what have been described as daughter cys/s or brood capsules, as part of which scolices,^ or rudimentary tape-worm heads, after a time develop. ' (;«cJA?/; = a worm. KENAL PARASITES. 229 These heads, which are not six-hooked like the embryos, but armed, like the mature worm, with a com])lete and formidable circle of hook- lets, are little else than tape-worms in brief, and are prepared to com- plete themselves whenever a fitting situation presents itself. For this opportunity they are indebted to accident, and to the catho- lic appetite of the dog. The vast majority must perish with a destiny unfulfilled, but those that find fruition and completion do so in the duodenum and upper small boAvel of that animal of whose food they have made part. From the tape-worm matured in this situation the circle recommences. The scolices or booklets which have been de- rived from them are continually found floating loose in the hydatid fluid, where their presence, easily detected with the microscope in small portions withdrawn with the hypodermic syringe or aspirator, furnishes ready and conclusive evidence of the nature of the cyst. But it is to be observed that these creatures are not naturally thus detached. Dr. Cobbold, whose account I have chiefly followed, points out that their separation from the brood-cysts, however frequent, is a result of acci- dent, and is attended with the death of the animalcule which has been thus cast loose. The hydatid fluid is aqueous, and slightly saline, in its uncomplicated state quite devoid of albumin. The saline matter is chiefly chloride of sodium, though organic salts of soda have been found in it, and also crystals of cholesteriu and of hasmatoidin. In renal hydatids have been noticed special renal products, such as crystals of uric acid, of oxalate of lime, and the phosphates. The absence of albumin is by no means invariable; indeed, after each tapping of a hydatid cyst the fluid will be- come more and more serous in character, until at last it is highly so. Finally, it may suppurate and be converted into an encysted abscess full of liquid pus, or the fluid portions may be gradually absorbed, to leave a shrunken semi-calcareous nodule, in which the shrivelled remains of the secondary cysts are flattened and folded together, imbedded in the earthy residue. Hydatids affect different organs with very different frequency. Dr. Cobbold, placing together his own researches with those of Davaine, gives the following statement of the number of times they have been found in the several situations they frequent:' — Organs affected. Cobbold. Davaine. Total. Liver 161 45 22 23 22 16 13 25 165 26 40 30 20 17 12 63 326 Abdomeu, pelvic cavity, and spleen Lungs 71 62 Kidney and bladder Brain 53 42 Bones 33 Heart and pulmonary vessels Miscellaneous 25 88 Grand total '327 373 700 The liver becomes the seat of the parasite far more often than any ' " Lecture on Hydatid Disease," by Dr. Cobbold, Lancet, 1875, p. 850. 230 RENAL PARASITES. other organ; about as often as all the rest of the body together. This organ is affected about five times as often as the lungs which stand next in order of frequency, about six times as often as the kidney, which has the next place. After the liver there is no marked difference between the important organs. The comparative frequency witli which the liver is attacked, being, as it is, the recipient of all the blood which returns from tlie alimentary canal, cannot but suggest that tbe blood is largely concerned in the distribution of the ova. Ova have indeed been detected in the blood of the abdominal veins, after the experimental feeding of an animal with tape-worm joints.' If one of the ova, on its way from the bowel, should enter a vein, the liver will, as it would seem almost inevitably, be the place of its arrest; it is not to be supposed that the hooked embryo could by any process short of boring traverse the capillary system of this, or indeed of any organ. The probably constant arrest of the blood-borne ova in the liver, and their corresponding exclusion from the general venous blood, ex- plains the position of the lung with regard to the distribution of hydatid tumors. The lung is not exempt from them, but shares only equally with most other organs. Did these germs in any appreciable proportion pass through the liver, and thus enter the systemic venous circulation, the lung, as presenting a capillary obstruction which must be traversed before any other organ is reached, would probably be affected, as in the case of pytemia, incomparably more often than any structure which re- ceives only a subsequent and fractional supply. But this is not the case. We may therefore infer, in the first place, that the eggs which come by the portal vein stop in the liver, and that the lungs, kidneys, brain, and other organs all receive, by some mode of distribution which is indepen- dent of the course of the blood, from the alimentary canal: whether the germs penetrate the aorta and are thus distributed with the arterial blood, or whether they scatter themselves by an impartial system of bur- rowing, remains to be seen. The liydatid disease affects most frequently the miudle of life, though perhaps no part of its course can be asserted to be absolutelv exempt. Hydatids have been found in tlie kidneys of the fu'tus, but they appear to be almost unknown in infancy. They attain their greatest prevaknce between thirty and fifty, but are known up to old age. The cases of hydatid of the kidney collected by Roberts — forty-seven in number — gave a mean age of thirty-four; the youngest sulgect was four, tlie oldest seventy-five. This statement corresponds with and evidently includes results obtained Ijy Beraud from forty-two cases. Hydatids in general appear to be distributed between the sexes with much impartiality, though in Iceland women appear to bo affected more often than men, probably in consequence of the closer confinement of the former to their dwellings, and more constant use of the water which dogs are liable to have fouled. With regard to the kidney in particular, and the disease as we know it in less extreme latitudes, men suffer more often than women in a proportion, as Dr. Roberts reckons, of about two to one. Of sixty-three cases collected by this author, the subjects of forty-one were males, of twenty-two females. Of Beraud's cases, forty- nine in number, twenty-nine related to males, twenty to females. It is rare for both kidneys to be affected with hydatids: the left is so ' Experiments by Leuckart upon the generation of the Tcenia serrata, quoted by Cobbokl, p. 109. RENAL PARASITES. 231 ratlier more often than the right. Of forty-two cases collected by Dr. Koberts, both kidneys were attacked in but two; of the rest, the left was the seat of the disease in twenty-two instances, the right in eighteen. Hydatid cysts are apt to be imbedded in the proper glandular sub- stance of the kidney, either in the cortex or the cones, and to present themselves, or possibly to originate, in the cellular spaces under the cap- sule and around the pelvis. The renal tissue undergoes various degrees of atrophy from pressure, the remnant often presenting, as when pres- sure is due to any other cause, a positive or relative excess of fibrous tissue. Hydatid cysts in connection with this organ vary in size from an exceeding minuteness to such a magnitude as to hold three pints or more. Many cysts of different sizes often exist together: in Baillie's case they were described as varying in size from an orange to a j)in's head. "When of considerable size they have a great tendency to open into the pelvis, which leads to the discharge of hydatids with the urine, which is so common and so characteristic of this disease. The orifice by which the cyst opens upon the pelvis may be comparatively small: in a case under Rayer, recorded by Beraud, it had a diameter of half a centi- metre.' It is stated that about half the instances of renal hydatids have at- tained such a size as to be appreciable as tumors during life; at least one instance has been known in which the tumor was regarded as ovarian,' and an operation performed in this view, and another in which it gave rise to a suspicion of pregnancy.* From the last case it would appear that hydatid growths may be large enough to cross the median line, but usually they do not go beyond the half of the body in which they have originated. They are usually globular. A growth of this nature in the kidney is commonly painless and un- attended with febrile symptoms or any constitutional disturbance. The prominent signs of the disease apart from the tumefaction are usually to be found in the escape of the hydatids by the urethra, or possibly by the urethra together with some other exit. Hydatids, or pus' from a sup- purating hydatid cyst, carrying with it shreds of membrane, have been known to make their way from the kidney both into the bladder and into the bronchial tubes, so that the contents of a hydatid cyst of renal origin have been expectorated and passed by the urethra by the same person. The tendency of a renal abscess, upon whatever it may depend, to burrow behind the diaphragm and into the root of the lung, is one of ' Beraud, loc. cit. p. 22. * Spiegelberg. Quoted in Ziemssen's Cyclopaedia, vol. xv., p, 7.")3. An opera- tion intended as ovariotomy exposed a hydatid cyst of the kidney of the size of a man's head; it was surrounded by firm and numerous adhesions. The tumor had been developing for one and a half years in the right hypogastrium ^Case related by Dr. Babington, Med. Times, 18.15, p. IGO ■* See case of Mme. B , which occurred in the practice of M. Fiaux, related by Mr. Beraud, loc. cit. p. 63. A hydatid cyst of the riglit kidney presented these two openings with the results described. The case ended fatally, and post-mor- tem examination was performed. An instance is related by Rayer (Inc. cit. vol. iii. p. 'S'2'S) in wliich the pus from a suppurating hydatid cyst connected with the left kidney burrowed behind the diaphragm into the base of the lung, and was thence expectorated. 232 RENAL PARASITES. the prominent facts in renal patliology. Hj'datids, presumably renal, have been vomited — a woman who had a tumor in the side, and' habitu- ally passed these cysts by the uretlira, vomited a large quantity.' It has more often happened that the urethral exit has been associated with one by the bowel; several instances have been put upon record in which hydatids have simultaneously made their way out by both these chan- nels, but either they have not terminated fatally or no post-mortem has been performed, so that the site of the formation must remain in ques- tion. " It is to be observed that presumably renal hydatids, becoming as they do the centres of suppuration, travel out of the kidney much as do calculi, which are apt to burrow their way out by the agency of the same penetrating process. Points of ditference are, however, to be observed in two notable re- spects. Suppuration in connection with a stone sometimes breaks into the peritoneum : this issue has not been recorded in regard to hydatids or a hydatid abscess. Matter of calculous origin, and calculi themselves, will sometimes make their way out through the back ; this mode of escape has never been verified with regard to renal Jiydatids. Several instances have been recorded in which hydatids have been discharged su- perficially from the lumbar region, but proof is wanting of their renal origin ;' in one instance indeed, in which a post-mortem was made, they were found to have come from outside the kidney. Roberts, to whose research in this subject all subsequent writers are likelv to stand indebted, thus analyses, with regard to their mode of opening, sixty-three cases in which hydatids were found in the kidney or passed by the urethra. The cyst opened into the — Pelvis of the kidney, in 47 cases. Pelvis of kidney and lungs, <. 1 «* Pelvis of kidney and intestines, " 3 " Pelvis of kidney and stomach, «« j «< Hydatids discharged by urethra in 52 cases. Lungs alone, u -^ << Did not open at all, " 8 " Opened artificial!}', , • . " 2 " No hydatids discharged by urethra in 11 cases. In the majority of cases in which hydatids are formed in the kidney it appears that some of them habitually escape with the urine ; the ten- dency of renal hydatids to break into the pelvis is, indeed, the charac- teristic by which the affection is generally recognized. Of presumably renal hydatids Roberts estimates this result, as has been seen, at -47 of 63 1 Schmidt, Jahrh. Bd. 87, p. 205, quoted by Roberts. Also quoted by Beraud, loc. cit. p. 70. 5 A case is related by ^I. Rayer, vol. iii. p. 552. footnote, in which a man who had a tumor in the left iliac fossa passed hydatids by the bowel, pus and gas by the urethra. The same author, vol. iii. p. 554, quotes from M. Fourcroy the case of a perruquier who after a debaucli passed blood and hydatids by the anus, hydatids with the urine. The patient recovered. The case of a woman is quoted by Davaine {loc. cit. 2d edition, p. 529) in which a tumor appeared in the right flank after an effort, and subsequentlj' hydatids and pus were discharged both with the motions and urine. The patient recovered after nine and a half months' illness. ^ See case quoted by Rayer, vol. iii. p. 578. RENAL PARASITES. 233 cases. Beraiid estimates it at 48 of 64. But it is to be borne in mind tliat all hydatids that thus esca}3e are not of renal origin. They may thus make their way out, and that abundantly, though the cyst belong elsewhere. In a case under Mr. Birkett, referred to at page :^34, hyda- tids obtained from the bladder by means of a catheter were found to have proceeded from the cellular tissue behind it. A number of cases in which hydatids were passed by the urethra were brought together in the "Med- ical Times," ' with an expression of belief on the part of the compiler that in most the parasites were derived, not from the kidney, but from the cellular tissue in some part of the abdominal or pelvic cavity. But however often hydatids are thus connected with the cellular tis- sue, we have abundant post-mortem evidence of their occurrence within the kidney itself. A preparation at Guy's Hospital which shows a hy- datid cyst springing from the 'liilum and pressing into the pelvis illus- trates the first stage of the process ; while the last is displayed by another at St. Bartholomew's, which consists of an ovoid mass of cretaceous matter, scarcely to be recognized as a kidney, but being all that was left " of this organ in a man who for ten years had jiassed hydatids by the urethra. The series of cases to which I have referred contains a curious instance in which a husband and wife were both in the habit of passing hydatids with the urine. This mode of getting rid of renal hydatids is often preceded by a sen- sation of something having broken in the lumbar region, and been im- mediately attributed to a blow or fall or jolting movement. The attack resembles the ordinary foi-m of renal colic which attends the passage of a stone, but is less acute than the latter often is. The pain begins usu- ally about the hip, and passes down the line of the ureter into the thigh. The testicle is often retracted. The process is often preceded or attended with hsemorrhage. These attacks are often attended with obvious les- sening of the renal swelling. Mr. Evans, of St. Neots,^ described a case in which a lobulated tumor, which presented througli the integuments the dimensions of eight inches by four, totally disappeared after successive discharges of hydatids with the urine. Many hundred cysts of this nature were voided in one day. The hydatid outbreaks are often separated by considerable intervals — a year or more — as if the cavity were emptied and refilled by slow growth. Having reached the bladder, the hydatid may cause temporary reten- tion of urine, and give occasion for the use of a catheter ; or they may be shot out of the urethra with considerable force. Women have been kuown to release the skins from the orifice with the fingers. The hyda- tid skins do not, as a rule, appear to have a very irritating effect upon the bladder, though occasionally some degree of cystitis, with a discharge of mucus or pus, has been traced to their influence. More often the urine contains pus which is of renal origin, being discharged from a suppurat- ing cyst in process of natural cure. Hooklets and cretaceous material have been found in the pus thus produced. Not only may retention of urine, though usually in this case of a passing nature, result from the transit of renal hydatids, but fatal retention has in at least one instance ' January, 1855, p. 159. See also Med. Times, 1863, vol. ii. p. 164. ''Related by Dr. Barker, of Bedford, '• On Cystic Entozoa of the Human Kid- ney,"' p. 11. 234: RENAL PARASITES. been produced by hydatids not of renal origin. The neck of the bladder was pressed upon by a growth of this nature belonging to the celluhir tissue between the bladder and the rectum, and the use of the catheter delayed until it was too late.' It is scarcely necessary to say that, as in the case of renal tumors in general, the urine is unaffected so long as there is no discharge of ^^e contents of the cyst into it. Calculi sometimes occur in the same kidney with hydatids, apparently as secondary productions. Crystals - of triple pliosphate, oxalate of lime, and uric acid, have been found within hydatid cysts passed with the urine, and it is easy to suppose that such a discharge may either estab- lish phosphatic dei^osition as a consecpience of the mucous irritation which it involves, or may simply furnish the nuclei on which any urinary deposit may collect. Chopart * found in tlie pelvis of the kidney of a child four years old hydatid cysts, or what were thus described, some of which contained a stone as large as a pea, evidently phosphatic, in their 'interiors. Stones of the same character were found in the bladder. In Blackburne's instance presently referred to, in which there was but one kidney, and that the seat of hydatids, its pelvis contained a stone.* And other instances of a similar association might be referred to. Paraplegia has been noted concurrently with hydatids of the kidney. Instances have been recorded in which the leg and the kidney of the same side have been affected.^ A case is related by Dr. Richardson as having come under the notice of Mr. Mackinder, of Gainsborough," in whicli a woman who had paralysis of the lower extremities and bladder was found after death to have hydatids in the liver and both kidneys. It is not to be supposed that there is any but an accidental connection between the renal parasite and the spinal failure. The spine may be diseased in- dependently and differently. Or it is possible that the spinal canal, as it proved to be in a paraplegic patient not long ago under my care in St. George's, may itself be the seat of a hydatid formation. Apart from such chances it is unlikely that a renal hydatid should affect the spinal cord. A cyst of this nature cannot encroach by filtration like a malig- nant tumor ; and our knowledge of renal abscesses sliows it to be highh'- im^jrobable that even should the cyst suppurate the matter should pene- trate tlie s^Dine or in any wa}' affect the cord. With r(!gard to tiie diagnosis of renal hydatid, this condition can scarcely be assured but by tlie passing of hydatids or booklets with the urine while a tumor of renal situation is recognized. The latter Avill be distinguished by the rules which have already been laid down, which should suffice todistinguisli a renal from an ovarian cyst the more surely when, as in case of hydatids, the formation in question is never of such large size as to obscure its relations. In case of otherwise insoluble doubt, the aspirator may be resorted to. The character of the fluid withdrawn might at once determine between the two. The presence or Related by Mr. Birkett, Med. Times, 1855, p. 161. ^ Found by Mr. Quekett iu case reported by Dr. Barker, loe. cit. p. 10. ^ Chopart, Traite dea Maladies des Voies Uriiiaires. vol. i. p. 145. Paris, 1830. It is not improbable tliat. though these cysts are described as hydatids, they may have been cavities of some other nature. At the date of this ticcount the distinc- tion was not clearly made ^ See footnote, p. 'i'-Mi. ^ Ziemssen's Cyclopaedia, vol. xv. p. 751, quoted from Frerichs. * Lancet, 1855, vol. ii. p. 366. RExN'AL PAKASITES. 235 absence of albumin must not be solely relied upon: hydatid fluid, though not usually albuminous, may be highly so, and conversely, cysts other than hydatid may be aqueous. The finding of booklets or lami- nated membrane would, of course, be conclusive. The hydatid fremi- tus is seldom if ever to be detected in connection with the kidney; it is probable that the tumor is seldom superficial enough to transmit vibra- tions from the cyst to the surface with the necessary distinctness. It is not possible to state the duration of hydatid of the kidney more exactly than as variable, sometimes very brief, sometimes apparently unlimited. The cysts are apt to escape by the urethra in successive crops, separated by considerable and uncertain intervals, so that it is difficult to say that any one is the last, notwithstanding that even years may have elapsed since its occurrence. One of the longest cases of the sort on record is one quoted by Beraud' from M. Vigla. A woman 37 years of age had passed hydatids with the urine every year of her life; she had had an attack lasting about four days every winter, mostly in Janu- ary, with now and then others at odd times. A woman mentioned by Davaine,* whose left kidney after death was found to have been trans- formed into a bag of hydatids, had been liable for twenty years to at- tacks of renal colic with escape of the cysts by the urethra. The case quoted from Blackburne^ by the same author, in which the disease at- tacked a solitary kidney, proved fatal in four years. Many instances of a different kind have been placed on record in which the patient has apparently recovered after a few outbreaks or even one. A natural cure is sometimes brought about by the process of suppuration. This finally arrests the cystic growth by killing the parasite, and leaves an abscess which may at last cure itself by discharge. Hydatid of the kidney, as already stated, is less fatal than when sin- gle organs or organs which have no such ready exit as the ureter affords are the seat of the disease. Of the cases recorded, only a minority have terminated fatally; and of those some have done so from causes uncon- nected with the growth which, in several, bas presented itself as a post- mortem surprise. Relying, as we must do in dealing with a disease of the infrequency of this, more upon published records than personal experience, it follows that the jiroportion of fatal cases should appear larger than it is. Those which present this ending are more noticeable than many Avhich do not; some instances are brought to light only by post-mortem examination, so that it is inevitable that cases whicli are com- pleted by death must show a larger proportion in literature than in nature. But even in literature it is not very great. Of sixty-three cases collected by Roberts, recovery was assumed to have taken place in twenty. Twenty terminated fatally, but in nine of tbese death was brought about otherwise than by the hydatid disease, so that this affection caused tbe death of but eleven of the number The tendency of renal hydatids, as has been shown, is to break into the pelvis and wear themselves out by discharge, while the functions are sufficiently carried on by the kidney which does not participate in the disease. But if this be incapacitated by any simultaneous or preced- ing accident, or if, as in Blackburne's case, the affected kidney be soli- tary, fatal results may be brought about by partial or complete suppres- ' Beraud, loc. cit. p. 57. ^ Davaine, loc. cit. p. 551. 3 Ibid. p. 551. 236 RENAL PARASITES. sion of urine, and in the rare instances where hoth kidneys have been involved in the hydatid disease, the same issue may present itself. Fatal results have followed the opening of the cyst' into the bronchial tubes, and have also been known to occur from extensive pleural etfu- sion,- set u]) by the progress of the growth in the same direction. Death has been known to have been brought about by the exhaustion of a ])ur- ulent discliarge with the urine, derived from a defunct hydatid cyst, and also to have ensued, as more often happens in the case of the liver, from the formation of a closed abscess in the place of one. In a case under M. Nelaton, related by Beraud,^' a fatal conclusion followed the artificial opening of a renal hydatid cyst: the cyst, which lay in close relation to the bowels, and had contracted extensive perito- neal adhesions, was punctured by means of caustic. It is difficult to say in this case how far the result was due to the disease and how far to the remedy. In other instances death has followed upon senile gan- grene, phthisis, or some accident not obviously connected with the para- sitic affection. The usually favorable delivery of renal hydatids makes it unjustifiable to encounter risk in search of artificial cure, save in the presence of cir- cumstances which add exceptional danger to the condition. What can be done beneficially may be briefly stated. Vermicides, administered by the stomach, appear to be powerless as regards parasites in the tis- sues. This is made evident in the case of the liver, an organ which is more advantageously situated than any other to receive the influence of drugs introduced into the stomach aiid admitted into the system prob- ably by the portal vein. Hepatic hydatids flourish in contempt of all such modes of attack; and there is no reason to suppose that such growths elsewhere will yield to them, exposed as they are only in a remote de- gree. I have satisfied myself that the oil of male fern is useless in this re- lation; and though many iiistances have been reported in which dis- charge of hydatids with the urine have ceased after the use of turpen- tine, there is no reason to believe that they would not equally have come to an end, transitoi'y as their nature is, had this drug not been given.' The question of surgical treatment can arise only in those few cases where a tumor presents itself near the surface. And even with such, if no danger obviously threatens, if there be no embarrassment of renal function, no rapidity of increase, and no sign of tlioracic complication, we may generally be content to wait upon nature. If there is reason to interfere, it would probably be best to use the method so often and so successfully used witli regard to the liver: puncture the cyst, where it is least covered, with a very fine aspirator, and with it draw off much, but not necessarily all of the fluid contained. This will at least be a measure of relief, and with repetition it may be curative; for the con- tents of the cyst, at first aqueous, will become more serous with each renewal until at last they are so much so as to constitute an element in which the parasite cannot live; the solid structures belonging to which will gradually shrink, concrete, and become inert. This method causes less pain and constitutional disturbance than that which has been of late ' Davaine, loc. cit. p. 467. ' Davaine, loc. cit. p. 550, Quoted from Livois. ^ Beraud, Des Hydatides den Reins, p. 80. •• See case of apparent recovery after the use of turpentine under Mr. Curling, Med. Times, 1863, vol. ii, p. 164. KENAL PARASITES. 237 employed under the name of electro-puncture, and is probably safer than it. I have tried both with hepatic hydatids, and have no hesitation in preferring the former. A single puncture, and that without the removal of fluid, or with the removal of but a trifling quantity, has been known to be followed by rapid diminution of the tumor. The larger methods, which seek the extraction of the cysts, in propria persona, by trocar, caustic, or inci- sion, are scarcely likely to suggest themselves with regard to cavities seated as deeply as in the kidney. Apart from the evacuation of hyatids from without, the fact that their escape into the pelvis and so out has been determined by blows and falls must be recognized; but such natural surgery — surgerv not of the surgeon — would be too uncertain in result to be recommended even were it possible, which it perhaps never is, to diagnose as renal a non-dis- charging hyatid. Measures of palliation are thus on every ground more likely to be called for than such as aim at cure. The vesicles have been helped along the ureter by external pressure directed by the patient himself, and their removal from the bladder has often been assisted with the catheter. This instrument will of course be at once resorted to should there be any distress from retention of urine. The use of diuretics has been thought to facilitate the discharge of the cysts; Beraud ' found in one case that these escaped after nitre or white wine; but probably such remedies will bring away only cysts which would as surely escape with- out them. During the attack, should it be attended with much pain, such treatment — opium, warm baths, etc. — may be indicated as would be proper were a calculus in transit. BiLHARziA H^matobia; Distoma H^matobium; Distoma Capejstse. Endemic Hematuria. It has long been known that several parts of the old world, most no- toriously the island of Mauritius, but also certain districts belonging to the continent of Africa, including Egypt, especially the valley of the Nile, and also the southern extremity of the same quarter of the globe, comprising the Cape of Good Hope and Port Natal, are tlie seats of an endemic disorder of which h^ematuria is a prominent symptom. The ha^maturia of Mauritius has been longest under notice, and its symp- toms have been minutely and repeatedly described, so as to leave no doubt that the disease is of the same nature as that which prevails on the continent; yet is has been imperfectly traced pathologically, and though it is said that the Bilharzia'- lias been found in the island, yet it must be allowed that the nature of the insular endemic is rather a mat- ter of inference than demonstration. The corresponding affections of Egypt and the Cape have been more completely worked out, owing to the labors chiefly of Bilharz at Cairo aad of Dr. John Harley in regard to the southern localization, and followed in both these widely-removed fields to identically the same cause, the ravages of a minute bloodworm, Avith which the name of its discoverer has been connected. It is hardly to be supposed that the intermediate ' Loc. cit. p. 93. * Sonsino, Lancet, May 27th, 1882, p. 553. 238 RENAL PARASITES. portions of Africa are entirely destitute of the parasite which infests its extremities; and indeed it is believed that the animal frequents the whole of the eastern seaboard of this continent, manifesting a preference for littoral rather than the inland districts, and for low rather than high levels. Further research must add to our knowledge of the distribution of the disorder; but we know enough already to make it impossible to consider the liEematuria of Africa excepting in relation to the parasite; and as to the haematuria of the Mauritius, it is so similar in symptoms to that of Africa that it can scarcely be of a totally different nature. The consideration of the Bilharzia, therefore, is inseparable from that of endemic hajmaturia, and it may be convenient to sketch in slight outline the natural history of the parasite before referring in particular to the symptoms which it has been ascertained to produce, or which are pre- sumably associated with a similar cause. Our knowledge of the animal in its Egyptian location has been largely contributed to by post-mortem research, and is fairly complete so far as relates to the portion of its ex- istence during which it is a denizen of the human body; as yet we know it at the Cape chiefly by ova which have been passed with the urine dur- ing life; it is i)ossible that our knowledge in this respect may soon be extended. The animal whose existence was discovered by Bilharz in the year 1851, and since described by Kuchenmeister and Leuckhart, is a distinct species of fluke or trematode.' The creature enjoys complete sexual dis- tinction: the male, which has much the contour of a leech, is about half an inch in length, the female measures about four-fifths of an inch, but is of such slender proportions that much of its body is imbedded within that of the male during the act of sexual association. The body of the male contains a canal which has been called gynecophoric, within which nujjtial chamber the female is for the time inclosed. The comparatively plum^) body of the male is somewhat tuberculated, that of the female is smooth. With both sexes there are oral and ventral suckers, by means of which the animal secures its position. The eggs are oval or pear- shaped. They have a spine or sharp jjoint, usually at the hinder ex- tremity, but sometimes at the side. Dr. John Harley found in his South African cases the hinder spine only; in Egypt both kinds have been found. According to Dr. Zincarol,-' of Alexandria, the ova from the bladder have a terminal spine, those from the intestine a lateral one. The eggs give exit to ciliated embryos, which move about with much activity, as Griesiuger witnessed in the bowel, and as has been often seen in the urine. Though the eggs may possibly be thus hatched in the urine, the em- bryo cannot live long in this fluid; water is the place of its further development. For its prolonged existence pure or only brackish water is required. Urine is fatal to it, though not at once. Harley never found a live embryo in this fluid. Eoberts was more fortunate, and wit- nessed the activity of the embryo in this secretion several hours after it had been emitted; but we have the evidence of Cobbold as to the impos- sibility of jDreserving its life for forty-eight or even for twenty-four hours, excepting in water which is free from organic admixture. Traces of blood, mucus, or decomposing matter of any kind added to spring water caused the death of the embryo within twenty-four hours, as also ' Cobbold, loc. cit. p. 197. *Path, Trans, vol. xxxiii. p. 410. KENAL PARASITES. 239 did a mere tinting with permanganate of potash or carmine. So small a proi^ortion of urine as a drachm to a quart was fatal to the embryo in forty-eight hours. Thus it api^ears tliat for the continuance of the race the egg or embryo must be passed with the urine into fresh or brackish water; if the egg, it is hatched, as Cobbold has shown, almost immediately upon coming into contact with the water; and it then commences the extra- human portion of its existence, of which nothing is ascertained excej^t that a time comes when the creature, in some shape as yet unknown, re- fcuriisfrom the water to the vertebrate body. The 2)arasite infests man and the monkey. A variety, which is stated to be distinct, has been found in the ox and sheep. In the portal vein of a monkey which had been imported from Africa and died in the Zoological Gardens, Dr. Cobbold found so fine a specimen of this fluke that he was for a time disposed to distinguish it as the Bilharzia magna. The animal in its adult state belongs especially to the blood; it is found particularly in the vessels of the bladder, and in the abdominal veins, the portal vein and its intestinal, mesenteric, and splenic tribu- taries, and the hepatic vein. Ova have been abundantly found in the liver, to which it is evident that they may readily be conveyed; and egg-shells within the left ven- tricle, the means of their reaching which are less obvious. Though the worms are, as a rule, confined to the blood, the eggs are somewhat widely distributed. Tliey are deposited mainly in the mucous membranes of the bowel and of the urinary system, in which they give exit to the ciliated and active embryos which escape with the evacuations to find adventures as yet unknown to us, but no douljt to provide adequately for the continuance of the race. The worm in the blood appears to cause less disturbance than would be expected; the presence of the parasite is chiefly made known to us by the irritation occasioned by its progeny in certain mucous membranes. In the large intestine, which is the jjart of the bowels chiefly affected, the ova were found in polypoid excrescences, and their presence indicated by diarrhoea, with discharge of mucus and blood, and much jiain of the nature of colic. In the urinary membrane, which is the chosen site for the dej)osition of the eggs, the results are produced by which the disorder is especially characterized. The blad- der is found to be extensively spotted with ecchymosis, and variously pigmented; the mucous membrane is sometimes partially detached or undermined by accumulations of eggs beneath it, and it is sometimes lifted up into warty or villous elevations. These changes are necessarily attended with much irritation and the discharge of blood and mucus, together with eggs, embryos, egg-shells, and now and then a deceased parent. The accumulated and partially imbedded ova often become the cen- tres of oxalic and lithic deposits from the urine, so that vesical calculi are common complications of the parasitic disease. Similar changes occur in the lining of the ureters, and, less often, of the })elves. The ureters are apt to become obstructed or constricted, and the kidneys to present in consequence the various phases of dilatation and atrophy which follow ujion urethral stricture. They may become the subjects of hydronephrosis, or tliere may be pyelitis even to the degree, as in a case described by Griesinger, of converting the organ into a mere bag of pus. But beside these consecutive changes it appears that the kidneys are affected by the parasitic disorder in ways which arise within themselves. 2-iO RENAL PARASITES. It is sufficiently clear that the pelvis of the kidney affords lodgment to the ova, as do other parts of the uriiiary membrane, though not with the same frequency, and adult animals have been found in the renal blood- vessels. Whichever may be the effective sources of irritation, the kid- neys are described as swollen and congested, affected with a dark red hyperemia, and, in tlie later stages, fatty. Whether these changes depend upon venous obstruction or upon irritation of the renal sub- stance by parasitic intrusion are questions which must be answered by further observation. Both in Egypt and also in a person Avho had come from Natal, filariaj' have been found in individuals who have also given residence to the Bil- harzia; but the animals and the symptoms produced by them are totally distinct and the concurrence accidental. AVe know the symptoms of the disorder as it occurs in Egypt, chiefly from the researches of Bilharz and Griesinger, as in South Africa chiefly from those of Dr. John Harley, though as regards both localizations many other observers have more recently added to our stock of knowl- edge. *' Gravel and ulcers of the kidneys," if we may trust the state- ment of Prosper Alpinus,^ appear to have been frequent among the Eg\'ptians even as far back as the year 1645 — not to mention a still older reference to the turning of water into blood, Avhich may have found its suggestion in the diseases proper to the place. So common is the para- site in Egypt that M. Griesinger found it in 117 of 303 autopsies. Its effects are most noticeable from June to August, and least so from Sep- tember to January. The prevalence of the disease in summer is owing, as Dr. Cobbold supposes, to the prevalence of the larvae, wheucesoever derived. The symptoms of the disease are, in the first place at least, chiefly local, vesical, and prostatic irritation, with the passing of blood, mucus, sometimes pus, and not seldom calculi, which may be either of vesical or renal origin. Pain in the back is mentioned, though the bladder-symptoms appear to be usually more prominent than the renal. A form of dysentery, diarrhoea with the passing of blood and mucus, is a frequent concomitant. "With the local symptoms there is often much loss of flesh, anaemia, and nervous prostration. ''Egyptian chlorosis '' has been spoken of as one of the results of the disease, but it appears that this especial affection is rather to be attributed to another parasite, the Ancldistoma duodenaJe.^ Beside dysentery, pneumonia has been mentioned among its fatal results, though it would seem from our ex- perience in South Africa that the disorder seldom leads to a fatal issue. It is stated that in Egypt it occasionally presents itself in an acute con- stitutional form, resembling typhus in its symptoms and duration. The symptoms appear, however, to be iisually, and as far as we know in South Africa always, of the chronic and local sort, with hematuria and vesical or i^rostatic irritation, without much or with no early effect upon the general health. A little blood is passed, mostJy after the urine; there is little fre- quency of micturition, though perhaps a difliculty in retaining the water when the call has come. In one instance the prostate appeared to be solely affected, since there were no properly vesical or renal symptoms. Mucous casts were passed, imbedding the eggs, while small quantities of ' Zincarol, Med. Times, January 21st, 1882, p. 76. Cobbold, Lancet, January 14th, 1882, p. 84. Sonsino, Med. Times, May 2Tth, 1882, p. 5.56. ^ Quoted by Davaine, 2d edition, p. 320. ^ Sonsino, Lancet, 3Iay 2Ttli, 1882, p. 553. KENAL PARASITES. 241 Tenons blood, mixed with nrine, were from time to time passed b}' ihe urethra, the rest of the secretion being nnaffected, save that it was clondy with mncns." Such symptoms appear to be seldom attended with danger to life; the only fatal case referred to by Dr. Harley is that of a Scotch- man, who died ''worn out by the various concomitants of the disorder '' at the age of seventy-six. Among concomitants must be mentioned the ]iassage of renal calculi, in two instances of which Dr. Harley found the irgs of the parasite in the interior of the stone; constituting, as we can •arcely doubt, the point of primary deposit. This observation is of interest as placing beyond doubt the particijjation of the kidneys in the disease. The calculi appear to be chiefly composed of oxalate of lime, though uric acid, which is a frequent deposit in such cases, takes part. The urine itself was not, in Dr. Harley's cases, usually changed in quantity, or specific gravity, or in quality, save by the addition of the jiarasitic pi'oducts, with blood, and its proper amount of albumin. It was not ammoniacal nor alkaline, but, on the contrary, apt to deposit uric acid. None of the ordinary products of cystitis Avere usually pres- ent, though sometimes there was a little blood-stained stringy mucus. In a case presumably of prostatic location the blood was passed only after breakfast or defsecation. The disorder in South Africa appears to attack foreigners and colo- nists in preference to the native population. KaflEirs are exempt, while coolies suffer. The disease seems to be nearly, but not absolutely, limited to males. When females suffer, it is said often to disappear with the advent of the menses, almost always to cease on the occurrence of preg- nancy.^ It was not transmitted to a wife whose husband had passed numbers of eggs every day of married life. Three or four healthy chil- dren had been born to the pair. Boys after the age of three or four are most liable, the complaint often disappearing about puberty. It has, however, been known to have been acquired at the age of fifty, and to have proved fatal at seventy-six. The endemic hasmaturia of the Isle of France has long been known, but has not yet been definitely traced to the Bilharzia ; there can, how- ever, be little doubt that it is produced by this or some closely similar parasite. The symptoms and incidence of the disease are almost exactly those described at the Cape. Repeated attacks of hsematuria occur with frequency of micturition and other signs of vesical irritation. The blood is in but small amount, not so much as to discolor the whole bulk of the urine, but only its last portion, after the discharge of which a few drops of blood may escape unmixed. Small clots are occasionally seen. Under the microscope have been found oxalate of lime, blood, mucus, and pus, with scales of blood-epithelium. Probably before long this list will include the parasite. =* The disorder is here, as elsewhere, often associated with attacks of renal colic. It is said that three-fourths of the children in the island suffer from it, both sexes being affected, but boys apparently with the more frequency, since of these it is said that few escape. The disorder, as elsewhere, often disappears about the time of puberty. It has been attributed to masturbation and the use of spiced dishes — causes which, ' Dr. John Harley, Med.-Chir. Trans, vol. liv. p. 48. •^ Dr. Allen, Lancet, July 15tli, 1883. ' Todd, Clinical Lectures on Diseases of the Urinary Organs, 16 242 KENAL PARASITES. were thej effective in this respect, might be expected to give rise to the disease in many other places — and with some probability to the quality of the water drunk. A form of hfematuria, presumably of the same ori- gin, has been stated to occur in Madagascar.' It is of importance to inquire Avith regard to the creature a portion only of whose existence is passed within the liuman body, whence it may be derived and how admitted. As it is not known save as a human para- site, its derivation must be a matter of conjecture, but water is to be suspected as the means of its distribution. The Nile is thought to be the vehicle of the parasite in Egypt, and it has been suggested that some of the fish of that teeming river may furnish its temporary abode. Dr. Cobbold thinks it more likely that the larval form infests some gastero- pod mollusc local to the district where the disorder occurs. At Uiten- hage and Port Elizabeth, at the other extremity of the continent, the disorder is likewise attributed to water which is supplied by exposed streamlets in which water-plants abound. It is stated that in South Africa those only are liable ^ who drink river water or the water from marshes or pools, those who use well or rain water being exempt. Dr. Harley has shown reason to suspect watercresses as conveying the para- site, Avhether themselves affording attachment to it, or, as he suggests, by means of minute mollusca in which the parasite is lodged adhering to the plant. It has been suggested that the ova find admission into the body during bathing, and that the frequency with which boys are af- fected as compared with girls is due to their more often doing so. The urethra has been regarded as the point of entrance, and it has been stated that in South Africa the natives are in the habit of tying grass round the orifice before wading or swimming across a river. On the other hand, it has been remarked that in South Africa the Kaffirs, who bathe often, are exempt from the disease, while the coolies, who bathe seldom, are often affected. Whether the parasite is admitted by the urethra or by the mouth must be regarded as at present uncertain ; what we know of the habits of other similar creatures and the abundance with which these are found in the jiortal vein, "where indeed they were first detected, would lead us to attach the greatest probability to entrance by the mouth; entrance by the urethra is supported by the concentration of the disorder upon the urinary organs and the blood-vessels in immediate connection with them. It has been suggested that the ova may be deposited in the skin and thus enter the superficial veins ; but if thus introduced they should be conveyed to the systemic, not the portal vessels. Dr. Harley tells us that persons bathing in the Booker river, about which the dis- ease is common, are sometimes attacked in consequence with an nrticari- ous eruption, and that the colonists of Natal are constantly affected, when first resident, with indolent sores, especially upon the legs, which resemble syphilitic ulcers.^ It is stated, however, by Dr. Guillemard, that the ''Natal sores " are distinctly and solely caused by the bite and subcutaneous burrowing of a species of tick which is quite unconnected with the Bilharzia ; and though bathing must be admitted as Avith pos- sibility affording means for the introduction of the animal, the evidence is against cutaneous entrance. The Bilharzia appear sometimes to die out like a dynasty, so that the ' On the Endemic Hcematuria of Hot Climates, by Dr. Guillemard, p. 36. ' Dr. J. Harley, Med.-Chir. Trans, vol. liv. p. 60. ^ The ova of the Bilharzia, which were found, as supposed, in Delhi boils, have been shown to be altered hair-bulbs. RENAL PARASITES. 243 disease comes to an end spontaneously ; this occurs especially about the time of puberty. As to treatment, since the habitation of the parent worms is in the blood, they are practically out of the reach of vermi- cides ; this organized fluid could not be supposed to tolerate any admix- ture which would be destructive to animal organisms within it. All we can do, therefore, when the disease is established is to support the patient against it and use such local measures as may be effective against its more accessible manifestations. The latter endeavor resolves itself into the destruction by some suitable injection of as much of the parasite or its progeny as is lodged in the coats of the bladder. Whatever may be ef- fected with regard to the unhatched eggs, it would not appear tliat any trouble is needed to destroy the ciliated embryo, since urine itself is fatal to it. With regard to the worms, most of them are obviously out of reach; those only which have penetrated the vesical wall are thus assailable ; and even here not too readily, for the guest is protected by the sensi- bility of the host. The more active disinfectants or parasiticides could scarcely fail to injure the bladder. Experimenting Avith non-irritant solutio7is Dr. Harley got the best results from iodide of potassium in a strength of five grains to the ounce. This gave rise to no vesical irrita- tion and was followed by the expulsion of various parasitic products. Dr. Harley made trial of other remedies, including oil of male fern, worm- wood, and quassia, with less satisfactory results. It is obvious that there is room for further experiment : quinine, the sulphides, and permanga- nate of potash might be suggested. Dr. Allen, of Pietermaritzburg, emi^loyed a concentrated solution of santonine in absolute alcohol, and injected this in quantities of two drachms into the empty bladder, with the constant result of cystitis, as might have been anticipated, but with the effect, as he thought, of destroying the parasite. It is indeed possi- ble that the ova, like the bladder itself, may have been seriously injured by this application and the disorder locally suspended ; but such relief is scarcely worth the cost if the parasite remain intact in the deeper veins. Dr. Allen ' supposed also that by the administration of santonine by the mouth the creature would be killed in the blood-vessels, a pre- sumption from which local treatment might be inferred to be unneces- sary. The destruction of the worm in the blood-vessels by medicine conveyed by the blood cannot as yet be regarded as proven or as possible. Dr. Cobbold disapjoroves of injection, and directs his attempts to the ar- rest of the hemorrhage rather than to the destruction of the parasite. He thinks the catheter should be avoided as injurious, and parasiticides as useless. Nothing, in his view, should be done to disturb the plugs which spontaneously form at the points of ulceration. He has found good results from the administration by the mouth of buchu and bear- berry. With regard to prevention, if the parasite is, as there is reason to be- lieve, brought by water and admitted by the mouth, it is obvious that spring or rain water should be drunk when possible, to the exclusion of that from streams and pools. But with the latter, infection should be completely intercepted by boiling or effectual filtration. Fish and vege- tables from suspected water shoiuld be wholly avoided, or at least never used as food until after having been raised in cooking to boiling point. In view of modes of entrance other than by the alimentary canal, there should be no bathing but in the sea. 1 Lancet, July 15th, 1882 ; also April 14th, 1883. 244 RENAL PARASITES. The Stroxgulus Gigas. The "worm which has been thus called, or otherwise the Eustrongyhis giqas, both names alike bearing witness to its rotundity and to its size, is not only the largest individual parasite which takes residence within the human body, but is the largest nematode known. It may nearly be compared in its dimensions to one of the snakes common in this country, the male to the adder, the female to the common field snake, AVith the thickness of about half an inch the male attains the length of about a foot, the female of about three feet. The serpentine proportions of the Strongnlus piRas in the CoDepre of Surgeons, "found in the kidney of a patient of the late Thomas Sheldon, Esq." The woodcut is of one-half the actual dimensions. The animal, a female, 18 inches long, has been laid open to show the intestinal canal, spiral CESophagus. and reproductive organs. creature are testified to by the older writers, who, when they found these parasites in the kidneys of wolves and dogs, described them as serpents in this situation. This variety of strongnlus, though not peculiar to the kidney, is most often found in this organ, of which it becomes the denizen in a large number of animals. It is said to occur with especial frequency in the BENAL PARASITES. 245 weasel and the North American mink, destroying the snbstance of the kidney and giving rise to calcareous dejiosit in its walls. Among the animals in which this worm has been found Cobbold mentions the dog, wolf, puma, glutton, racoon, coati, otter, seal, ox, and horse. The general aj^pearance and something of the anatomy of the animal may be gathered from the accompanying woodcut, which represents the specimen which, on Cobbold's authority, we may accept as undoubtedly from the human body, which is preserved at the College of Surgeons. The adult worm, to follow Cobbold's description, is cylindrical, more or less red in color, and somewhat thicker behind than in front. The head is broadly obtuse, the mouth being supplied with six small wart-like pa- pillae, whereas the lumbricus, which the strongulus someAvhat resembles, has but three. Two of the papillre correspond with the commencement of the two lateral lines of the body. There are six other longitudinal lines Avhicli traverse the body from end to end. The tail of the male shows a simple cup-shaped bursa, which jiartly conceals the simple spi- culum. The tail of the female is blunt and pierced by the centrally placed anal opening. The vulva is situated near the head in the ventral line. The eggs are stout and oval, measuring -j^o-" in length and -^^-a" in breadth. In the stages of existence through which this parasite passes before entering the human or mammalian body and assuming the form to which the term gif/fts is applicable, it appears that certain fish, as probably in the case of the Bilharzia, play the part of intermediary bearers. It has been inferred by Hchneider, and the interference accepted by Leuckart and Cobbold, that the worm known as the FUaria cystica, which is found encysted beneath the peritoneal membrane of the Galaxias scriba and Si/ndranchus laticandatus, is the sexually miniature and undeveloped strongulus. It is easy to imagine that the minute inhabitant of the fish may be transferred to the fish-eating animal, the otter, seal, and even the dog and the wolf, and man himself, but it is less easy to explain its transmission to the ox and the horse. Probably water is the vehicle. With regard to the geographical distribution of the strongulus, it ap- pears to be less uncommon in the Low Countries than elsewhere both in man and animals. Of the eight cases i-eferred to as probable, two were recorded in Holland. Of another, the subject was a Frenchman who had been to Walcheren. Two others occurred in France. Of the eighth, from which was obtained the specimen in the College of Surgeons (see woodcut), nothing further is known than that it was taken from the kidney of a patient of the late Thomas Sheldon, Esq. The chosen position of this worm is the pelvis of the kidney, in which it lies in a coil or knot; but as it has been passed with the urine in the human subject, it is obviously not limited to any subdivision of the urinary cavity. In dogs, in which opportunities of observing the habits and effects of the parasite have lieen more frequent than with other ani- mals, it has been found stretched along the whole length of the ureter, in the bladder, in tlie peritoneal cavity, into whicli it had i)assed from the renal pelvis, and in external swellings in the neighborhood of the ])enis. Davaine has gatliered so many of the scattered instances in which this worm has secured its admission into the human body that it is to his re- search that we are chiefly indebted for our knowledge of its clinical results. From the year 1074 to his date of publication, 1877, this writer has collected seven cases which he regards as '"probable," eight as ''very uncertain,'' which may be taken to represent our whole recorded ex- 246 RENAL PARASITES. perience of this parasitic disorder in the human subject. Among the seven " probable " cases were two in which the worms had been passed by the urethra only, one in which they had escaped by lumbar fistulae, and the urethra also, four in which they were found in the kidney after death. Of these four to Avhich alone we can apjjeal for pathological in- formation, there is but one in which the condition of the kidney is de- scribed with any minuteness: in this case the secreting structure was nearly destroyed, and the weight of the organ reduced to about half (see p. 247). With animals the kidney has often been noticed in these circumstances to have displayed all the effects of pyelitis, to have be- come variously dilated, as happens from stone, and in the North American mink in particular to have become converted into a cyst, the walls of which are the seat of calcareous deposit. An instance has already been referred to in the dog, in which worms of this nature had passed from the renal into the abdominal cavity. The instance' relating to the human subject in which stronguli were discharged through a lumbar abscess may be further mentioned, not- withstanding that it has been quoted by other writers. A boy was cut for stone by M. Moublet at the hospital of Tarascon, and a large calculus removed. Four years later, after an attack of partial sup- pression of urine with much constitutional disturbance, an abscess was found in the lumbar region, was opened, and healed. But the cicatrix after a time was undermined by renewed suppuration and again opened. From the opening thus made a living strongulus was withdrawn by the child^s mother, and a few hours afterwards another by M. Moublet. Two days afterwards two worms of the same kind were passed by the ure- thra, one with the help of forceps, the second spontaneously. Having thus got rid of four of these formidable interlopers, the child recovered. If we may accept a case, which, however, Davaine has shown to want corroboration, the concurrence of a stone with this parasite, which M. Moublet's patient presented, is not singular. A worm apparently of this nature was, as far back as the year 1595, found in the kidney of a Belgian archduke, together with a calculus. Given the Avorm, the stone is not improbable as a result; some of the exuvi* might readily give ground for concretion." The symptoms produced by the presence of this parasite in the kid- ney are those of stone aggravated in respect that rest brings no relief, and with the repulsive addition, if we accept the evidence of a single instance, of a sense of movement in the renal region. The symptoms are gra])hically displayed in a case related by M. Aubinais^ and quoted by Davaine. A French husbandman, sixty years of age, was seized with shar[) pains in the region of the right kidney, which were supposed to be nephritic. For three years, then, in spite of many anodyne and other remedies, these were incessant and most severe, and the man, formerly somewhat obese, was reduced to a skeleton. In this condition of atten- uation, movements of swelling and undulation, apparently in the situa- tion of the right kidney, could be felt and seen through the thin abdominal wall. The patient himself was conscious of crawling move- ments, or movements of ''' reptation,'' as M. Aubinais terms them, in ' Moublet, Joum. de Med. et de Chirurg., Juillet, 1758. Quoted by Rayer, Davaine, Chopart, etc. ' D. M. Jausoiiiiis, 31ercurii Bello-Gallici, tome ii., cite par Schenck. — Da- vaine, op. cit., p. 2y5. ^ Quoted by Davaine, 2d edition, p. 285. KENAL PARASITES. 247 the same position. After three years of these sufferings, bed-sore.? formed, and death was brought about by wasting and exhaustion. The right kidney was removed twenty hours after death by an incision through the flank, Undulatory movements were still perceptible within it, and a living strongulus over seventeen inches long and nearly a quarter of an inch in thickness (from five to six millimetres) discovered in the pelvis. The tissue of the kidney was much altered, its parenchyma in great part destroyed, and its weight reduced by half. It is scarcely needful to dwell further on the symptoms: severe at- tacks of hjematuria have in some instances marked the presence of the worm, but this symptom has not been noticed in all. Temporary suppression of urine has occurred apparently in consequence of its enter- ing the ureter; in such a case, the other ureter must have been also ob- structed, possibly by other means. This distinction from stone or growtii must be seldom practicable until either worms themselves or their eggs have been passed. The passage of the latter with the urine, should the domestic relations of the parasite be consistent with their production, ought, considering their conspicuity as microscopic objects, to furnish ready means of detection. As to treatment, it may fairly be inferred that parasiticides are useless. If in the bladder or urethra its removal will be indicated ; the means must be suggested by the case itself. If in the kidney, it may be considered whether the circumstances are such as to justify nephrotomy. Pentastoma Denticulatum. This creature, which would be comprehended under the common term tick, must ap])areutly be counted as a renal parasite, though it has no clinical significance in this relation. Like many other parasites, it presents two different phases, which have become known by different names. In the adult state, as the Pentastoma tenioides, it lives at large in the nasal cavities, chiefiy of the dog, where it presents the shape of a maggot or wingless insect, covered with rings of mail, varying accord- ing to sex from one to three inches in length, the male being the shorter. In the larval state, as the Pentastoma denticulatum, it attains the length only of about an eighth of an inch, and is narrowly confined within a cyst which is imbedded usually in one of the abdominal organs. The animal in this stage of its existence, in which only its interests are con- cerned with those of the kidney, is somewhat ship-shaped or navicular, with a rounded forej^art, where are placed four booklets or anchors, with lines narrowing towards the stern and sides beset with fine spines. The relationship between the largo and active adult and the minute and imprisoned offspring appears to have been fairly ascertained. The ova of the nasal intruder, carried out Avitli mucus or expelled by sneez- ing, may readily attach themselves to the food of men or of animals; thus taken into the stomach, the embryos escape and bore, for which purpose Nature, with an impartial consideration of their necessities, has provided them with a suitable api)aratus; they thus enter various organs and tissues, among which the liver appears most often to snpi)ly their resting-place, but occasionally the lung,- the submucous tisssue of the small bowel, and the kidney. The kidney, so far as I know, has been mentioned but once in this relation, aiul that by Wagner; but our knowledge of tlic distribution of this parasite in its larval stage makes it more than probable that this localization of it is not solitary, though 248 RENAL PARASITES. otherwise unnoticed. The imbedded larvae, or those of them which are destined for further development, are released when the flesh in which they lie is torn up by the dog or wolf, and thus liberated, sniffed into, or otherwise enabled to enter the inquiring nose of the quadruped. From this the completed cycle begins again. The embryo having reached its place of rest, repeatedly casts its skin with rapid growth, and at last attains tlie perfected larval form to whicli the name Pentastoma deiiticulatum has been given, wliich remains en- cysted and inactive in the organ in which it has been imbedded until it is introduced to the upper world by some such process as has been referred to. Unlike the Pentastoma constrictum, the presence of which has been associated with destructive inflammation, no symptoms have been traced to the denticulatum. It appears to be by no means uncommon in some parts of the Continent, however rare in this country. According to Frerichs, it is to be found in the liver more often than theecchinococcus; though Murchison, in England, long sought for it without success. It appears to be especially common in Brazil.' In the only instance in which the parasite was recognized in the kidney, a small Avhitish, slightly raised oval patch of flbrous appear- ance, about one-seventh of an inch in length, was found underneath the capsule. This little body was hollow in the interior; it contained a yel- lowish mass, which on examination disclosed the presence of the worm." Tetkastoma Kexale. The so-called Tetrastoma renale may be briefly dismissed as of un- certain origin, though probably parasitic. A parasite to which this name was given was found by Lucarelli in the urine of an old woman who was thought to have symptoms of stone, and it was inferred that it had come from the kidney tubes. On the death of the patient, however, two months afterwards, no such parasites were to be found there or else- where.^ This trematode was described by Delia Chiage as having a length of five lines, an oval flattened body, and four suckers at the cau- dal extremity. Worms Accidektallt Present ix the Urixary Passages. Worms belonging to the alimentary cavities may accidentally enter the urinary. Oxyurides, or thread worms, may crawl from the rectum and reach the vulva, or the orifice of the female urethra, into which channel they may possibly intrude themselves to be passed witli the urine. Other bowel worms, should they be found in the urinary cavities, must have come through a fistulous communication. This has most often been the case with regard to lumbrici, animals whicli have a re- markable propensity for penetrating into small holes of every kind. Tliese worms have often thus fatally entrapped tliemselves in buttons and "hooks and eyes," which have been accidentally swallowed, and others have penetrated into abscesses and other cavities opening upon the alimentary canal. With regard to the bladder, a large number of ' See Cobbold's Parasites, 1879. p. 259. Davaine, Traite des Entozoaires, 1877, p. cxxiv. ' Wagner's description quoted by Roberts, Renal and Urinary Diseases, 2d edition, p. 594. 5 Entozoa, by Cobbold, 1864, p. 204. RENAL PARASITES. 2^9 instances are on record in -whicli these worms have got into it through fistulous openings and been passed with the urine, and we are indebted to Davaine ^ for bringing them together. Several of these worms have at intervals been expelled or withdrawn from th6 same urethra. A boy seven years of age, after having reten- tion of urine for seven days, perceived the extremity of a worm protrud- ing from the meatus, pulled it out and was relieved. A year later an- other lumbricus presented itself, and was removed by the boy's mother. During the two years succeeding the second removal, many worms of the same sort were similarly got rid of. Subsequently, many similar worms escaped by the anus, violent pains occurred in the region of the bladder, purulent urine was discharged with the stools, and the patient sunk. It was found that the vermiform appendix was displaced, and was adherent to the bladder, with the interior of whicli that of the vermiform appendix communicated by a fistulous openiiig. A large calculus was found in the bladder, and in the calculus a pin. This had probably been the origin of the whole complication ; it had been swal- lowed, had entered the appendix, and thus set up inflammation, which had led to adhesion and then to ulceration, by which it had reached the bladder and become the nucleus of the stone. The symptoms, after the early retention of urine, were apparently due more to the stone than to the worms; indeed, Avhere lumbrici have reached the bladder from the bowel, unless they have entered the urethra and caused retention, the symptoms appear to be little more than those which commonly attend the fistulous communication. Another case is recorded nearly parallel to that mentioned, in which lumbrici, passed from the bladder, were found to have reached it through an adherent and perforated vermiform appendix. In this case also a stone was found in the bladder. Instances are likewise on record in which a similar intrusion has occurred by way of a fistula between the bladder and rectum." Joints of t^enite have been known, though rarely, to have been simi- larly introduced into the bladder. Spurious Worms. An endless variety of insects, worms, and vermiform bodies have been introduced into the urine by accident or design, and placed upon record as urinary parasites, while some have been not i)arasitic, and others neither parasitic nor urinary. Some supposed worms have clearly been vermiform coagula from the ureter. Of other supposititious para- sites, the extraordinary research of Davaine has provided a largo selection collected from ancient and modern literature. These would appear to include all possible and some impossible insects. These are variously described as winged, provided with legs, antennae, or eyes of fire, while others present tlie form of scorpions or the more familiar shapes of beetles and grasshoppers. Though such obvious mistakes are little likely to be now repeated, nevertheless modern days, as if the art of deceiving improYed pa?'i passtc with the means of detection, have witnessed such successful imitations of urinary parasites as to pass current with observers of approved skill and technical accomplishment. ' Loc. cit., p. 300. ■ W. Kingdon, London Med.-Chir. Review, July, 1843. 250 RENAL PARASITES. A girl five years of age was supposed to have passed with the urine a number of worms of from four-fifths to two-fifths of an inch in length. These were carefully examined by Mr. Curling, and described by him in a paper read before the Medico-Chirurgical Society as a new urinary parasite under the name Dactylius aculeatus. For a time the discovery appears to have remained unquestioned, but there appears to be little reason to doubt from the observations of Cobbold and others that the worm was but a species of earth-worm known to frequent flower-pots, and described under the name Euchytroeus aJbidus. The mode of migration, as Cobbold observes, from the flower-pot to the receptacle in which the supposed parasite was found is not difficult of explanation. Two other spurious urinary parasites, which were furnished by the same patient, and have been dignified by the names Sjriroptera Iwminis and Diplosoma crenatum, need a passing mention, as connected with one of the most remarkable of those female simulations which are so incomprehensible to the masculine mind. The primary victim and sponsor of the imposture was, together with Mr. Barnett, the acute and sceptical Lawrence, who brought the case as one of parasitic disease be- fore the Medico-Chirurgical Societ}^ A 3'oung woman had obstinate re- tention of urine with symptoms such as commonly indicate stone in the bladder. The catheter Avas used as frequently as such a patient could desire. She was sounded for stone in vain, but described a " fluttering" in the bladder, presently succeeded by the withdrawal of several small worms which had become curiously entangled in the eye of a catheter retained for a time in the urethra. "Worms, or what passed for them, were evacuated actually or ostensibly to the number of above 800. These were of two kinds: small veritable worms, which were desci'ibed as Spiroptcra hominis, and larger vermiform bodies, which Dr. Arthur Farre, after elaborate examination, entitled Diplosoma crenata. Speci- mens of both were forwarded to Continental museums ; the discovery was for a time accepted, and two parasites were added to the list of these concealed enemies of mankind. The small worm, however, truly parasitic though it was, proved to belong not to the human being but the fish; it was identified beyond doubt by Dr. Schneider as the Filaria piscium, a worm of common occurrence in the haddock and cod ; while the Diplosoma crenata, as Cobbold has shown, almost certainl}' consists of slices of haddock's roe. The smaller worms, from half an inch to an inch in length, sometimes made their appearance alive, and lived in the urine for tliree days. The report is explicit as to the circumstances that most or many of these were actually discharged through or withdrawn with a catheter, so that it is certain that some at least actually came from inside the bladder. The patient, therefore, must have introduced not only sham worms, but loathsome living parasites, within the pene- tralia of her own body. The satisfaction she derived from so doing must have been considerable if it bore any proportion to the sufferings entailed: these comprised the utmost distress from strangury, typhoid prostration, arid a large abscess which burst into the vagina after con- stitutioiuil disturbance which well-nigh proved fatal.' 'See "Case of a Woman who voided a large number of Worms by the Urethra," by W. Lawrence, Med.-Chir. Trans., vol. ii. p. 383. Dr. Arthur Farre, Archives of Medicine, vol. i. p. 2!t(). Also Dr. Farre's article "Worms," Libntry of Medicine, vol. v. p. 241. Di-. Beale, Kidney Diseases, etc., 3d edition, p. 399. Cobbold, Entozoa, pp. 406, 409. OHAPTEE XIX. CHYLURIA. HiSTOEY AND ClINICAL AsPECT. The disorder which is known by this name, and characterized by the passing of urine, which has been regarded as chylo-serous, chylous, or haematochylous, or more barely described as oleo-albuminous or albu- minous and fatty, is one which both in its cause and in its symptoms presents itself with remarkable isolation and distinctness. The leading symptom^ is the admixture with the urine of a fatty emulsion which has all the properties of chyle; while its most common if not its only cause is the presence in the living body of parasitic worms, of which the adults appear to be located in the absorbents, while the progeny find their habitation in the blood-vessels, and their element in the blood. The disorder is one which has long excited curiosity; and, indeed, it seems to have received its name almost prophetically at a time when, neither chemically nor by the microscope, could the chylous admixture be ascertained. John Peter Frank, in his fifth book, De Frofluviis, which represents the state of knowledge in the year 1794, speaks of diabetes chylosus, or flux2(s per renes cmliaciis. It is needless to interpolate that, in the language of tlie older writers, a coeliac flux was an escape of what they thought to be chyle. Further than this, Frank uses the actual term chyluria, and distinguishes between this condition and one of purulent admixture; though it is not impossible, and is indeed suggested by his description, that urine which was thus regarded as chylous may have been merely phosphatic. He attributes it especially to persons, otherwise in good health, who take active exercise after a full meal; a familiar cause of phosphatic urine, and, it may be added, no less an in- centive to a chylous state of that secretion in a chylurious subject. Cruickshank,' also, in the year 1806, speaks of urine of a white color, as was supposed from chyle; but since he attributes this to children who are subject to worms, it is probable that he also refers merely to urine milky with })hosphates. Thus chyle, although conjecturally spoken of as passed with the urine, does not appear to have been conclusively recognized in that relation until the time of Prout,^ who, in the year 1821, described some urine as so closely resembling chyle in all respects that, had it been brought before him as a specimen of that fluid, he might not have discovered the imposition. This observer, however, though he gives a clinically excellent sketch of the disease, scarcely at- tained to an adequate idea of its nature. He saw in it only an arrest of ' Experivients on Urine and Sugar. Appended to Rollo's work on Diabetes, p. 451. " An Inquiry into the Nature and Treatment of Oravel, etc. Edit. i. p. 41. 252 CHYLURIA. assimilation, and the discharge by the kidneys of chyle which had failed to undergo its proper transformation into blood. In describing the urine as chylo-serous rather than chylous, he pointed to its supposed analogy Avith the disorder characterized by serous urine, of which he held this to be a mere variety. Dr. Bence Jones ' thought, with Prout, that the chylous discharge was derived from the blood, but attributed it, not to defective assimilation, but to some slight alteration in the structure of the kidney, which allowed the constituents of chyle to transude from the blood-vessels, and which remained without repair for years. He thought the leak could be closed by means of gallic acid, and detailed a case with much minuteness which afforded this inference. The cure, however, was only temporary, and the habit of the complaint to inter- mit for long periods, independently of treatment, must make us cau- tious in dealing with the effects of remedies. The views held by Prout and Bence Jones were not very different from those expressed at a later date by Dr. Waters,'^ who believed that ''the main pathological feature of the complaint was a relaxed con- dition of the capillaries of the kidneys," which allowed fibrin fat and corpuscles to filter from the blood-vessels into the urine, the leading idea up to this time being that the addition to the urine was supplied by the blood; a view which, besides other objections, is inconsistent with the fact, which frequent observations have placed beyond doubt, that though the urine be milky the blood is not; the peculiarly subdivided fat which is a characteristic of chyle and of chylous urine being uni- formly absent from the blood. Perhaps it may be fairly said that until quite recently, though many examples have been placed upon record and the clinical characters of the disease well illustrated, yet no clear light has been thrown upon its pathology further than was apparent to Prout. The important suggestion that the urinary change was produced by a direct discharge of the contents of the absorbents into the urine was made by M. Gubler,^ and the derangement attributed to a varicose state of the renal lymphatics, analogous to that which on the surface of the body had been known, especially within the tropics, to be attended Avith a lymphatic discharge. Later this view presented itself to Dr. Vandyke Carter, of Bombay, who, in an admirable paper read before the Medico- Chirurgical Society, went far to prove the change to be due to the direct discharge of chyle into the urinary system. He attributed this to some morbid communication between the lacteals and lymphatics of the lum- bar region with the pelvis of the kidney, ureter, or bladder. Lastly, Dr. Lewis, of Bengal, made the striking discovery which as- sociates the mechanical derangement with the presence in the blood, in the kidneys, and elsewhere, of vermiform parasites; a discovery to which important additions have been made by other observers. AVithout further preface I will proceed, with the aid of a series of cases collected from different sources, including several under my own care, to sketch the more i)rominent features of the disease as in the present day it presents itself to our view. The definition lies in the state of the urine, and is implied in the name. Though the chylous admixture appears to be commonly associated with a tropical parasite, ' Lectures on Pathology and Therapeutics, 1868, p. 256. ^ Med.-Chir. Trans, vol. xlv. p. 221 (1862). ^ Gazette Medicate de Paris, 1858, p. 646. CHYLURIA. 253 and the disorder correspondingly frequent in such regions, yet it is clear that beside the endemic we have what may be termed an accidental form of the disease, which occurs in persons who have never left our own country; either because the parasite may be engendered as well in tem- perate as in tropical places, or because the necessary communication be- tween the channels of chyle and those of urine may be made otherwise than by its agency. To touch first upon the geographical distribution of the disease, I find that among 72 cases (67 placed on record by various writers to whom reference has mostly been made in the course of this chapter, and 5 within my own knowledge) there are 5 in which tlie disease was une- quivocally of English origin; 59 in which it had originated in tropical or subtropical regions, using the last expression somewhat liberally, so as to include that large proportion of the earth's surface which lies be- tween 40° of north latitude and 40° of south latitude; from the south of Europe, that is, to the south of Australia; and 8 in which the place of origin was uncertain, among which is classed one to be presently related, of which the subject had lived in India, but had been in England for five years when the symptom appeared. First, as to tlie cases of European beginning. One, under my own observation, was in tlie person of a man who was born in Suffolk, had lived almost all his life in London, and never left England. Dr. Beale relates a case, which was witnessed by Mr. Cubitt, of which the subject, a woman aged 50, was a " native of Norfolk, in which county she had always resided." Another case, from the same county, that of an agri- cultural laborer, 57 years of age, is reported by Dr. Dale in the "Lan- cet" for July 23d, 1877. The man was a patient in the Norfolk and Lynn Hospital, and had never left Great Britain. It is of interest to observe in passing that this patient was the subject of a fluctuating swelling on the left of the spine, which was thought to be a chronic abscess, but disappeared. The fourth instance, that of a woman who was born in the neighborhood of Manchester, and had never lived out of the country, is related by Dr. Koberts. The changed appearance of the urine in this case was first observed after delivery — not the only case in which a relation has been apparent between chyluria and gestation. Another instance, not, however, of persistent chyluna, is mentioned by the same author, in which a transiently chylous condition of the urine, associated with a chylous discharge from the surface of the al>domen, was noticed in a man '^always a resident in Lancashire." Another in- digenous case is recorded; the young woman wlio was tlie subject of it was born in a suburb of London, and had never left England, or indeed been far from home. These instances, a minority though they be, are enough to show that the disorder is not necessarily of tropi- cal or subtropical origin. But how often it is one or the other is shown by the fact that among sixty-five instances in which the place of origin was known, sixty pertained to persons who had been born in or had visited the latitudes between that of South Australia and that of Gibral- tar, and had probably contracted the disease within these limits ! We have evidence of its origin in many parts of India; it is well-known in each of tlie three Presidencies; in China; in the West Indies, with especial mention of Barbadoes, Trinidad, and Demerara; in Cuba, Ber- muda, Brazil, frequently in Mauritius, in the Isle of Bourbon, and further south, so as to include the southern parts of Australia. We have, indeed, received important information from Brisbane, where the 254- CHYLURIA. disorder is well known. It appears to prevail especially in insular and maritime districts, and with this preference to include within its range portions of each of the four quarters of the globe and of Australia, It may be doubted whether any parasitic or endemic disease is equally widely scattered. For our extensive knowledge of it we are indebted to the extent of our empire and the wandering propensities of our race. Within its chosen localities it attacks, without exemption, natives, per- sons of European birth, Jews, and negroes. As to sex, of the seventy- two cases mentioned the subjects were of the male sex in forty-one, of the female in thirty-one instances. The preponderance of males in our records may be due to the more numerous exposures of men, among Europeans, as the more frequent travellers, to the endemic influence which causes the disease, while perhaps among Orientals women may be less accessible to medical observation than are men. Dr. Lewis, indeed, tells us that at Calcutta the patients sulfering from chyluria have for the most part been women; but, on the other hand, it is to be noted that the larger number of instances he has recorded were of the male sex, while of the cases referred to by Dr. Vandyke Carter, whose field of observation was Bombay, all were males. The disorder is probably divided with much impartiality as regards sex. With regard to age no period of life appears to be exempt from its attacks. Prout mentions an instance at the age of eighteen months. I was consulted touching the son of an Indian surgeon, who was attacked with the disease before completing his fifth year. A case is known to have proved fatal at the age of twelve. After this period the frequency of the disorder appears to increase; it is common in adolescence and middle age, and not unknown in advanced life. Eayer' refers to the case of an old woman, a native of the Isle of Bourbon, who had the disease, with one short intermission, from the age of twenty-five to that of seventy-eight, when it was still unconcluded. The course of the disorder, and its symptoms so far as there are any, may be broadly sketched. Putting aside the condition of the urine, it ma}' be said that of sjjecial or distinguishing symptoms there are none. It is remarkable even that the urinary organs themselves seldom show any signs of disturbance. There is sometimes pain in the back of a somewhat indefinite kind, but there are no dropsical, uraemic, or any other constitutional signs of renal disorder, and what perhaps is more surprising, there is no frequency of micturition or evidence of vesical irritation. Such symptoms as are produced are those of inanition; in one case, wasting, pallor, loss of strength, and depression of spirits were marked so long as the discharge was unchecked, at once mitigated with its control. Tlie catamenia were irregular; the temperature of a some- what low average. The constitutional results of the disorder appear to be produced solely by the waste of nutritive material. Some persons bear the loss better than others, and in several instances the general health seems to have been perfect; the patient has remained of robust aspect, and displayed no failure in strength; women thus affected have repeatedly borne children. As it happens when nutrition is impaired in other ways by waste or want, tuberculosis often supervenes, and in- deed has been found in most of the cases Avhere chyluria has ended fatally. Whether the tubercles are always strictly of this nature, or whether, as is possible, they may in some cases have been local results ' Quoted from Quevenne. Rayer, Maladies des Reins, vol. iii. p. 427. CHYLUKIA. 255 of the parasite with which the disease is connected, we have no evidence to show. In the condition of the urine lies the definition of the disease; and, indeed, so solely is its recognition dependent upon the state of this secre- tion, and so little may disturbances of any other sort obtrude themselves that, as Dr. Bence Jones observes, were a patient blind he might not know himself to be ill. The urine becomes milky in appearance, so as to resemble rich and creamy milk. The milky admixture has no tendency to subside, but Chylous urine showing molecular base. X600 diameters. will remain apparently in uniform suspension for many days. This peculiarity is due to the presence of fat in a state of molecular or im- measurably fine subdivision. Occasionally oil globules have been de- tected as such, but this is rare. Usually the fat appears in a delicately granular shape as represented, and sometimes in so fine an emulsion that though the milkiness is evident enough, yet under the microscope nothing more can be discerned than an indefinite turbidity. The fat sometimes collects on the surface in the shape of cream or creamy flakes. The amount of fat or of milkiness in chylous urine depends closely upon 256 CHYLURIA. food, the urine of digestion containing this addition most abundantly, that of fasting containing less or even none at all. Besides the fat, blood is a nearly constant constituent of chylous urine. This often gives a delicate i^iukish tint to the fluid, though this tint is less deep than would be expected from the quantity of blood in- volved, the red color being covered by the Avhite opacit}-. On standing, however, the corpuscles fall as a bright bloody sediment. It has been observed that whether wholly derived from blood or otherwise, the pinkish tint of the chylous clot deepens on exposure to air,' a circumstance which points the resemblance between the urinary admixture and the sujierficial discharge from absorbent glands, Avhich has in some instances been associated with it. A more distinguishing peculiarity of chylous urine is its habit of spontaneous coagulation; shortly after expulsion it will, if rich in its characteristic addition, set into a tremulous jelly which has been likened to blanc-mange, and which will after a time break into a mixture of liquid and flaky coagula. The gelatinizing process sometimes takes place in the bladder, and the clots have often formed troublesome obstacles in the urethra. Some observations upon chylous urine, which need not be recapitu- lated here, are given with cases under my own care, subsequently related. Dr. Beale describes the urine passed in the morning 'by Mr. Cubitt's patient as having the appearance of fresh milk. It became clear on the addition of an equal volume of ether. The reaction was neutral, the specific gravity 1.013. A second specimen of the same patient's urine, jaassed during the same day, which was not albuminous nor milky though slightly turbid, was also examined. It had a specific gravity of 1.010. a reaction very slightly acid. Analysis of 1000 parts of Chylous and Xon-chylons Urine passed hy the same Patient on the same day. By Dr. Beale. Chylo us. Xon- chyloiis. AVater 947.4 .52.6" 7.73 13.00 11.66" 9.20) 2.70 - 2.00 1 1.65 4.66 13.9 i 1 978 8 Solid matter 21 2 Urea 6 9.") Albumin Uric acid Extractive matter with uric acid. ... Fat insoluble in hot and cold alcohol but soluble in ether .lo 7.31 Fat insoluble in cold alcohol Fat soluble in cold alcohol Alkaline sulphates and ciilorides Alkaline phosphates ) .0 5.34 1.45 Earthy phosphates [ .15 The milky urine contained no oil globules. The fatty matter was equally diffused throughout in a molecular form. By the highest powers of the microscope only very minute granules could be detected which ex- hibited molecular movements.^ ' Dr. Vandyke Carter. Med.-Chir. Trans., vol, xlv, p, 192, ' Beale, Kidney Diseases, etc., third edition, p. 301. CHYLURIA. 257 In Dr. Beale's analysis the chylous urine differs from the non-chy- lous chiefly in the presence of albumin and fat, the larger proportion of phosphates and the smaller of sulphates and chlorides. Occasionally, as in a case published by Dr. Bence Jones,' the oil has been known to take a globular form, collecting on the surface in this shape, and leaving the bulk of the fluid clear. Even in this instance, however, as in others, the fat was usually finely divided and evenly diffused. Corpuscles indistinguishable from those of chyle have also been found. Dr. V. Carter, in the case of a Hindoo who had also a chylous discharge from the scrotum, points to the resemblance between the superficial and the urinary discharge. Both coagulated on exposure, and assumed an increasingly pink color. In the superficial discharge besides red corpuscles were bodies ''resembling the lymph corpuscles of blood." In the urine, together with red corpuscles, were "granular cells much larger than these, and showing, on the addition of acetic acid, three or four nuclei in their interior; they were in short chyle cor- puscles/* I must also draw attention to large rolling cells of globular ?m ^ a" ' '^■ Large globular cells, probably vesical, from chylous urine. X 350 diameters. form and epithelial type, which resemble some which belong to the bladder so nearly, that it is at least probable that they have this origin. I have never had opportunities of watching a case of chylous urine with- out finding these cells repeatedly and abundantl}^ in men as well as in women. If they be vesical tliey afford a pathological indication of some importance. Next to the fat the most remarkable constituents of chylous urine is the fibrin, conferring as it does the power of spontane- ous coagulation. In Dr. Bence Jones's case the urine could not be got out of the bottle until the coagulum had been broken up by agitation. A patient of mine who had passed cliylous urine in India, described it as retaining for a time the sliape of tlie vessel in which it liad solidified, like jelly turned out of a mouhl; and the same phenomenon was observed in another case, tlie urine falling out of its receptable in a ju'iik tremulous mass like a large jelly-fish. The coagulation sometimes takes place in the bladder with consequent difficulty in expulsion; clots sometimes ' Med.-Chir. Trans., vol. xxxiii. p. 314. 17 258 CHYLURIA. stick in the urethra, or have to be drawn from its orifice. The fibrin, however, is not alwa3'S present in chylous urine, or at least not in suf- ficient quantity to show itself by coagulation. The fibrin is most de- ficient wliere the molecular base is most abundant. The chyle in its passage from the bowel to the thoracic duct becomes, according to Dr. Vandyke Carter, increasing fibrinous in its course, and the varying amount of fibrin and fat in chylous urine he explains on the hj^othesis that in different cases the chyle which enters the urine is withdrawn at different stages in the course of the absorbents. The fibrinous constituent of chylous urine has never been found in the form of casts,' though these shapes have been sought by, I believe, every observer of late years who has written upon the subject. This alone is suggestive of a view which is corroborated by many other cir- cumstances of the disease, that the chylous admixture reaches the urine Large globular cells found in chylous urine. X 600 diameters. © o n O O O o ^ o ® ^ m^ & Large globular cells from chylous urine. X 600 diameters. From case of a man 50 years of age, a native of Suff ilk, who had never left England. The molecular base was very abundant. otherwise than by the renal tubes. The faults of the urine appear to be essentially those of addition. Taking from it the constituents of chyle, the characters become those of health or depart from them only to the ex- tent of an impoverishment which leaves the urine still sufficient for the relief of the system. The disease is not productive of uremia or any effect of renal deficiency. And that the urine must sometimes fall short in its essential ingredients is as evident as that the materials which should go to form them are discharged in other shapes. In a case Avhere the urea was estimated for twenty-four hours, its amount was found to be little more than 15 grammes, while in relation ' I once found two hyaline casts in a case, but as none were ever seen again, though the disease persisted, it was inferred that they were due to some passing and accidental condition and furnished only an apparent exception to the state- ment in the text. CHYLURIA. 259 to the weight of tlie body the amount should have been about 22 grammes. In Dr. Bence Jones's case the iirea amounted to 13.26 in 1000 parts; the salts to 8.01, a diminution in both particulars. Dr. Beale's observations, as already quoted, show the same change in a greater degree. Instances, however, have been published, one, for example, by Dr. Golding Bird,' in which no want of urea appeared. Uric acid crystals have been fre- quently noticed. They were abundant in one of the cases under my own observation. Perhaps the most important inference to be drawn from the state of the urine in this disease is one for which we are chiefly indebted to Dr. Vandyke Carter. Rayer long ago demonstrated experimentally that when chyle and urine were mixed together a liquid closely resembling the chylous urine of disease was produced. He, however, does not seem to have inferred that the morbid process involved any such direct mingling. Dr. Carter showed how minutely chylous urine corresponds with a mix- ture of normal chyle and normal urine, and insists that the disorder is produced by a direct admixture of the contents of the absorbent with those of the urinary channels. Fibrin is absent from the early course of the lacteals, to be acquired in'the mesentery; so chylous urine is some- times coagulable and sometimes not, as if the admixture were derived at different points in the route of the chyle. Again, the proportions which the albumin and the fat bear to each other in chylous urine are the same which they have been found to display in chyle itself; in one case of chylous urine the albumin and the fat were equal, in another the albumin was twice as much as the fat; both these proportions have been found in chyle. There are further points of resemblance or rather indications of iilentity in the molecular base common to both, and present in no other fluid; in the corpuscles indistinguishable from those of chyle which have been found in chylous urine; and, lastly, in the peculiar deepening of color under exposure, which both fluids have been known to present. The urine is sometimes rather lymphous than chylous; the molecular base, even Avith well-marked chyluria, is not always present; the urine sometimes remains perfectly transparent, but becomes loaded with transparent jelly, not easily distinguishable from the fluid itself. '^ In such cases fat is probably entirely absent, as if tlie contents of the lymphatics instead of the lacteals had been poured into the urinary channels. The disease is of indeterminate, always long, duration, sometimes extending, usually with intermissions, over a considerable proportion of ordinary life. Dr. EUiotson mentions a lady then sixty-four years of age, who had had the disorder interruptedly for twenty-eight years; and I have already referred to Quevenne's case of a woman who had it from the age of twenty-five to that of seventy-three without interval, and at seventy-eight was still suffering from it. Looking at cases of which the history has been closed by death, we find that within the experience of EUiotson a woman died at the age of thirty, having had the complaint for twenty years ; in that of Lewis, one in whom it proved fatal together with general tuberculosis after six- teen years, with however an intermission of half the time. The same ' Urinary Deposits, 5th edit., p. 420. ' Goodeve's case. Trans. Med. and Phys. Soc. of Calcutta, vol. viii. Quoted by Dr. V. Carter. 260 CHYLURIA. observer, however, mentions an instance in Avliich it proved fatal at the age of sixteen. In this instance the disorder was, as proved by post- mortem examination, uncomplicated. Prout records a case in which it proved fatal at the age of fifteen, together with some inflammatory con- dition of the bowels. It is a habit of the disorder to be dormant or make long intermissions often without obvious reason, and as capriciously to return. A lady, whose disease had presumably originated in India, showed no symptoms of it until five years after her return to England. With Dr. Elliotson's patient also, who had probably acquired the seeds of the disease in India, it did not attract her observation until nine years after her return to Europe; it then continued for seventeen months, disappeared after bath- ing in the sea, and remained absent for thirteen years ; it reappeared after an attack of infiammation of the lungs, which had been treated by calomel and bleeding, and afterwards held its ground with shorter but still with occasional intervals. One of these ensued upon violent grief, another accompanied the formation of a carbuncle, and another occurred together with a second attack of pulmonary inflammation. Dr, Lewis refers to a native of Madras who had six attacks, each of about two months' duration, within the space of two years and a half. The chylous condition has also its lesser variations, being influenced by food, posture, exercis3, abdominal pressure, and pregnancy. The effect of food has often been noticed, the urine of fasting being some- times natural, or at least clear or only bloody, while that passed after food is milky. In the case of Dr. Bence Jones's patient, the urine was most chylous after dinner, and least chylous before breakfast. It was more frequently chj^lous after animal than after vegetable food; and it was oftener free from chyle before breakfast when the diet was vegetable than Avhen it consisted more of animal food. My patient Eugenia P passed during the day what looked like rich milk or cream, in the night and before breakfast urine which was less opaque, often urinous in color or conspicuously sanguineous. Carter noted, with regard to one of his Hindoo patients, that ingestion of flesh or wheaten bread increased the disease, while in the case of another, if he abstained from food for a whole day, the urine ceased to be chylous. One case has been recorded as exceptional, in which " the urine passed during the day Avas clear and free from chyle, while that voided during the night and in the morning was deeply loaded with it."' It may be suggested that in this case there was some peculiarity whereby the dis- charge was alTected by jjosture, as sometimes occurs. As a rule, the urinary admixture is tlie most plentiful when the pro- per chyle channels are at their fullest, and on the other hand it is to be observed that conditions of health which interfere with nutrition are apt to cause the urine to revert to its normal state. Thus, in Dr. Prout's experience the urine ceased to be chylous during an attack of hepatitis with much fever, and again during severe mercurial salivation. The same suspension has been known to occur upon the appearance of a carbuncle,* during inflammation of the lungs, and on the approach of death. The disorder is influenced also by movement, as a rule increased by ' G. C. Dutt, Lancet, July, 1863, p. 87. * Elliotson's case. Med. Times, 1857, vol. ii. p. 287. CHYLURIA. 261 exercise, mitigated by repose, though, in oue of Rayer's cases, riding on horseback was thought to favor the return of the urine to its natural state; it is affected also by position. An instance is mentioned in which the urine ceased to be chylous when the patient lay on his right side. A tight belt round the belly and loins was found by Bence Jones to have but a slight restraining influence upon the discharge. The striking re-, suits in this respect of pressure upon the front of the lower lumbar verte- brje is related in another paragraph. Among the conditions which influence the disease, perhaps pregnancy and its sequelre are those which boar upon it in the most striking manner. The disorder often begins during lactation, or returns or becomes exag- gerated after delivery. With Mr. Pearse's patient the chyluria three times appeared during lactation, and twice subsided on its discontinu- ance. Dr. Roberts saw a case in" which the disorder came on imme- diately after confinement. Dr. Lewis mentions one in which it began two months afterwards, and tinother in which the complaint ap- peared in the third month of pregnancy, passed off, and reappeared upon the birth of the child. S.uch cases cannot fail to suggest that the channels necessary to the perversion of the chyle are less patent when the uterus is full than when it is empty, as if they were pressed upon by its larger bulk. But conditions aft'ecting in other ways the state of the pelvic vessels appear sometimes to influence the disorder. A case ' is mentioned in which the urine always became chylous for eight days pre- ceding menstruation; and another in which the chylosity was suspended for three years on the establishment of a hsemorrhoidal flux. Thus it appears to be promoted by turgidity, relieved by evacuation. A discharge of chyle with the urine is in a certain proportion of cases accompanied by a similar flux from the surface of the body, usually from the lower part of the abdomen, groin, scrotum, or thigh. Such super- ficial discharges are apt also to occur where chyluria is endemic in per- sons who have not become subject to it ; circumstances which suggest that the superficial and urinary discharges are common results of the same peculiarity of the absorbents, whatever that may prove to be. Dr. V. Carter has related several cases of these kinds, and shown how close is the resemblance between the discharge from the surface and the ad- mixture with tlie urine. Dr. Carter describes the case of a Hindoo, the skin of whose scrotum was peculiarly corrugated and studded with small tubercles or pimples, which varied in size from a pin's head to a pea, and opened from time to time, discharging milky fluid, often to the amount of a pint daily. The inguinal glands on both sides were enlarged, soft, and doughy, and diminished in size under pressure. The urine was sometimes chylous, this condition alternating with the swelling of the inguinal glands, which was greatest two or three hours after a full meal. The fluid that escaped from the scrotum Avas, says Dr. Carter, probably chyle or a mix- ture of this with lymph. AVhile flowing it assumed a decided rose tint, which increased on further exposure. It coagulated entirely in eight or ten minutes. The urine also coagulated more or less completely, and assumed after some exposure a pinkish color. The microscopic charac- ters of the two fluids were almost the same; chyle corpuscles were recog- nized in the urine ; in the scrotal discharge corpuscles like those of lymph, together with the molecular base characteristic of chyle. The ' Referred to by Roberts. 262 CHYLURIA. blood serum was quite clear. In such a case it is scarcely possible to doubt that the same chylous fluid escapes both into the urinary channels and also by way of the inguinal glands to the skin of the scrotum. Instances have also been recorded in which, without any alteration of urine, milky, apparently chylous fluid has been discharged superfi- cially from the lower part of the trunk or upper part of the thighi?. always, it would seem, from some surface which is within the range of regurgitation from the lacteals or receptaculum, supposing valvular hindrance to be overcome. Pellucid or lymphous discharges have indeed been known to proceed fi-om the upper parts of the body, as from the eyelids, and Dr. Lewis' has described an instance in which this discharge was "" slightly milky; " under the microscope, however, it dis- played " clear fluid ^'' with numerous granular cells; the molecular base of chyle was apparently absent. The fluxes which have the characters of chyle, that is to say, are milky from molecular fat, are without ex- ception within the anatomical range specified, a fact which is suffi- ciently suggestive that in these cases, as in those of chyluria, we have but the simple retrogression and escape of chyle. Such an instance is related by Dr. Y. Carter. A Parsee youth had, in the cutaneous sur- face of the thigh, a few inches below Poupart's ligament, a small, hardly perceptible pimple, from which there occasionally issued a milky fluid, sometimes so copiously that in the course of a day a pint could be collected. Pressure just above the spot caused the flow to cease; when the spot itself was comi)ressed the fluid squirted out as if from accumu- lating pressure behind. The inguinal glands were enlarged, soft, and doughy. The fluid resembled rich milk in appearance; it coagulated spontaneously, it was uniformly hazy, under the microscope contained blood corpuscles, granular cells, and oil globules — had, in short, the character of a ch3'lous fluid. Another striking instance of this kind is related by Dr. A. B. Buchanan.^ A woman forty-six years of age had a semi-excoriated surface as large as the j)alm of the hand upon the inner and posterior aspect of the left thigh. From this and from broken ves- icles upon and about it flowed milky fluid so jirofusely that five ounces were collected in an hour. The fluid was often absolutely undistin- guishable by color and smell from pure new milk; it coagulated through- out after being passed, the mass breaking down on agitation. It was albuminous; under the microscope it displayed cells like the white cor- puscles of blood, a molecular base like that of chyle, and a few fat corpuscles. Chemical analysis showed that it nearly resembled in its composition the chylous urine examined by Dr. Beale (see p. 25G), ex- cept that the crural discharge contained more albumin and less fat than the renal. Dr. Buchanan repudiates as anatomically impossible, and pathologically unnecessary, "the theory that in such a case the dis- charge is actual chyle, which has found its way by the absorbents to the surface, and prefers to regard the flux as a functional affection of the glandular a})})aratus of the skin." But that so small a cutaneous sur- face should yield so profusely and so long as the result of any change limited to itself is inconceivable; and if the skin but furnishes the exit — and it would seem that it can scarcely do more — to fluid derived from within, tli9 characters of the discliarge, as in the case of chylous urine, assimilate it so nearly to the contents of the lacteals that it is scarcely ' On a Hd'inatozoon inhabiting the Human Blood. Calcutta, 1872, p. 13. - Med.-Chir. Trans. 1863, p. 57. CHYLURIA. 263 possible but to assign its origin to those channels. In Dr. Carter's case there was no altered extent of skin, but merely a pimple which gave exit to the discharge; so that in this case, at least, the theory of cutaneous secretion is inapplicable. A case of the same sort came under the observation of Dr. Eoberts of Manchester. A man always resident in Lancashire had a succession of subcutaneous abscesses in various parts, among others, one upon the abdomen. This Avas succeeded by an extensive vesicular eruption upon the front of the belly, between the level of the umbilicus and the groin. Some vesicles were scarcely visible to the naked eye, others as large as peas; all were at times filled with fluid which looked like rich milk, gel- atinized when discharged, contained albumin, and displayed under the microscope fat molecules, sometimes distinct oil globules, and white corpuscles like those of blood. This exudation varied in color accord- ing to the state of digestion, was pale or lyraphous with fasting, milky after food. The vesicles discharged freely; one which was punctured at the rate of eight ounces an hour. Tlie discharge was apparently identi- cal with that which forms the admixture in chylous urine, and, indeed, on two occasions chylous urine was passed by this patient. He died with pulmonary tuberculosis. Nothing abnormal was detected about the thoracic duct or large lymphatic vessels. The affected skin was thickened and excavated with large lacuna, of which the suj^erficial ves- icles formed the orifices. The sweat and proper cutaneous glands were not involved in the change, which Dr. Eoberts regards as the develop- ment in the skin of an abnormal lymjjhatic structure, analogous to Pey- er's patches or the lymphatic glands, which new structure is, in his view, not merely the outlet but the source of the discharge. The pathology of cutaneous " chylorrhoea '*' has been made the sub- ject of further inquiry in regard to a case published by Mr. Sydney Jones in the " Pathological Transactions " for 1875. The inner and back part of the right thigli and the cleft between the thigh and the buttock Avere cov- ered with knotty swellings and varicose lymphatics, from which chyl- ous fluid escaped sometimes to the amount of one or two quarts a day. Similar fluid also escaped from a tuberculated prominence on the shin, and the skin on some of the toes was tuberculated as in elephantiasis. When the discharge from the thigh was absent the inguinal glands swelled. Portions of the affected skin were removed from the thigh and one of the toes and minutely examined. They were traversed in both instances by large communicating chambers which were dilated lym- phatics or lymphatic spaces. These were lined by an endothelium, but appeared to be destitute of any proper secreting cells. Veins were in close apposition to their walls, and in some instances appeared to com- municate with their cavities. No filarijB were found in the blood or tissues, but the superficial dilatation of the lymphatics, together with the swelling of the inguinal glands when the discharge was absent, are enough to suggest a similar state of the deeper and larger channels, and the probability of regurgitation from the j^roper chyle vessels. This case affords no support to the idea of a local chylous secretion; and in- deed it is probable that, with the knowledge which has now been gained, those who formerly held this view will no longer maintain it. As touching the relationship between cutaneous and urinary dis- charges of clwle, some cases reported by Dr. Lewis have especial inter- est. Dr. Lewis gives examples of the concurrence of chyluria and ele- phantiasis, and relates an instance of the latter disorder in which from 264 CHYI.UKIA. the scrotum, which was the part affected, exuded by minute orifices a chylous fluid in which living filarice were detected.' ^Ye here see a superficial chylous discharge associated, not indeed with chyluria, but with a cause of chyluria. The evidence adduced by Dr. Lewis suffices to show that all three conditions, a discharge of chyle both by the skin and with the urine and elephantiasis, are alike associated with filarise. The discharge from the eyes already referred to was also found by Dr. Lewis to contain these parasites. The Filaria. The pathology of chyluria, together with that of superficial chj'lous discharges and of elephantiasis, has been reconstructed, I may also say created, by the recent discovery of the filaria sanguinis hominis and the larger worm, also a denizen of the human body, of wiiich the filaria is the offspring. The accumulated evidence that the filaria is nearly always to be found in the blood at certain times, in concurrence with superficial or urinary chylous discharges and often in the urine when the flux occurs with this secretion, makes it necessary to preface the morbid anatomy of these disorders with a description of the parasite. The great discovery of Lewis, for it is no less, and the observations which have been added, esi^ecially by Bancroft, Manson, and Macken- zie, have not only made our previous knowledge coherent and intelligi- ble, but have removed the pathology of chyluria out of the region of speculation and guesswork to that of knowledge, incomplete as yet in some of its details, but enough to give the assured outlines of a strik- ing and even astonishing picture. It had long been known that dogs, particularly the pariah dogs of India, were liable to be infested with a peculiar round worm, to which from its red color the name filaria sanguinolenta was given, which lodged chiefly in the walls of the oesophagus and aorta, and discharged its ova according to circumstances into the alimentary canal or circulation. More recently another similar parasite, to which the name Jilariainwiit is was given, was ascertained to exist chiefly in the dogs of China, taking its residence in the right ventricle, and pouring living embryos into the blood. The parent worms in both these cases are of considerable size, the filaria sanguinolenta approaching four inches in length, the filaria immitis exceeding six. The embryos, which in botli cases are abundantly distributed throughout the systemic blood, nearly resemble the filaria sanguinis hominis, which will be presently described. The minute human haematozoon, whose existence as such was made known to us by Dr. Lewis at Calcutta in the year 1872, is a minute ver- miform creature about forty-six times as long as it is wide, and whose width is about that of a red blood-corpuscle. Its structure is nearly simple, granular matter within a hyaline sheath, with a point at each end which appears and disappears with movement, one passing as a tail the other as a tooth. Dr. Lewis found six of these in a single drop of blood from the ear, and gave 700,000 as an approximation to the number contained in the whole body. This estimate has been very greatly ex- ceeded since it has been recognized that it is the habit of the parasite to come abroad at night. Dr. Mackenzie calculated that a jjaticnt whose case he has reported had nightly from thirty-six to forty millions of em- ' The Pilhological Significance of Nematode Hematozoa, p. 46. CHYLUKIA. 265 bryo filarifB in his blood. The worms show much vivacity among tlie corpuscles, throwing them aside by their active serpentine movements. It was at once conjectured that these minute creatures were the young of a larger worm, and the surmise was verified by the discovery of the parent on Dec. 21st, 1876, by Dr. Bancroft of Brisbane. The mature form, a worm of the nematode class about the thickness of a human hair and three or four inches long, was first found in a lymphatic abscess of the arm, and afterwards in hydrocele fluid obtained from patients who were known to be infested with embryonic filarise. The adult was mi- Filaria sanguinis hominis, orBancrofti. a, female (natural size); b, head and neck (X 55diam.> c. tail; d, free embryo (X 400 diam.); e, egg containing an embryo; /, egg showing the yolk. After CobboU) . nutely described by Dr. Cobbold, from specimens sent by Dr. Bancroft, and named filaria JBancrofti, different names being thus awarded to dif- ferent stages of the same parasite. Tlie annexed figure is copied from Dr. Cobbold's description.' I have added anotlier from a photograph published by Dr. Stephen Mackenzie, which enables the immature off- ' Parasites, 1879, p. 188. " Discovery of the Adult Representative of Micro- scopic FilariiB." Dr. Cobbold. Lancet, July 14th, 18T7, p. 70. ■266 CHYLURIA. spring as it is found in the blood to be compared in size with the corpus- cles. Dr. Lewis himself found the parent worm at Calcutta on tlie 5tli of the following August, in a scrotum infiltrated with chylous fluid in connection with elephantoid disease. ' Two white threads were found in a blood-clot, which proved to be male and female specimens of the adult filaria. The female contained ova witli embryos identical with those which Dr. Lewis had already found in the blood. The occurrence of these creatures in pairs in tlie remote recesses of the human body shows the efficacy of the sexual instinct, in virtue of which one worm follows and eventually finds anotlier witliin a maze to which that of Fair Eosa- mond was comparatively uninvolved. Dr. Manson ' has recently demon- strated the position of the parents in a dilated lymphatic belonging to a h/mph-scrotttui which he had recently amputated. The creature is viviparous, normally discharging its ott'spring extended and free ; mis- carriage, however, appears to be a frequent accident, in Avhich case the ova are discharged unhatched, with the worm curled up within, thus presenting a larger bulk than when the process is more happily con- Filaria in human blood. After photograph pubhshed by Dr. Mackenzie. ducted, and producing pathological consequences which will be presently adverted to. Many valuable observations have since been added throwing light upon the habits of the j^arasite, its means of transmission, and its rela- tions to disease.^ Dr. Manson, in China, in the year 1877, provided the next step by a discovery not inferior in interest to any that had been already made. Believing that the asexual embryo did not attain matu- rity in the place of its birth, but required, after the manner of parasites, to be transferred to another animal for further development, he sought for the nurse among the insects that feed on blood, and found it in the By Dr. Lewis. Lancet, Sep- ' Cobbold. Lancet, October ' " Filaria Sanguinis Hominis" (mature form), tember 29th, 1S77, p. 453. " On Filaria Bancrofti. 6th, 1877, 11. 49"). '■' Path. Trans., vol. xxxii. p. 285. 2 Dr. Manson. ''On the Filaria Disease at Amoy." Customs Med. Reports, China, 1877. " Lymph-Scrotum, showing Filaria in situ." Dr. Manson, Pac)AV tint like that of slight jaundice. AVith this as the outline of a t}^ical case, I INTERMITTENT HEMATURIA OR H^MO GLOBINUKIA. 275 will proceed to fill in from my own observation and that of others such details as have as yet been brought within our view. Front as early as the year 1825 ' alludes to an instance of obstinate hgematuria in which the bleeding was constantly preceded by a shivering fit. In the later editions of his work * he enlarges upon malaria as a cause of this form of hajmorrhage, dwells upon " the multiform degrees and shapes assumed by this fearful scourge," as making it difficult justly to estimate its effect, and discusses the treatment of " haematuria decidedly connected with affections of malarious origin," recommending the mineral acids, quinine, and perchloride of iron. In the mean while the subject had attracted the notice of others. Dr. Elliotson ^ described a case of irregular ague which had been contracted in the Walcheren expedition, in which he mentions as a peculiarity un- exampled in his experience that with every cold fit the urine became bloody. There were also symptoms which were held to indicate hyper- trophy of the heart, but the bloody urine, says Dr. Elliotson, was inter- mitting like the rigors, and was thought to belong to the ague, not to the cardiac disturbance. The jiatient recovered under quinine. In the year 1837, Gergerc's' reported a similar case as one of quoti- dian hrematuria. A naval captain had fits, apparently of severe ague, in which he passed blood instead of urine. These attacks recurred at tlie same hour for three successive days, and they were cured by large doses of quinine. More recently the conjunction of aguish symptoms with haBmaturia was referred to by Sir Thomas Watson," with the men- tion of a case within his own experience in which this discharge was always marked by a smart rigor. Details have since been added to these broad observations, of which the most important is the distinction between the intermittent and com- mon hematuria in the absence of blood-corpuscles in the discharge be- longing to the former; and attention has lately been drawn by Dr. Wickham Legg " to a paper by Dressier,' published in the year 1854, which had hitherto escaped notice, in which this and other particulars of the disorder were pointed out and the names Intermittent Albuminu- ria and Chromaturia employed. More recently fresh attention was drawn to the subject by two jmpers Avhich were read on the same evening at the Medico-Chirurgical Society (May 9th, 1865). The first read and first contributed was by Dr. George Harley, the second by myself. These recorded, with micro- scopic details not hitherto attainable, cases which had been observed in- dependently. The attention thus drawn to the curious particulars of the disease was followed by the publication of many instances which at this date it is not necessary to enumerate, but of which a list up to the year 1874 may be found in Dr. ^Yickham Legg's paper to which I have referred. My own experience, besides fragmentary observations, is re- presented by 21 cases, of which I have tolerably complete notes, and in ^ An Inquiry into the Nature and Treatment of Diabetes, Calculus, etc., 26. edit., p. 299, ^ On Stomach and Urinary Diseases, 3d edit. 1840, pp. 432 and 437. ^ Lancet, 18:52. vol. i. p. oO(). * Gazette Medicate de Pai'is, 1838, p. 151. Quoted from Journal de Sociite Royale de Medecine de Bordeaux. * Lectures on the Principles and Practice of Physic, 4th edit., vol. ii. p. 725. ' See Paper on Paroxysmal Hcematuria, by Dr. Wickham Legg, Bartholomew Hospital Reports for 1874. ''Dressier, Arch, f Path. Anat., 1854. 276 INTERMITTENT HEMATURIA OR H.EMO-GLOBINURIA. AV'hich the nature of the complaint was beyond doubt, though in two of them I did not see the urine under the paroxysm. I shall appeal to these as presenting facts for which I can vouch, and experience which is for the most part unrecorded. First as regards sex and age: of my 21 cases 15 related to males, G to females. In age the subjects when brought under notice varied from 3 to 48 years. 4 were between 3 and 5 years of age; one 9; one 10; one 19. Afterwards the disorder was distributed between the ages of 25 and 48 without great inequality. The earliest age at which the disease has been observed, according to Dr. Legg's inquiry, is 2 years; the latest at which it has been known to commence, 52. Next as to the antecedents of the disease and of its attacks. As preceding the liability, the influence of malaria is to be traced more often than any other, though by no means always; while cold with much constancy is the excitant of the attacks. As to malaria, careful inquiry among the 21 cases I have referred to gives the following re- sults: In 3 there had been tertian ague. In 2 there had been fever, which was described as of malarial origin, but which was less exactly de- fined. As to the 16 cases in which no intermittent or malarial fever had been recognized, they were thus circumstanced as regards the marsh poison. Two patients had formerly lived in households others members of Avhich had had ague; one with a brother at Waltham Abbey, who died with it; one in a village near Tunbridge where two uncles had it. Three had lived or worked where there was evidence or suspicion of malaria of a less direct kind; one at Barking in Essex; another used to go harvest- ing to the Essex marshes, and sleep in a barn. And I have made esi^ecial mention of the case of a man who was attacked with the dis- ease, and apparently contracted it, while digging foundations at Char- ing Cross in the ancient bed of the Thames. It is notorious that newly exposed soil in a malarious district is especially dangerous. Be- side these instances in which a malarial influence may be regarded as ascertained, there are others in which it may be suspected. Five came from the immediate vicinity of the Thames in AVestminster, Pimlico, Bermondsey, and Oxford. Two came from Haverstock Hill, where, according to the testimony of one of them, ague was known. I have ascertained, however, from Dr. Coffin, Avho practises in that neighbor- hood, that though there have undoubtedly been cases of ague there they have apparently all been imported. Putting aside, therefore, the Haver- stock Hill cases, but including those from the banks of the Thames, there are out of the 21 cases 15 in which there had been a history of ague or a probability of exposure to malaria. I may mention in connection with this origin of the disease that a late physician who suffered fi'om the disorder but did not consider it to have had this this source, was born at Hythe in Kent, where ague was, and probably is, well known. I have preferred to appeal to cases which I have myself inquired into with this end in view, but I might adduce evidence to the same purport from other sources. I find that among 22 published instances taken without selection ague is mentioned as an antecedent in 0. But I think it is clear that the precedence, often remote, of malaria must be admitted in many cases where ague has not been definitely declared. In some cases the malarial fever, as in the case of Catherine Evans, has been accompanied or immediately succeeded by the h^ematuria, but more often there has been an interval between the two affections, in one of my patients, one of 3 years, in another of 9 years, in a third INTERMITTENT HEMATURIA OR H.EMO-GLOBINURIA, 277 of 14 years. In one instance mentioned by Dr. Ilarley a West Indian intermittent had not subsided when the htematuria commenced; one of Dr. Roberts's patients who had repeatedly had ague, also in the West Indies, lost it two years before the later complaint declared itself. The disease, also, as has been made sufficiently clear, may ensue upon malarial exposure without the intervention of anything that can be recognized as ague. We have evidence in those cases where the haematuria has immediately succeeded upon ague that malaria is able by itself to sot up the condition in question, while in others, and those the more frequent, this agency presents itself rather as a predisposing than the exciting cause. But it is present in one guise or another so frequently that considering the tenacity of the malarial influence, its in- sidious and often latent character, and the certainty that it is often present where it cannot be traced, it must be allowed, that this is, to say the least, the most frequent of the causes to which, whether pre- disposing or exciting, this peculiar form of hfematuria is to be at- tributed. The disease presents itself almost invariably without any suspicion of heredity. It has been known, at least in one instance, to occur m two generations — a young man had h^emoglobinuria and much enlargement of the spleen,' his sister presented traces of hfemoglobin in the urine, but had no enlargement of the spleen. Their father had passed dark urine and died with a spleen weighing 7 pounds. The organic enlargement in father and son would at least suggest the possibility that both may have been malarial, and the disease endemic rather than hereditary. Instances have been reported in which violence or exertion have appeared to be concerned in the production of the disease. Sir W. Gull mentions that of a young lady in which the peculiar condition of urine followed an injury to the back in a fall in getting into a railway carriage. Eosenbach has reported a case in which the first attack succeeded upon a fall from a wagon, though recurrences were induced by exposure to cold. A case is recorded by Fleischer in which hemoglobinuria, unac- companied by shivering or sweating, appeared in a soldier first after a long march, and recurred as the result of walking, not from stationary exercise or from cold. Among the other antecedents of the disease which require mention are syphilis and alcoholism, but it is to be questioned whether either is really concerned in its production. Among my 21 cases, mostly men of the hospital class, there was evidence of syphilis in 6, perhaps not more than might in any circumstances have been reckoned upon. As to alco- hol, it presented itself apparently as the exciting cause in two cases, in one of which the disorder presented itself during a debauch; in the other the bloody urine was said to have been first passed immediately after in- toxication. In one of these there was no malarial history; in the other there had been malarial exposure but no ague. In both there had been syphilis. In one or two instances haemoglobinuria has succeeded immediately or remotely upon suppurative conditions; haemoglobinuria does not present itself with the lardaceous state so common a result of suppuration; and it may be doubted whether the evidence is sufficient to connect this process with the disease in question. ' Case of continued Haemoglobinuria, apparently hereditary, by Dr. Saundby, Med. Times, May 1st, 1880, p. 476. 2TS INTERMITTENT H.EMATURIA OR H-EMO-GLOBINURIA. The excitant of each attack is generally cold; but the actual cause of the disease must be sought in the circumstances which have rendered the subject of it liable to be thus peculiarly influenced by an agency which commonly produces no such result. Cold with intermittent htema- turia appears to stand in the place which time occupies with regard to ague; it does not cause the disease, but determines the paroxysms. The influence of cold in this respect is one of the most striking char- acteristics of the disease. The patient is well so long as he is warm. The flit beginning with rigors is, as a rule, produced immediately by a chill; among our modern instances, however, where the description is minute and conclusive, there is at least one instance, that of Dr. Druitt, where the disorder occurred diurnally. and by the older writers such haemorrhagic attacks are frequently spoken of as periodic. The cold by which the sequence of symptoms is started is usually applied in some obvious manner, and is productive of a distinct sense of chill. A laborer is habitually attacked as soon as he goes out on a very cold or frosty day. The same man, though commonly exempt in the summer, once brought on an attack in warm weather by cleaning win- dows with cold water. A greengrocer attributed an attack to his having been for several hours on a cold day in an oj^en shop; a laundress, hers to standing all day in a damp wash-house. An excursion into the coun- try in an open cart instigated a seizure in another instance. A sailor who had many years before had ague in Havannah was first affected b}' the hfemorrhagic disorder during seven days of exposure after shipwreck. Some persons, however, have become so susceptible in this respect that waiting in a cold out-patient room, exposure to a chance draught, leaving bed in an attempt at convalescence, drinking, or washing the hands in, cold water, have been sufficient to re-initiate the morbid series. Thus started, a fit follows which might be taken for one of ague with, however, the distinguishing peculiarity that it is succeeded by the dis- charge of urine which contains the substance of blood, and displays its color but not its shapes. As typical of the commencement and course of the seizure, I may adduce the habitual experience of a man whose case I brought before the Medical and Chirurgical Society. He would get up and go to his work as a builder's laborer api)arently well. If he hap- l^ened to get chilled he would very shortly be attacked with shivering and retching, together with yawning and an inclination to stretch him- self, pain in the loins and down the thighs, and retraction of the testi- cles. Within an hour or so he would pass a considerable quantity of black urine, and the pain in the loins, up to this time on the increase, would gradually subside, and the constitutional disturbance cease. When the attack came on he used to leave his work and go liome and to bed, taking care to be very warm. The urine usually retained its character for two or three times of passing and then resumed its natural appear- ance. The attack varied in length from three to twelve hours. It was often succeeded in the evening by griping or colicky pain about the um- bilicus. Next day Aveakness and pallor were the only remnants of the attack, and upon recovery from these he remained without ailment until after an uncertain interval the process was repeated. In the larger number of instances the sanguineous discharge has ceased after two to three emptyings of the bladder, or even with one, the whole attack being comprised within the period of twenty-four hours. INTERMITTENT HEMATURIA OR H^MO-GLOBINURIA. 279 In others the hnemorrhage has continued for several days, with little alteration. It has frequently been observed that under the attack the patient has become jaundiced or yellow. It is probable, however, that the discolora- tion has nothing to do with the secretion of bile, but is a tinting of the skin by the hgematin which is set free. And not only may hsematin be thus generally diffused, but local haemorrhages have been known to occur in the shape of purpura, and there is at least clinical reason to suppose that effusions of blood or of some of its material sometimes take place into the joints or cellular tissue. "When beginning with a marked rigor, yawning, retraction of the testicles, and pain in the loins and thighs are seldom wanting. The attacks are most apt to come on in the early part of the day, though they do not invariably do so. A patient assured me that he could bear in the evening with impunity an exposure which in the morning would never fail to bring on an attack. In some cases the coldness and lividity of the extremities, or of the nose or cheeks, in the beginning of the attack, have been almost as if the parts were about to mortify. Dr. Druitt describes his face as spotted with blue-like patches of incipient gangrene. And it has been observed, from whichever point of view Ave regard the concurrence, that together with the attacks of local coldness and arrest of circulation followed by symmetrical gangrene, and described by Eeynaud, haemoglobinuria has occurred. When repeated in a severe form the patient is apt to become pallid from loss of blood, or may present a yellowish or earthy complexion. Loss of sexual power has been noted, as in a case reported by Mr. Neale. ' Urticaria sometimes appears in connection with the disease. Dr. Forrest^ has recorded an instance in which a sufferer from hgemoglobin- urla often had patches of the same nature after washing in cold water or exposure to rain or a cold wind. The concurrence has been held to in- dicate a nervous origin for the urinary disorder, and from another point of view may be taken to associate it with ague and with Eeynaud's dis- ease, in connection with both of which this eruption has been known to present itself. The attacks vary in degree from severe rigor and profuse hasmorrhage to a transient chilliness, succeeded by urine which is merely lithatic or but slightly discolored. Even with the slighter forms, however, the complexion may be yellowish, sallow, or earthy. Such abortive attacks, in which there is no rigor but 07ily an approach to one, and in which the urine becomes only lithatic, ofte present themselves in the place of the more complete fits when the mplamt is on the decline; and possibly such mutilated symptoms may be the only evidence of the disease in an obscure form in which it sometimes presents itself. The range of temperature under the attack is generally lower than that of ague, and the fluctuation smaller, though some instances have been recorded in which both in level and variation the ha^maturic chart has closely resembled that of the more common intermittent. With a fit of ordinary ague the temperature begins to rise, as the first intimation that the cold fit is beginning, and continues to mount until the sweating ' Lancet, Nov. 1879. p. 725. " Glasgow Med. Journal, 1879 280 INTERMITTENT H-EMATURIA OR H^MO-GLOBINURIA. period, when it descends rapidly. With intermittent haematnria it has frequently been noted that the temperature is lower than normal in the cold stage, and the elevation on its termination small or unol;serv- able. In Dr. Harley's case, the temperature in the axilla during the cold stage was 96.1°. In one recorded by Dr. Eoberts, the thermometer in the same situation, at the same period of the attack, marked 96.6''; a few minutes afterwards the patient passed bloody urine, and five minutes later said he felt quite well, and displayed a temperature of 98.6°. Dr. Druitt, after a statement of the large variations which he underwent in some paroxysms of apparently ordinary ague with which his disorder was complicated, remarks that, with these exceptions, the temperature of the mouth and axilla were steadily 98.4°. Thus, in some cases, unlike what occurs in ague, it is clear that the cold stage is one of actual coldness, while in others there is at least no abnormal heat. Other examples, however, present more of the aguish character in this respect. One of Dr. Greenhow's patients gave under the rigor on three occasions temperatures which varied from 100'' to 100.4°; while after the rigor it was once found to have reached 103.2'. Added to this, the attack has in several instances been succeeded by profuse sweating, so that at least sometimes the pyrexial character of the haematuric paroxysm has been marked and the resemblance to ague obvious. It is not improbable that in all attacks which are sufficiently acute to be at- tended with a cold stage, the temperature, however low at first, must rise as the fit goes on, and so present some sort of parallelism to that of ague, however much lower may be the general level of the curve and less marked the fluctuations. It is worth noting that in two of the cases presently recorded — those of Dare and Dr. Druitt — venous coagula were formed in the limbs. Other disorders may attack the subjects of this disease and run their course independently of it; instances are recorded in which diphtheria, quins}', and measles have thus presented themselves, the last Avith a fatal issue; pneumonia, in one case, came on while the patient was in the hospital, as if connected in some way with the disease or its treatment; and it is to be observed that this disease was the immediate cause of the death of Dr. Druitt, though not obviously connected with hsemoglobin- uria. Perhaps the only disorder to be traced as a direct result of that condition is nephritis, of which association more than one instance has come under my observation. To comprise in a few sentences what is known of the condition of the urine in this disorder, the secretion in the intervals of the attack is ab- solutely natural. With the attack it suddenly assumes a color which is ostensibly due to the admixture of blood, though the range of tints, how- ever deep, is rather vinous than red, smoky or black, as with other forms of hfematuria. The urine is, on standing, divisible into two portions, a bright superstratum, perhaps of the color of port or burgundy, or of the lighter tint of brown sherry or Madeira. This is coagulable with heat and acid to a greater or less extent, usually giving a dark brown floating clot in which most of the coloring matter is comprised. The coagulum produced by heat is sometimes, but by no means constantly, largely dis- solved by nitric acid. The solubility of albumin in nitric acid admits of great variation. Paraglobulin, as estimated by precipitation with sulphate of magnesia, is usually present, though in much smaller quantity than the albumin (see cases of King and Collingbourne). After LNTEEMITTENT HEMATURIA OR H.E.MO-GLOBINURIA. 281 the urine has resumed a natural, or nearly natural, appearance, tlie guaia- cum test will often give the blue. Many observations with the spectroscope have been made of late upon urine under the peculiar form of haemorrhage in question. Haemo- globin or oxyhgemoglouin has been always found together with, in some instances, methtemoglobin. In the urine of Taylor under an attack Dr. Stone found the double absorption band of oxydized htemoglobiu. Drs. Forrest and Finlayson in similar cases found similar evidence together with that of methsemoglobin or acid hsematin ; and we have much other testimony to the same purport — hgemoglobin being constant and methae- moglobin occasional.' I have of late habitually examined specimens of urine under this disease with a large pocket spectroscope recommended by Mr. Browning for the purpose. Oxyhtemoglobin has never failed to present itself when the blood was fairly abundant. I have not recog- nized methsemoglobin. The spectroscope as a test for blood, whether corpuscular or disintegrated, appears to be inferior in delicacy to others. Nearly amorphous translucent web of fibrin imbedding sparkling specks and casts. From urine <}f a bo}»5 years old during an attack of intermittent haematuria. The sediment examined with the microscope consists of two compo- nents: first, a translucent filmy expanse, which has no more structure than the non-corpuscular basis of mucus, or the fibrinous sliape which belongs to the most delicate form of tube-casts; secondly granules which the first imbeds. The web is soluble in potash and acetic acid, and probably consists of coagulated fibrin. The granules entangled in it may be too small for recognition, excepting as a fine brown powder; but in many instances this is mixed with crystalline or crystalloid masses of a yellow color, closely resembling the blood-crystals often found in the pia mater and elsewhere. Frequently, where no crystalline shapes are to be discovered, much of the deposit presents itself as sparkling gran- ules, which are suggestive of crystalline structure, though too small to ' Forrest and Finlayson, Glasgow Med. Journ. 1879; Neale, Lancet, Nov. 1879, p. 725; M. Cazeneuve, Lyon Med., 1880, vol. xxxix., p. 89. 282 INTERMITTENT H^EMATDRIA OR H^MO GLOBINURIA. be identified. In two of the cases I have referred to as under my own observation distinct crystals or crystalloid particles were found; in four ^.:^:'^ -. W C'Vl^A^ 0-..0"'-- cS Urinary deposit in case of Edw. Harvey, April 1st, 1878. Fine pranular matter interspersed •with bright yellow crystalloid masses, apparently blood -crystals. Two of these are represented black. Also granular casts and leucocytes. From drawing by the late E. H. Cowburn. refracting specks, possibly of the same nature. The larger masses as N€» Mj0 ^Vi^ *n%^2s C^'^^-^J^ 5^ m ^^' ^ -j^V./:."— Urinary deposit from John Dare, aged 34, with intermittent haematuria. Yellow translucent crystalloid masses, api)arently imperfect blood-crystals, sprinkled through a faintly j-ellow finely granular web of irregular outline. No definite casts. XOOO D. seen under the eighth were distinct, strongly yellow and translucent. INTERMITTENT HEMATURIA OR H^MO-GLOBINURIA. 283 obviously blood-crystals, though generally irregular or rounded in out- line. In one well-marked instance I found them to be soluble in liquor potassae, not in acetic acid, as would be the case did they consist of haemin or oxy-h£emoglobin. Taking their characters, together with the spectroscopic evidence as to the urine, it is probable that they should be called oxyhfemoglobin, though the point is one upon which further ob- servations are needed. Sir W. Gull ' described them, in a case under his own care, as prismatic crystals of hgematin. Next to the presence of disintegrated blood prominence must be given to the absence, complete or nearly so, of corpuscles. Sometimes a few red corpuscles are to be seen, especially in the later stages of each at- tack, as if the modified hasmorrhage were succeeded or accompanied by Urinary deposit in case of Cath. Evans from June 8th to 27th. Amorphous brown granular mat- ter held together by a faint translucent web. Many renal cells tinted of intense Drown color. Casts containing brown granular matter and epithelium. One was filled with translucent specks of yellow blood-pigment. Uric acid crystals were seen, but are not represented; neither are a few blood-corpuscles, whic^li were found in the later examinations only. Generally magnified 260 D. Two cells of renal epithelium and the cast to their left are magnified 500 D. traces of ordinary haemorrhage; occasionally also a few leucocytes are associated with the other deposits; but such evidences of the escape of unaltered blood are trifling and probably secondary, and it frequently happens that not a single blood-corpuscle can be seen at any period in the course of the paroxysm. As an exception to these statements I may refer to the case of King, in which the disintegrated discharge occurred at one time and at another one wholly corpuscular, and I might ' A case of intermittent haeniaturia. Guy's Hospital Reports for 1866, p. 381. 284 INTERMITTENT HJEMATDRIA OR H^MO-GLOBINURIA. refer to other cases in which considerable ordinary haemorrhage has oc- curred together with or after the peculiar flux. Mixed with the brown powder}' sediment which has been described, and often chiefly composed of it, are casts of the renal tubes, usually somewhat narrow, as if the pulverulent material of which they are made had been moulded, together probably with some recognizable flbrin, in the normal channels. Besides such casts, hyaline and epithelial kinds may often be seen in considerable variety, should the special attack be succeeded, as often ha])pens, by a transient condition of renal inflamma- tion. In such cases renal epithelium is often found stained of a deep brown color. Oxalate of lime and crystals of uric acid are found, the former frequently, the latter occasionally. Amorphous lithates are gen- erally present, and that abundantly, in succession to the haemorrhagic products as the attack is subsiding. Lithates may also present them- selves as substitutes for these products in the imperfect or abortive at- tacks which are apt to occur on the decline of the disorder. Attention has been directed rather to the abnormal than the normal constituents of the urine since the alterations are chiefly by way of addi- tion. Under the paroxysm the diurnal quantity appears to be usually increased, as also is the specific gravit3^ In Dr. Druitt's case, in which the paroxysms were quotidian, the quantity ranged during 7 days from 40^ to 67 ounces; the sp. gr. from 1.007 to 1.028, generally higher when the sanguineous discharge was present than when it was not. My patient, Parker, passed on the day of a severe fit 1,525 CO., which was his maximum as compared with other days, though not a marked in- crease. The specific gravity was taken for every urination during a week for which the urine was sometimes bloody and sometimes not. The average sp. gr. for 16 observations on which the urine was bloody was 1.015; for 22 observations on Avliich it was clear it was 1.011. In a case I published in the " Medico-Chirurgical Transactions'" the spe- cific gravity of the bloody urine was 1.025; the next urination, which was natural, had a specific gravity of 1.009. With regard to the urea during the paroxysm observations conflict. In Dr. Harley's cases * it was in increased proportion in the bloody urine, in one 3.6 per cent, in another 2.5 per cent; the urine in the latter instance presenting before and after the attack the percentages of 1.7 and 1.8 only. In my case,* published in the same volume, the percentage of urea during two par- oxysms Avas found to be 2.35 and 4.25 respectively, while in an interval it was 1.6 per cent. Later observations have given different results. In Dr. Druitt's case the urea during the paroxysms for three consecu- tive days ranged from 1.00 to 1.10 percent, while two specimens of clear urine passed after the fit gave percentages of 1.62 and 2.26. The uric acid in Dr. Druitt's case was somewhat diminished during the paroxysm, increased on its subsidence. It is a matter of common observation that lithates are often superabundant after the blood has ceased to appear. Observations are wanting as to the mineral salts. In my case the chlo- ride of sodium, both during the ])aroxysm and afterwards, was somewhat low; .45 per cent in the bloody urine, .5 per cent in the clear. Some details may be referred to in the case of Collingbourne, which show that the variations of quantity, specific gravity, and urea as be- tween the fit and the interval were not constant; the phosphoric acid ' Med-Chir. Trans, for 1865, p. 161. ''Ibid., p. 175. INTKRMITTENT H>EMATURIA OR H^MO-GLOBINURIA. 285 was generally increased in the 24 hours which included the fit. the chlo- ride somewhat diminished, though during the haemorrhage this con- stituent displayed a larger percentage than immediately after it. The indigo or similar pigment was seen in several of the appended cases to be much increased both during the hccmorrhage and in its absence. The blood and serum have been examined under attacks of this dis- ease with results which, though as yet scanty, are enough to show that products of corpuscular dissolution are present in the general circula- tion. Eed blood-corpuscles withdrawn from a frigid great toe at the outset of a paroxysm have been described by Professor Murri ' as dis- torted or deformed, while the surrounding serum displayed granular material. Further, blister fluid produced during an attack has been found to give evidence of hajmoglobin.'' Besides these significant obser- vations the ordinary blood conditions of ansemia have been found to be j^resent in this disease. With regard to the morbid, anatomy of this disorder a case which was concluded by a post-mortem examination is related in an earlier part of this work, in which the symptoms of it were somewhat equivocally associated with those of acute' nephritis. Beyond that my own experi- ence is limited to four instances. I may now refer to a case which presents the state of the organs twenty-five days after a paroxysm. The particulars may be condensed into the statement that there was intense injection, particularly about the junction of the cones and cortex, and several evidences of extravasa- tion, the most marked of which was an interstitial mass of blood, of ir- regular shape, three or four times the diameter of a Malphighian body. The extravasations appeared to be chiefly of arterial origin and to con- sist mainly of corpusles, but in part of granular matter, apparently the result of their disintegration. I shall place next an instance in which death occurred two months after the cessation of a severe and long-continued hemorrhage of the kind in question, which was sequent upon malarial fever. Extravasations were found in many parts, whether connected with intermittent hematuria, or directly with malaria; there were corpuscular extravasations in the liver and a preposterous quantity of blood-pigment in the spleen, as shown in woodcut, p. 286. The kidneys were marked by intense injection, and contained minute extravasations in connection both with the cones and cortices, the most striking of which surrounded a Malpighian body, as represented in Avoodcut, p. 28G. The extravasa- tions appeared to be wholly corpuscular, both of red and white. There were evidences of tubal and interstitial nephritis, and the tubes con- tained granules of blood-pigment. Together with these facts I must revert to the remarkable case of congestive nephritis related in an earlier part of this work, which presumably took its origin in the intermittent condition, though the clinical evidence was not complete on this point. The kidneys were not only intensely congested, but Taoth had burst their capsules, with much superficial extravasation, an exceptional result of renal disease which cannot but point to a connection between that case and those more recently adduced. In this case, in addition to the tubal and interstitial results of acute nephritis, many of the tubes were lined ' Professor Murri, Emoglobinuria da Freddo. Bologna, 1880. ■Fleischer, Berl. Klin. Wochenschrift, 1881, No, 47. Hayem; case by Mesnet, Archives Generales de Medecine, May, 1881, p. 513. 286 INTERMITTENT H.EMATUKIA OR H.EMO-GLOBINURIA. •with black, granular matter, evidently blood, for the most part, though not entirely deprived of its corpuscular shape. Since these cases have occurred several other post-mortem examina- mm m^ ;:^f"»i- :.£) '^ .^cQ^'S:- ^■r Hsemorrhage around a Malpighian body and about the adjacent structures in case of Evans, tions have been recorded, but none which throw any further light upon the disease. We owe two to Professor Murri, of Bologna, one upon a patient also syphilitic, who died apparently of tuberculosis seven months Granules of pigment in spleen in case in which haemoalobinuria was associated with malaria fever. after his last attack of haemoglobinuria. There was general miliary tuberculosis. The kidnerys were of unequal size; the left natural to the naked eye, excepting a few tubercles, the right hypersemic and with an INTERMITTENT H.EMATURIA OR H^MO-GLOBINURIA. 287 increased cortex. Upon microscopic examination besides the tubercles which were present in both, it was found that the interstitial tissue was increased, the epithelium in some parts of the cortex swollen and de- tached, and collections of yellow and black pigment seen in the cortical tubes. Taking these cases together "with the perfectly natural action of the kidney often observed during life in the intervals of the attacks, we may conclude that no permanent or structural change either of the kidney or of any other organ is necessarily involved in the disorder. But at the same time interest must necessarily attach to the extravasations which were found in three cases, if the third, in which the capsules were thus ruptured, may — of which there seems to be little doubt — be reckoned as of the same nature, and to the remarkable and intense injection which was uniformly observed when the haematuria was of recent date. We thus may regard intense renal hyperaemia frequently accompanied with extravasation as the immediate result of the attack, while tubal catarrh, interstitial overgrowth, and chronic fibrosis are to be traced as sometimes consequent upon it, due probably to the repeated congestion which the disease involves. The renal changes, essentially consisting of hyperemia which is usually transient, are consistent with the belief that the dis- order is primarily of the blood, the kidneys affected only as the channels of elimination. With the facts now before us we may take a general view of the phe- nomena of the disease. They have been differently interjireted. Dr. George Harley ' was led by the Jaundiced appearance to infer that the attacks were in some way connected with disturbance of the hepatic function. I ventured at the same time'^ to attribute the symptoms to a disintegration of blood-corpuscles within their proper vessels, and the subsequent discharge of the debris by the kidneys rather than to any hepatic or primarily renal change. The view which thus presented itself nearly twenty years ago has now found general acceptance. Sir W. Gull =* held, that whatever the primary change might be, there was at least good evidence that the kidneys were affected, and adduced in an instance of the renal source of the disorder the case of a lady who passed the urine characteristic of it in consequence of having received an injury to the loins. ^ Dr. Greenhow, the next commentator, used the term dyscrasia in connection with the disorder, and while admitting the evidences of renal congestion during the attack which are sufficiently obvious, accepted the view which placed the essential change in the blood. Dr. Stephen Mackenzie,^ to whom we are indebted for an able and comprehensive paper on the disease, though formerly he thought that the corpuscular destruction occurred in the kidney, has found himself unable to resist the accumulated evidence that it takes place in the gen- eral circulation. And that it is here would seem now beyond doubt, since the products of corpuscular dissolution, hcTemoglobin, and, accord- ing to Murri, granular matter, have been found in the serum or liquor sanguinis. In what system of vessels the destruction takes place may be less certain than the fact of its occurrence, but it has been supposed ^ Med.-Chir. Trans., 1865, p. 170. ^IbicL, 1865, p. 183. 3 Guy's Hospital Reports, 1866, p. 390. * Clin. Soc. Trans., 1868, p. 53. ^Lancet, 1884, vol. i.. pp. 156, 198, 243. 288 INTERMITTENT HJEMATUBIA OR H.E.MO-GLOBINURI A. with probability to come to pass in the parts of the body, chiefly the extremities, the blueness and coldness of which mark the outset of the attack. In these regions of local cyanosis, from which Professor Murri infers that the arterial blood is shut by a spasmodic vascular action, he supposes that the corpuscles are broken down by the combined action of cold and carbonic acid, to be eventually eliminitated by the kidneys. It has been often observed that a feeling of general illness precedes any urinary change, any lumbar pain or renal symptoms. The rigor probably marks the time of contamination. A rigor, says John Hunter, is commooly the first symptom of a constitutional affection. And whether the poison be febrile or septic, the truth expressed is one of daily experience. The change in the urine is subsequent and probably due to an escape by the kidneys of the morbid product. Dissolved or broken-up corpuscles cast loose into the circulation may easily account for the tinting of the skin as if by hfematin ; and also for the articular effusions, presumptively of blood or blood substance, which were ob- served, as if the blood waste had sought other exits beside the renal. That the kidneys become congested, sometimes intensely so, under the process, is evinced by the lumbar pain, the retraction of the testicles, and the other passing signs of irritation which they manifest; there is even the suggestion of the case, to which I need not again recur, that they may become congested to bursting or fatally inflamed under the disturbance. But it is clear that whatever happens to the kidneys is consequent upon the disorder, not antecedent to it. The natural ac- tion of these organs in the intervals, and the post-mortem evidence which we have, are suflflcient to show that their change of function is due to passing circumstances, not to permaueut change. Apart from ha?moglobinuria as an intermittent or paroxysmal dis- order, a similar condition of urine is known to occur as the consequence of many states of blood, some produced by disease, others by matters artificially introduced. It has long been known that the inhalation of arseniu retted hydrogen produced a condition of urine in which blood was apparently dissolved, and the same result has been extended to other toxic agents, among which may be mentioned naphtha, benzol, hydro- chloric acid, and chlorate of potash. With regard to the latter. Dr. Dreschfield and Mr. Stocks have recorded the case of a woman who. after taking, in the course of twenty-four hours, an ounce and a half of chlorate of potash, passed haemoglobin in the urine, by vomiting, from the rectum, and from the vagina. The convoluted and straight tubes of the kidneys were filled partly with granules and partly with blood- corpuscles, in which the coloring matter appeared to be precipitated. The Malpighian bodies were natural. Blood-corpuscles are known to be soluble in water, and it has been stated that the injection of Avater into the veins of animals, as well as of glycerin and water into the cellular tissue, have been followed by the exit of dissolved blood with the urine, and the same result has been noted in dogs who have been subjected to a starvation diet of sugar and water. The same condition has been found in the human subject in connection with certain septicaemic and febrile conditions, among which is typhus ; and it is said also to have been found with scurvy and purpura, though I may say that in my own not very large experience of the latter disorders I have noticed the blood discharged with the urine to retain the corpuscular form.' Thus ' M. Cazeneuve, Lyon Med., 1880, p. 88. M. Mesnet, Archives Generates de INTERMITTENT HiEMATCRIA OR H^MO~GLOBINURIA. 289 it appears that blood-corpuscles may be dissolved within the body by many agents and in many circumstances, and the product make its way out by the kidneys; but these conditions of haemoglobinuria, in which the solution is ostensibly and primarily due to some toxic agent in the blood, or change in its composition, present only a partial analogy with the obscure and recurrent disorder under consideration. A closer analogue to this is occasionally presented in cases of the symmetrical gangrene, or localized asphyxia of Reynaud. This condition may. concur with the state of urine which has been under discussion: and, indeed, the disorder of Reynaud appears to be so closely connected with intermittent hsematuria that no distinct line of demarcation can be drawn between the two. The essentials of Rey- naud's disease are the arrest of circulation, with coldness, blueness, and often subsequent gangrene, in certain parts often prominent, such as lingers or toes, and often disposed with bilateral symmetry. In certain instances and in certain phases of this disease hgematuria has occurred and recurred, much after the manner of the intermittent haemorrhage under discussion, either with the escape of corpuscles or as hasmoglobin- uriii. A boy, whose case is related by Dr. Wilks,' had, after protracted suppuration, the result of an injury, gangrene of the fingers, such as is described by Reynaud, attended Avith the discharge of haemoglobin and casts with urine, with only the occasional presence of corpuscles. Dr. Southey gives the case of a lad who had gangrene, first of the right in- dex and then of other fingers, while purple patches, which threatened to lead to the same condition, appeared on one ear and the nose. The parts about to become gangrenous first became red, swollen, throbbing, and hot like chilblains. The skin generally was peculiarly sensitive to cold impressions, becoming on exposure remarkably mottled, while parts that were covered were apt to become hot and red, and throbbed and burned, so that he could no longer bear anything upon them. The mottlings referred to developed into patches of urticaria, which pre- sented themselves widely over the face, trunk, and limbs. The urine became bloody under superficial cold, then, after exi^osure and being washed, it would be bloody; a few hours later not so. Blood-corpuscles were found, but no casts; the urine was often albuminous out of pro- portion to the blood. No haemorrhages occurred, except with the urine; iliere was no dropsy. In this case, though the hgematuria might be termed intermittent or j)aroxysmal, there was no evidence of the corpus- cular destruction which belongs to what is termed hemoglobinuria. A case recorded by Dr. Barlow is more to this point. The subject was a girl five years of age who had, especially in cold weather, repeated attacks of coldness, blueness, and pain in one or both feet, or one hand, which lasted several hours, but did not proceed to gangrene. Some of these attacks, but not all, Avere attended Avith the passing of urine, usually once only, Avhich had all the haemoglobinuric character. It was very dark; contained no corpuscles, but much brown granular matter; gave a blue reaction with guaiacum, an albuminous clot of a tenth, and a deposit of oxalate of lime. Occasionally under the attacks the urine I)ecame lithatic, but not bloody. The coldness in the limbs Avas often preceded by abdominal pain. Dr. BarloAv points out — Avhat indeed is Medeeine, vol. i. 1881 p. 513. Dr. Dreschfield and Mr. Stocks, Trans, of Inter- national Med. Congress, vol. i. p. 398. Dr. Sauiulby, Birmingham Mel. Review, March, 1882, p. 9T. ' Med. Times and Gazette, 1879, vol. ii. p. 207. 19 290 INTEKMITTENT HEMATURIA OR H.EMO-GLOBINURIA. sufficiently striking — the resemblance between this combination of symp- toms and that described as intermittent or paroxysmal haemoglobinuria. The condition of urine may be the same in both, even to tlie lithiasis which ap])ears to replace the iieculiar haemorrhage. The attacks occur usually with the same irregularity and from similar causes; in both abdominal pain, yawning, and vomiting may mark tlie beginning of the attack, and in both urticaria may present itself. The difference may declare itself by little else than the more narrow limitation, and the greater intensity, of the superficial arrest of circulation in the one case than in the other. Indeed, the two conditions seem so to approach each other and mingle as to make it impossible to make a distinct demarca- tion between them. With the facts which have been passed in detail, it will now be possi- ble to present in brief retrospect a rational view of the intermittent condition of hfemoglobinuria. It occurs independent of organic disease, though the kidney is concerned usually temporarily in the attacks, but depends on a destruction of blood within its proper vessels from causes which have to be considered. The association of the disorder with ma- larial fever and its sequence, without the intervention of fever upon malarial exposure, is such as to lead to the inference that, at least in many cases, it is but ague misdirected. With ague of the common sort, we may presume that the rigor indicates the presence of a poison in the blood, which is presently eliminated by sweating and the discharge of lithates with the urine. With the hfematuric attack, the disorder points renally. The heat of skin is not indeed always absent, but is usually little marked, to be replaced, as we may fairly infer, by a corre- sponding condition of the kidney, with relief by renal instead of cutane- ous evacuation. The frequent mixture of lithates with haematuric dis- charge, and their substitution for or succession upon it, bears out the analogy. The increase of urea, which is so marked under the ordinary ague fit, is not equally so with that of hemoglobinuria: probably the mate- rials which should form the urea are expended as haemorrhage. Under paroxysms of ague the urine has often been found to be albuminous, and sometimes bloody: the hiematuria of an ague fit may be attended with corpuscular disintegration, and the one disease may jjass into the other, so that the two conditions present themselves but as phases of the same disease. This is seen with the malignant malarial disorder described as bilious or haematuric fever, in which it is said that the urine presents the hae- moglobinuric characters.' The renal congestion of the ague fit is indeed a prominent fact in its pathology, and is probably the means by which granulation of the kidney is brought about, as has been insisted upon in an earlier section of this work, by intermittent fever. And not only are the two disorders associated by the renal congestion common to both, but it would seem, from the anaemiating results of common inter- mittents, as well as from the diffusion of pigmentary products under their influence and the occasional yellow tinting of the skin, that with them as with hgemoglobinuria there is extensive destruction of blood in its own vessels. Another point of resemblance is to be found in the enlargement of the spleen common with ordinary ague and occasionally ' Corre, Arch, de Med., Nov., 1881. Gazette Hebdomadaire, April, 1881, p. 249. INTERMITTENT H.EMATURIA OR H^MO-GLOBINURIA. 291 found in the hsemorrhagic disorder. The heaps of blood-pigment found in the spleen of Catherine Evans (see woodcut, page 286), are quite such as might have belonged to malarial disease, with which, indeed, this case was associated, insomuch that it might have been termed, with equal truth, haemoglobinuria or malarial fever. But the association with malaria, though possibly more frequent than our records show, does not comprise the wdiole history of the condition. Cases present themselves in which no malarial influence can be ascer- tained or suspected. 1 have adverted to the occurrence of hemoglobin- uria with the local asphyxia of Reynaud. We do not know enough of this condition to assert that it is regularly, or often, of malarial ante- cedents, but Reynaud has given a case on the authority of Dr. Landry, in which this sequence held; and it must be noted in connection with this occurrence that gangrene has frequently been observed in connection with, and apj^arently as a result of malarial fevers.' Whatever be the remote cause of the condition, it appears that the immediate precursor of the discharge is contraction of the superficial arteries, whether in connection with ague, with the local asphyxia of Reynaud, or possibly, independently of both, as belonging to an isolated and unexplained form of hemoglobinuria. We may accept provi- sionally the view of Professor Murri that the corpuscular destruc- tion takes place in the superficial vessels in which the stagnation has occurred, and that arterial spasm, whatever be its cause, is the essential factor in the disease. These conclusions are not contradicted by the exceptional appear- ance of the disorder after violence, exercise, and alcoholic excess; the dis- ease has not been thus created; the attacks have been brought on in a person who has previously acquired the liability. As to treatment: tenacious as the disorder proves itself in many cases, there are others which show that, independently of medicine, it has a tendency to recovery. No patient is as yet known to have died directly of the disease, though many have died with it; some have been ajjpar- ently cured, and others have outlived it. The measures which are indi- cated are of two kinds: quinine as possibly curative of the disorder; uniform warmth as jn-eventive of the attacks. The most remarkable point in the therapeutics of the complaint is the effect of temperature. Patients when attacked instinctively seek warmth; go to bed if they can, cover themselves with clothes, and await the relief which the warmth brings. In most instances, cold is the only exciting cause of the attack; in constant warmth they are totally absent. Even when, as in the case of Dr. Druitt, the disorder in a temperate climate has displayed a periodic or diurnal tendency, its habit in that respect has been completely broken by a tropical temperature. Dr. Druitt had but one attack of his disorder, and that brought on by a definite chill during his winter in Madras. Possibly some such tropi- cal, or a subtropical, resort, with quinine if indicated, and especial care to avoid malaria, would be more often desirable than attainable in this disease. Where not attainable, much may be done with warm clothing and by the avoidance of exposure, together with a dietary, including wine or some alcoholic drink, somewhat oftener than might otherwise be needed. Such measures may keep off the attacks; and with a disor- der often of limited duration, this may be equivalent to curing the dis- ' Hertz, Malarial Diseases, Ziemssen's Cyclopaedia, vol. ii. p. 613. 292 INTERMITTENT H.EMATURIA CR H.EMO GI.(>BINUKIA. ease. Dr. Barlow' found that a patient of his wlio from childhood had been washed in very hot water, became less susceptible to the disorder Avhen cold water had been gradually substituted for hot: the suggestion presented must be put to the test of further experience. As to pharmaceutical measures, quinine takes the first place. Ob- viously suggested by the aguish similitude and the occasional aguish an- tecedents of tlie disease, tlie remedy is no novelty in this relation. It was, as already stated, employed by Prout. Though its specific action appears to be less marked than with the common forms of ague, the facts which have been accumulated do not allow us to doubt that something of the same effect must be attributed to it. Dr. Druitt, who spoke from an experience which probably no other member of the profession can adduce, says, "of medicines deserving the name there was but one, and that was quinine in full doses." He found that the attacks were kept off by large doses of the drug, but that its beneficial effect dimin- ished with repetition, until at last, though it still continued to be gen- erally beneficial to health, it lost its control over the hasmorrhage. And many other cases testify at least to the suspension of the disorder under quinine, while with some it has totally ceased under its influ- ence. My own experience amounts to this: I have treated seven patients with quinine alone; four with quinine and iron; one with quinine and iodide of potassium; one with iodide of potassium alone; one with iron alone; and several without medicine. Of those who took quinine alone, five were ob- viously benefited, two of whom were apparently cured. In one the remedy was discontinued on the occurrence of measles; in another, no definite result was obtained. Two considerations make it difficult to estimate the effects of any remedy in this disorder: one is the capricious manner in which it will sometimes come to an end; the other is its tendency to re- cur after a long interval when thought to be cured. The cases most amenable are those in which the aguish antecedents are most distinct. The man whose case I brought before the Medico-Chirurgical Society in the year 1865, who had had ague fourteen years before his attack, and*- was attacked in an aguish district, having all but died under the com- bined effects of mercury and pneumonia, lost his symptoms under qui-' nine and iron, left the hospital apparently well, and when by chance I saw him four years later (1869), had had no return. A man who had had a malarial affection three years before the hae- maturia, lost the latter under quinine and iron, and three years later was still free. In five cases the attacks ceased to occur under full doses of quinine conjoined, in two of them, with iron, though the evidence of recovery is inconclusive. In one of these, the hrematuric symptoms entirely ceased, and remained absent until her death, which was due to another cause. The remaining four patients — Madden, Hercock, Tay- lor, and Jones — left the hospital apparently well, though it was not known how long they remained so. Two cases, treated with quinine alone, left the hospital apparently well, but had recurrences afterwards (K. Baker and Stone). The quinine to be effective, whether permanently or temporarily, needed to be given in full doses, generally about twenty grains a day. One of these, a child nine years of age, had recurrences under six grains a day, none under nine grains. ' Clin. Trans., vul. xvi. p. 188. INTEKMITTENT HiEMATURIA OR H^MO-GLOBINDRIA. 293 Other drugs may be more briefly dismissed. Arsenic has been nsed, and may be i;seful as an antiperiodic, should quinine fail or be inadmis- sible. Antisyphilitic measures have been resorted to, though we have no reason to suppose that syphilis is often, or especially, associated with the disease. Yet it may co-exist, and in two of my cases iodide of potassium was given with apparent advantage. Professor Murri has attributed benefit to mercury in similar circumstances. Apart from syphilis, mercury proved so obviously injurious in a case I have already adverted to that I have refrained from employing it. The yellowness of the skin has occasionally directed the efforts of the practitioner to the liver, and suggested mercurials, nitro-muriatic acid, and other reputed remedies for jaundice. But bile is not wanting in the motions; and if the color of skin is by blood and not by bile, such drugs at best are useless. The action of this metal in reducing the number of blood-cor- puscles and causing anaemia would seem to render it better suited to increase than to diminish the effects of the disorder. Of direct means of stopping the htemorrhage there are none except it be warmth. Iron is an obvious requirement to mitigate the results of the haemorrhage, and may be given in an astringent form. I CHAPTER XXI. OX EXCESS OF THE EARTHY SALTS, MORE PARTICU- LARLY PHOSPHATE OF LIME, IX URIXE. L^XTiL recent years much confusion attended the use of the terms phosphatic urine and phosphatic diathesis ; the urine was said to be phospliatic and the i^erson to have tlie phosphatic diathesis whenever the urine deposited earthy salts: in other words, whenever it was alka- line, whether it had become so in the bladder by ammonical decomposi- tion, or had J)een so secreted by the kidney from a deficiency of acid, or an excess of alkali. Urine alkaline from whatever cause necessarily de- posits its earthy salts, whether they be much or little, and thus the jDhosphatic diathesis was found by the older writers in a large number of widely different conditions, comprising some of constitutional disturb- ance, and may others in which the reaction was simply due to the state of the urinary organs. Urine is very seldom — it used to be thought never — secreted ammoniacal. There are excejjtional conditions of ex- haustion or prostration apart from any localized disease, either of the nervous or the urinary systems, in which it will at times, and even for a long time together, present itself in an ammoniacal state in circum- stances which lead to the belief that it has been so secreted (see page 145); but these may be put aside as exceptional, and the general rule asserted that its being passed in this state is merely an evidence of retention or cystitis. AVith such various conditions leading to alkalescence and deposition, it would seem impossible without reference to their differ- ences to discern any common diathesis or systemic state as antecedent to the urinary condition. Prout, however, in whose time the necessary distinctions had not been made, associates these depositions, however various their origin, with depression and nervous irritability; and though it is clear that in many of the instances to which he alludes the urinary state has been brought about only by disease of the urinary organs, yet there would seem to be a partial truth in his view which has escaped some later observers. Dr. Hassall attributed grave constitutional symptoms to the precipi- tation of the crystalline phosphate of lime ; but this view also has been shown to need modification since this deposit may be caused either by the increased excretion of lime, which may be caused by the a a. s a 55 o C8 <3 ,>>C "if S « S ^ ^ ^ CC 00 5 O S so 5 S!» § ^'^ o ^ u beg >. s S =D T3.S _, 'i S CO ^ a> fe ^^ g o c ®^ c C a = • ^ q; O s-d-^ c.S ■^ i o c .2 o s >.s be 05 in C i) '^i; :^ S _ 03 goo TO 0) -«•- a C j: a> .2 - i "B ^^ 1 5-- K jg CO > a S a "i c ■Sag to a^ -*^ "=* fi a, . " .= S.2 . a ^ a: a S cs o p '■ij ^ 'C a C a '^— " CJ r ^ **-* "^ !»-r!£ a --a c- a: a a ?^ 5 g^ — ;* '^-t « a a o a >. SJ: a i =« • - S ^ ?^ - >.'.2 a !■ ® >i: jf a :=>..= " 2 ~ -> _2 -"^ "« -^ •a ic- 'a ° c a. a >>s x-a i ?: o- > o a Qj — ?— . .i; ,-. t. 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CJ CO 3 CO ^ 03 c« 11 "2 CO "kji "5 CO .J3 Si Is' ^ be s CO 01 > bC « CO ■5 to x^ s CO -O >> (J ■^ -^ ■*"^ a~o3 cS _o s '&< s 'fe CD > 0> CO 2 2 "is ed Disease of the 's, Epilepsy, etc. 'hiee attacks on p CO O' ■/i C3 c3 a; o; bp aT D _c t3 i =<-i 0> 0) O* z3 i3 CO 1) ■*-* S- a c3 r to § ^ S 01 5 =4-1 01 > .2 ■0 •^5 0) "^ ■ji CC CC 'co 01 . >i . ^ ^ a. ^ '^ CS a ^ ■;:?=« ■-; -J3 so ^ 3 c c c % 3 ,0 a .s 1) 9 *» to 01 ^ ^^ "Si • -t-^ £og S ti2 F 5 s 5 .2 t3 32 co' "^ Sd U-l v ■-^ y 0) CO ^2 i± 03 t3 00 T3 o; -5 CO -C 01 -c a a> 0) -u a 13 1' rl. 01 .s 01 01 c tc iX,'" CSM -t-> bC^ be" -" bC« S_ <^ -l is o> Oi — to -t 03 - a - 01 c« — 01 a, bf> )5 a 03 a 2^ 0> .a >,H X! S J CO 4* JS a U4 V 3 ^ m X 03 OJ rr> bO 03 Ooo 01 CO O' V ^2 C ^ ^^ 03 s 0; 4^ 0> 0) br .^ be "* bro 0) a- rH .a > 03 o> s ■u "^ J "s 03 CO CO 03 ^ on *-t 01 fli a a bd jj .3 <-> ce a ^ 01 a j2 a Cl-I .4^ n' =4H CS .!.:> —! r^ 05 OJ 1< a « a •3 . .. 1-^ 4-> 3 T. 11 es 2 V ■0 u C- 5 "5 ■>-, 2 03 n Si y bj-, i ■^ 3 «*j a 3 c :o 14 73 03 0) > 01 c^^ 3 3 ^ ij y-i V •Xl cfl V bO ■V JD 0) is- 03 ?S 2 -3 01 > 4) 0) be i*- 0) tl. n B c« OJ ■4J »^ j3 a be ■ M .^ > ■^ -1^ C4-I r* 3 Ot3 (J y n ^ J3 <^ 5 n o> s ■ ' ' 0) >-> ^ -3 a ... B s 3 03 (1) i J if H t - 03 OJ 1 a ^ a. 298 EXCESS OF EARTHY SALTS IN URINE. amount of tlie earths passed in twenty-four hours, or where this was not possil)le in 100 parts of urine, are subjoined in a tabular form, [See p. 296.] Tlie only one of the tabulated cases which needs further mention is the last of the first series. It was remarkable in the habitual presence of profuse alkaline sweat which was poured out abundantly, particularly under the arms, even though the patient kept cold and perfectly still. The secretion was alkaline from fixed alkali. It increased with depres- sion or exhaustion, and lessened with rest, good diet, and tonics. Both lime and magnesia must be considered as increased, considering the age of the patient. To take a somewhat wider view of the urinary secretion of lime and magnesia, I have subjoined a few observations in reference to other dis- orders, from whence it appears that in instances of tubercular disease of the brain, tubercular meningitis, epilepsy, and cerebral amaurosis, the exit of lime was increased. 'J'o the foregoing facts may be added that in some cases of diabetes, especially the most acute, there is, perhaps, a larger increase of phosphate of lime than occurs in any other circum- stances. The woman Mackay passed as much of the salt in one day as she should have passed in ten; more than three grammes of lime, or about six of the phosphate. This salt was increased out of proportion to the urine, and in larger ratio than any other of its constituents. The condition was associated with cerebral changes of unusual extent and rapidity. In another rapid and severe case was nearly as great an increase of the earth in question. It is noteworthy that this enormous increase of lime was not dependent on any increase of food; but, on the contrary, was most marked when the disorder was approaching its fatal termina- tion, the power of taking food almost lost, and the urine no longer sac- charine, or but slightly so. Observations on the excretion of phosphates in disease were made by Bence Jones as long ago as 184G. ' The most marked result of his in- quiry was the contrast in this respect between inflammatory affections of the brain and delirium tremens; in the former, meningitis and the like, both the total i^hosphoric acid and the earthy phosphates being much increased, in delirium tremens both being as strikingly diminished. According to the view of Bence Jones, the phosphorus which so largely enters into the composition of the brain undergoes under inflammation in- creased oxidation, with a correspondingly increased production and exit of phosphoric acid. The lessened discharge of this acid in delirium tremens was no doubt partially due to absence of food, but it was shown that it could not wholly be thus accounted for, and might with ])rob- ability be attributed to lessened chemical action in a brain of which the condition was the opposite of the inflammatory. About a third of the phosphoric acid which is normally passed with the urine is in combination with lime and magnesia, the rest with potash and soda. It is not my purpose to dwell upon the variations of phos- phoric acid in disease, which have received full attention, but rather to re- fer to those of the earths which are more striking, and appear more indicative than any alterations in the urinary phosphoric acid taken as a whole. For purposes of chemical estimation, it may be assumed that the earths occur in the urine wholly as phosphates; lithate of lime is a rar- LMed. Chir. Trans, for 1847. EXCESS OF EARTHY SALTS IN UKINE. 299 ity; and the oxalate, however frequent, does not attain an amount to be appreciable save with the microscope. The amount of earthy phosphates can be judged of either by ascertaining the amounts of lime and magne- sia separately, the more laborious process, but as distinguishing the earths the more instructive, or by precipitating both together as phos- phates. A rough but trustworthy bedside guide, if the urine be clear, is the bulk of the precipitate presented to the eye on the addition of liquor potassae or ammonia. Perhaps it is more to the purpose to associ- ate the earthy excess clinically with conditions of nervous irritation, than to speculate on the internal chemistry by which the discharge is produced. "What lime can have to do with brain is hard to see; it enters most spar- ingly into its composition, and can scarcely be an appreciable product of its waste; phosphorus, on the other hand, abounds in nervous tissue, and under disintegration or change may be a copious source of phosphoric acid. And this poured into the blood, the conversion of much of it into phosphate of lime, and its exit in this shape, is what may be reckoned upon having regard to the affinities of the acid and the base. Against this view we have the lack of evidence that the phosphoric acid is in- creased otherwise than in earthy combination, and also the minute but at least suggestive appearance of lime in other forms than as phosphate. Whatever be the explanation of the facts which have been noted, it is clear as a matter of clinical experience that an increased discharge of earthy salts in the urine appears in connection with many forms of ner- vous irritation, and affords in some circumstances a ready and valuable therapeutical guide. CHAPTER XXII. ALBUMINURIA GENERALLY CONSIDERED IX RELATION TO RENAL AND OTHER DISORDERS. Ukine may be secreted albuminous, or may be made so, since its secretion, by admixture with some albuminous product. To dispose, in_ the first place, of what may be termed accidental albuminuria: this may be due to the intrusion of blood, pus, or chyle. It was formerly thought that the spermatic fluid could produce this effect, but now stated that semen is not albuminous. These vehicles of albumin are easily recog- nized by their obvious and microscopic characters ; the only doubts which ever need present themselves are, supposing the urine to contain blood or pus, whether the albumin is wholly or only in part due to this cause. It is not my design to dwell at length upon the means of testing for albumin, some of which have occupied much attention of late.' "When- ever the urine is described as albuminous in this work, it is upon the evidence of heat and nitric acid. I examined for albumin by five methods the urine of 100 patients, as they presented themselves consecu- tively in hospital and private practice. The results which are given in the annexed table are scarcely calculated to make us abandon the old tests for the new. The potassium mercuric iodide gave a precipitate in every instance, including many in which there was no reason to doubt that the urine was absolutely natural. Picric acid was the next frequent in result. It is known that both these reagents precipitate other mat- ters besides albumin, more particularly the peptones. Whether urine always or almost always contains a substance analogous to albumin, which is not true serum albumin, niust be determined by further inquiry. Dr. Greeve has published some interesting researches, from which he concludes that healthy urine contains an albuminoid substance which he calls leth-al- bumin,^ a modification of albumin not recognizable by ordinary tests. Whether this be so or not, it is certain that a slight precipitate or opa- lescence with the mercuric iodide is not necessarily a sign of disease, and that the test cannot be accepted as a practical guide. Probably nitric acid and heat, used so as to be mutually corrective, and the ferro- cyanide with citric acid are the best tests for practical use. Picric acid and the mercuric iodide are not sufficiently discriminating. The reactions of albuminous urine with the precipitants of albumin, apart from the peculiarities which depend upon its occurrence in acid or alkaline urine, are liable to variations whiqh appear to be explicable only on the supposition that there are differences in the albumin. Prout describes chylous urine as containing a substance which was coagulable ' See Bedside Urine Testing, by Dr. Oliver, of Harrogate. ' Leth-Albuinin, by John Greeve, Brit. Med. Journ., May, 1879, p. 696. ALBUMINURIA IN RELATION TO OTHER DISORDERS. 301 Urine from 100 Cases taken consecutively from Hospital and Private Practice tested for Albumin hy several Methods.^ Cases. Albuminuria from disease of kidneys Convalescent t'roni nephritis Stone in kidney , Disease of bladder or prostate Diabetes mellitus Diabetes insipidus Excess of uric acid or urates Excess of phosphates ', Intermittent hsematuria Organic disease of nervous system, tumor of brain. locomotor ataxy Functional nervous disease, epilepsy, chorea, tinnitus. Nervous debility Valvular disease of heart and aneurism Tubercular disease of lungs, peritoneum, etc Pneumonia and broncho-pneumonia Bronchitis Fluid in pleura Typhoid Measles Tonsillitis. ... Convalescent from acute febrile affections Disease of liver Ulcer of stomach Diarrhoea Enteralgia Peritonitis Rheumatism, sciatica, muscular pain Eczema Anaemia and amenorrhcea 100 39 54 41 100 45 by acid, but not by heat, which he regarded as hydrated or incipient al- bumin. I suppose it would now be called paralbumin. Presuming the urine to be acid, this reaction must be exceptional even in chylous urine. A peculiar albuminoid substance was discovered by Bence Jones'^ in the ' When the urine of the .«?anie case has been examined repeatedly, the first ob- sei'vation alone has been tabulated. No examination was made without finding a precipitate or opalescence witii the potassium mercuric iodide. ^ A substance resembling albumin, which Bence Jones regarded as a hydrated deutoxide of protein, was discovered in the urine of a patient who had mollities ossium. This substance was discharged in large amount — twice that of the urea — the urine was acid, of verj- high specific gravity — 1.085 to 1.040 — frothy and glu- tinous. Heated to boiling, it gave a precipitate like albumin; with nitric acid, however, in the cold, no immediate precipitation took place, though after a time the urine became converted into a yellow, transparent mass, which, like gelatin, was dissolved by heat and again consolidated on cooling. Though some degx'ee of 302 ALBUMINURIA IN RELATION TO OTHER DISORDERS. urine of a patient who had mollities ossium. On the addition of nitric acid, no change was at once produced; on standing, the urine became solid; with heat it resumed its liquidity. With regard to the reaction of albumin and nitric acid, it was long ago pointed out by Bence Jones that the addition of a minute quantity of this acid to albuminous urine will often prevent its giving a coagu- lum with heat, though it will still coagulate on the addition of more acid. This he supposed was owing to the formation of a nitrate of albumin, coagulable by acid, but not by heat. This reaction appears to present considerable variation in the proportion of acid needed, and to be not always obtainable. Next, it is to be recognized that albumin is soluble in excess of nitric acid, and that this solubility differs greatly in dilfer- ent specimens. An albuminous cloud produced by acid will often dis- appear on the addition of only a few drops too much, while a bulky co- agulum, produced by acid or heat, will disappear with excess of acid, the amount required for this re-solution being liable to great variation. Sometimes an amount of acid equal to that of the urine will do; more often three or four tinaes the bulk is needed. A gentleman who recently died with albuminuria, presumably de- pendent on the granular kidney, habitually passed alkaline urine, which with heat and one drop of nitric acid in an ordinary test tube, coagu- lated to about a fifth. Three or four drops reduced this to a mere opalescence ; five or six made the urine clear. I may add that this urine, when it chanced to be acid, displayed abundance of casts, and that it gave evidence of globulin with sulphate of magnesia. Albumin precipitated by acid is generally more soluble in excess of it than that thrown down by heat. The albumin of lardaceous disease is often more soluble than that which presents itself in other forms of albuminuria, and it has been occasionally noticed that the clot produced with hsemo- globinuria is re-soluble in more than ordinary proportion, and the pecu- liarity in this instance attributed to admixture with globulin. We probably have much to learn with regard to the behavior of albumin and its allies in different circumstances. Such differences as have been adverted to, together with the occasional slowness with which nictric acid causes coagulation, have given use to the term, peculiar albumin/ to signify albumin which is less coagulable or more soluble than common. Some of the phases of incoagulability may be supposed to indicate an approach to the peptones. I do not propose to dwell upon the subject of peptone in urine, of which both the chemical and clinical relations are as yet imperfectly understood. Peptone 'is not precipitated by heat or nitric acid, and so does not complicate the subject of albuminuria if only these tests be used; but it is thrown down by picric and citric acid, and also by the potassium mercuric iodide together with citric acid. The formation of a precipitate with these reagents, particularly with the mercuric test when the older means of discovering albumin give no result, is so com- mon, that the presence of something which acts like peptone in this oedema was present in this case, the kidneys were found to be natural after death, so that we can but attribute the peculiar discharge to some condition of blood connected with the softening and wasting of the bones. Case of Mollities and Fragilitas Ossium, by W. Macintyre, M.D Med.-Chir. Trans for 1850. Also paper by Dr. Bence Jones in Phil. Trans., for 1848. ' See Dr. Haddon on Peculiar Albumin. Brit. Med. Jour., 1876, Part i., pp. 191, 256, 286, and 381. ALBUMINURIA IN KELATON TO OTHER DISORDERS. 303 respect must be the rule rather than the exception. But it is probably not peptone, but rather something else allied to albumin not yet identi- fied, for it is often present in considerable quantity when the copper test gives no result. Peptonuria, as recognized chiefly by the latter test, appears to be comparatively infrequent, and to have scarcely as vet acquired practical interest. It has been found in a variety of disorders not especially renal or attended with albuminuria, among which phos- phorus poisoning, suppurative conditions, and gastric and'intestinal dis- turbances have been mentioned. The presence of globulin, or rather paraglobulin, in urine has more to do with albuminuria than has that of peptone. I'he occurrence of this substance together with the other constituents of blood in hemo- globinuria has no separate interest. The amount of it may be easily estimated by precipitation with sulphate of magnesia.' It would seem that paraglobulin is almost never present in urine except it be also albu- minous, and that when it is so, unless it be also bloody, this addition is found only exceptionally or only in very minute amount. Para- globulin is not soluble in pure water, though it is so in weak saline solu- tions. Dr. Roberts has recently pointed out tliat a drop of albuminous urine allowed to fall into a glass of distilled or even ordinary drinking water, a delicate ring of opacity, like a puff of smoke, will often accom- pany its descent. This he attributes to the paraglobulin separated from the albumin by its insolubility. This reaction is often to be found when globulin is not to be detected with sulphate of magnesia, and it must still remain suh judice upon what it depends. This constituent of the blood appears to have been found in urine more frequently with the acute and the lardaceous forms of renal disease than with others. A fatal instance of acute nephritis with dropsy has been described, in which the urine contained globulin, to the entire ex- clusion of serum albumin. Casts were present as in ordinary cases. ^ Speaking of albumin as something which is to be detected with heat and nitric acid, it may be said that urine which is secreted albuminous is to that extent abnormal. The arrangement is faulty either in the renal mechanism, or in the composition of the blood, or in the pressure to which it is subjected. Whether a minute trace of albumin, such as to be inappreciable to most tests, may consist with health, or whether healthy urine contains traces of an albuminoid substance, possibly occu- pying a position between albumin and urea, are questions which must be postponed; but, at any rate, it is certain that any such considerable admixture of albumin as to be readily detected with heat and nitric acid is evidence of disease, whether permanent or temporary. Albuminuria has been divided into permanent and temporary, and many observations have been made to show in what proportion of persons one sort or the other exists, and with what disorders they are associated. Thus, of 303 adults in the medical wards of University College Hospital, 39 had, according to Dr. Parkes, ])ermanent, and 37 temporary, albu- minuria, while in the remaining 'Z'Zl cases no albumin was present at ' Dr. Marcet reminds me of the reactions of globulin as obtained from the crys- talline lens. It is precipitated by carbonic acid; soluble in ammonia; precipi- tated from the ammoniacal solution when this is neutralized with acetic acid ; redissolved in excess of acetic acid. ^ Lancet, 1883, vol ii. p. 1001. Dr. Womer, of Heidelberg. 304 ALBUMINURIA IN RELATION TO OTHER DISORDERS. any time. Thus the proportion of albuminuria, passing or lasting, was almost exactly one in four.' Dr. Saundby examined the urine of 145 male out-patients at the General Hospital, Birmingham, and found albumin in 105.^ In 64 the albumin was attributed to renal disease. Deducting these, there remain 81 cases of non-renal disease — dyspepsia, debility, phthisis, morbus cor- dis, etc., among which the urine was albuminous in 41, or about half. I have already stated the proportion of albuminuria in patients taken in- discriminately from hospital and ]u-iYate practice as deduced by different tests (p. 301). Of the 100 cases referred to, 19 were of kidney disease, necessarily attended with albuminuria : of the remaining 81, the urine showed albumin to heat, and nitric acid in 21, about one case in four. It is seen with sufficient clearness in the table how much the results differ with different reagents. Dr. Mahomed found albumin to be pres- ent in the urine of persons proposed for life assurance in a proportion of 15.5 per cent. Dr. Mann^ in the same circumstances found albumin in 11 per cent. With our present knowledge we must believe that, how- ever slight or transient a disturbance may make the urine albuminous, this condition, as it is ordinarily recognized, is not consistent with abso- lute health. The causes of albuminuria afford a more convenient basis of classifica- tion than its persistence. Urine which, independently of admixture, is persistently albuminous indicates a persistent change in the kidney, wliether arising in it or secondary to disease elsewhere ; but, on the other hand, it is possible that, though such disease exist, the urine may be al- buminous only at times. Thus no safe distinction can be made between permanent and temporary albuminuria. To bring within a simple classification the various circumstances upon which an albuminous state of the urine may depend, they may be arranged into three great classes : the first may be termed accidental albuminuria, or albuminuria by admixture, in which the secretion has been rendered albuminous subsequently to its secretion ; the second com- prises the many modes in which the urine may be made albuminous by renal disturbance, whether connected with structural change or circula- tory embarrassment ; the third includes those rare instances in which the kidneys secrete albumen in consequence of an altered condition of the blood "itself . In the accompanying table all the subdivisions except the first and last presumably belong to the second class. Causes of an Albuminous State of the Urine. Admixture with blood, lymph, chyle, pus, or the contents of cysts opening into the urinary channels, or with products derived from the bladder or tissues after death. Independently of such admixtures, urine maybe albuminous from : — f Nephritis, tubal or diffuse. „ , ,. f fi I Granular degenenition of kidney, or interstitial ne- otVnCtn 1*3,1 U.1SG3.SGS 01 tnG J viln-itic -' I Lardaceous disease of kidnej-. [Abscesses in kidney, pyeemic or uriseptic. ' Parkes on the Urine, p. 187. ■ Di-. Sauudbv, on the Diagnostic Value of Albuminuria. Brit. Med. Jour,, 1879. vol. i. p. G99. 2 Quoted by Dr. Middleton. Discussion on Albuminuria, Glasgow, p. 122. ALBUMINUBIA IN RELATION TO OTHER DISORDERS. 305 f Embolism. I Thrombosis. ^, ^ , ,. - ,v I Tubercular disease of kidney. Structural diseases of thel Cancer or other growths in kidney, kidney | Qygtic disease of kidney. I Dilatation of kidney from present or past obstruc- ts tion. f Pregnancy, with consequent renal congestion. Disease of heart " " " r< f f ir'H irn I Obstruction to renal circulation by other mechanical Congestion ot Kianey irom, causes, tumors, etc., pressing on emulgent veins mechanical causes ^, or venk cava. I Dyspncea from croup, laryngitis, bronchitis, etc. [ Respiratory embarrassment of epilepsy. r Exposure of surface to cold, as in bathing. ^i.1 4.- ^..^ Ague fit. Other causes, actmg P^e- J Venous congestion of the dying ? sumably by way of renal^ Generally increased vascular tension from state of congestion j blood? Is Masturbation. „ . • -i. ^ < Cantharides, arsenic, phosphorus, lead, silver, mer- Extraneous irritants j ^^^^ ^,^^ ^^^^ ("Bile in cases of jaundice, sugar with diabetes. . . J With stone the urine may be slightly or temporarily inherent u-ritants < albuminous, though there be no disease of the [ kidney itself. „ .„ , ( Scarlatina, diphtheria, typhus, typhoid, erysipelas, Specific fevers | g^.^y p^^^ measles, etc. Pneumonia. Cholera and diarrhoea. {Certain nervous conditions — injury of brain and state connected with exophthalmic goitre— pre- sumably affecting renal blood-vessels. 'Large ingestion of albumin. Dyspepsia? ? ? Destruction of blood-corpuscles, as in intermittent ~, J! ui J • hsematuria. Changes of blood irrespec- , p^j-pm-^ tive of renal disturbance, j gQ^r w Various septic and febrile conditions. I A state of blood connected with certain conditions (s of the liver. Albuminuria, so far as it relates to renal changes, has been fully dis- cussed. Casts often throw liglit upon the source of albumin. If these contain blood, or, as with intermittent haematuria, its substance, it is obvious that the glandular structure gives exit to the discharge, though it may remain to be determined whether local congestion or humoral change is the cause. If epithelial, they indicate tubal disturbances and an organic reason, though possibly only of a transient kind, for the albu- minous discharge ; if merely fibrinous, they show at least that not albu- min only, as if that substance were in excess, but the liquor sanguinis in toto is making its way out by reason probably of local hyperemia or structural change. But while casts as a rule show that the issue of the albumin depends upon some change in the structure of the kidney or in the tension of its vessels, it is not to be concluded from their occasional 20 306 ALBUMINUKA IX RKI.ATION TO OTHER DISORDERS. absence that it is not so. In the early stages of the granular kidney casts are often as infrequent as in tlie early stages of nephritis they are abun- dant. The evidence afforded by the presence of casts is therefore more to be relied upon than any inferences to be drawn from their absence. "Witli embolism and renal pyasmia easts are usually to be found, often Avith blood ; with tubercular disease of the kidney, though casts are not necessarily present, yet they are often to be found in consequence of some localized tubal disturbance in the affected organ or secondary lar- daceous change in the other. "With renal stone a few casts are occa- sionally found, probably from localized irritation, though it may be practically certain that there is no general disease of the kidney substance. As to whether albumin be the result of mechanical congestion as from heart disease or of some disorder particular to the kidney, the distinc- tion may often be made at a glance ; with cardiac congestion the urine is apt to be scanty and loaded with lithates ; with disorders primarily renal, the urine however scanty is only exceptionally lithatic. In distinguishing the structural diseases of the kidney from each other, the albumin is often a guide in its mode of accession ; with ne- phritis it becomes early large, to decline gradually with disease ; with the granulating kidney it is at first, and often for long, slight, or inter- mittent, in the later stages sometimes little and sometimes much ; with the lardaceous it is early in minute quantity, latterly abundant. There are few structural diseases of the kidney which are not apt to make the urine albuminous, though they may not do so of necessity. Albumin appears with renal embolism, and also when the renal veins are obstructed by thrombotic clots. Tubercular disease often appears, probably from tubal disturbance in the neighborhood of the formation, to cause more albumin than the pus can account for, and it has even been stated that at the outset of the disease the urine may contain albu- min and rarely epithelial cells. Cancers and other growths do not neces- sarily make the urine albuminous ; it may hapjoen, indeed, that this secretion is absolutely natural, notwithstanding the extension in the kidney of large growths, so long as these be not exposed in the pelvis ; but traces of albumin are apt to present themselves apparently from irritation of the gland by pressure or contiguity. The urine may be albuminous from cystic disease as with the granu- lar kidney ; and it commonly shows at least a trace of albumin, the urine being pale and of low specific gravity, if the kidneys have been much impaired by dilatation. The urine, usually pale and copious, which is passed after obstruc- tive suppression, is sometimes slightly albuminous, whether, as has been suggested, from compression of the renal veins, or, as perhaps is more probable, from distention of the tubes, and irritation of the gland by its own secretion. Next to structural disorders it is sufficiently clear that mere increase of pressure within the renal vessels, particularly when this is connected with venous obstruction, may cause the transudation of serum. Dr. Kobinson long ago made the urine albuminous by compressing the renal vein, and we see a similar process in operation, as has been enough dwelt upon, when the abdominal veins are compressed by the gravid uterus or the whole venous system made turgid by cardiac obstruction. Though struc- tural changes may be produced by these causes, yet from the frequently fugitive nature of the albuminuria so engendered, it is certain that the transudation may take place quite independently of renal disease. Of ALBUMINUKIA IN KELATION TO OTHER DISORDERS. 307 the same nature is albuminuria of dyspnoea; it is very general to find at least a trace of albumin in croup, even though this be catarrhal, not diphtheritic; and the urine has been found to be temporarily albuminous after severe epileptic convulsion, no doubt from the respiratory embar- rassment pertaining to it. To these causes of increased blood-pressure within the kidney must be added the influence of the cold stage of ague with the internal congestion which it involves, and also the external action of cold in bathing. All these are causes of albuminuria, though the kidneys be undisturbed, save temporarily in their circulation. We may have to add another. Increased arterial tension is a marked ac- companiment of certain diseased states with which the kidneys are apt to be granular and the urine albuminous. Does this increased arterial tension ever cause the urine to be albuminous irrespectively of renal change ? This question must wait for its answer ; my own observation so far points to the negative. Many of the causes of albuminuria her 3 referred to have been con- sidered in the preceding pages and need no further notice ; with regard to some which relate less particularly to the kidneys a few words are re- quired. The transient albuminuria produced by the various drugs which act as renal irritants has been considered in connection with tubal nephritis; as also has the sometimes more lasting condition which results from the renal exit of bile and sugar, and from the influence of several exanthem- ata which presumably act similarly by discharging through the kidneys a special morbid irritant. Eeference Avill also be found in connection with nephritis to the form of albuminuria which has been known to ensue upon extensive injury to the skin by disease, or in animals by the experimental arrest of its func- tion by impervious coverings. There is, however, another mode in which cutaneous disease may render the urine albuminous ; I have re- cently seen a case of extensive and fatal eczema in which the kidneys had become lardaceous, possibly in consequence of the protracted and exhausting discharge. Pneumonia as a cause of albuminuria requires mention which has not yet been accorded to it. This disease, though not to be recognized as a cause of enduring renal disease, is perhaps as frequent a cause of albuminuria as diphtheria or scarlatina. This complication of pneumonia has been much studied, and its phenomena fairly exposed to view. The frequency of albumin- uria in this relation has been variously estimated. Parkes found it in 6 of 13 cases, and quotes Finger, who found it in 15 of 33 cases, and Becquerel, who found it in 9 of 21, giving a total of 30 instances of al- buminuria among 67 of pneumonia, or a proportion of nearly 4:5 per cent. Dr. Wilson Fox found the urine to be albuminous 10 times in 32 cases, and Griesinger 03 times in 121 cases. On the other hand, Metz- gar failed to find albumin once in 48 cases ; while Martin Solon and Ziemssen each found albumin only twice in 24 cases. My own experi- ence, so far as it relates to true lobar pneumonia, more clearly corre- sponds with the figures of greater frequency; though with pleurisy and bronchitis the urinary complication is comparatively rare. Dr. Isam- bard Owen, when Medical Kegistrar at St. George's Hospital, kindly drew up for me the following table, the accuracy of which may be re- lied upon. From this statement it appears that of 26 cases of pneu- monia treated in St. George's, the urine presented more or less albumin 308 ALBUMINURIA IN RELATION TO OTHER DISORDERS. in all but four; and of those four the opportunities for observation were not always so frequent as to allow of the inferences that the urine was free from albumin throughout the whole course of the disease. It will be observed that the albumin appeared at all times between the second day and the tenth, and that no fixed relation held between its date of appearance and that of resolution. Table showing the Period of Alhuminnria in Twenty-six Cases of Pneumonia. The following table includes all the cases of acute pneumonia admitted into St. George's Hospital, from January to August, 1877, with nine exceptions. Of these, one was complicated with acute rheumatism, four were rapidly fatal, and in the remaining four other causes prevented the collection of the urine. The morning secretion was, as a rule, examined whenever obtainable until convalescence was approached. The fourth column of the table contains the result of each examination made, whether positive or nega- tive. <6 ■a s 03 M 3) . Q o M. , 40. 6th. M. , 44. 7th. M. , 23. 1st. M. , 26. 3d. M. , 40. 8th. M. , 26. 1st. M. , 56. 14th. M. , 29. 5th. M. , 20. 8th. M. , 27. 8th. F. 26. 3d. Period of Resolution. Albuminuria. Temperature declined from ad- mission; normal by 11th day, on which resolution com- menced. Crisis on night of 8th. Resolution from 3d day. Resolution commenced on 5th day. Crisis on night of 10th, Resolution commenced on 4th day. In full resolution on admission. Temperature declined from Gth morning ; normal by 9th. Resolution commenced on 7th day, In full resolution on admission. In full resolution on admission. Resolution commenced on 6th day Urine albuminous on 7th and 8th days; a trace of albumin present on 10th ; a faint trace on 11th ; none on 12th. Urine albuminous on 10th; no albu- min present on 8th. 11th, 12th, or various subsequent occasions. No albumin on any day from 1st to . 5th. A trace of albumin on 4th and 5th days; none on 6th, 7th, 9th, 10th, or 11th. Urine slightly albuminous on 9th day; albuminous on 10th; a trace of albumin present on 11th; none on 13th. Urine albuminous on 2d day ; a trace present on 4th. No albumin on admission. Urine slightly albuminous on 5th, 6th, and 7th days; suppressed on 8th ; free from albumin on 10th, 11th, and 12th. No albumin on admission. Urine albuminous on 9th day; free fromallnunin on 18th; collection irregular owing to delirium tre- mens. A trace of albumin present on 5th, 6th, 7th, 8th, and 11th days, and on discharge; none on 9th. ALBUMINURIA IN RELATION TO OTHEB DISORDERS. 309 be d o 5'fl Period of Resolution. Albuminuria. F., 18. 5tn, Resolution commenced on 12th Urine slightly albuminous on 9th day- day; a trace of albumin present on 11th, 15th, and 19th : none on 13th or 16th. F., 32. 5th. Crisis on night of 5th. Urine slightly albuminous on 6th day; a faint trace of albumin present on 10th. M., 17. 2d. Crisis on night of 6th. Urine albuminous on 3d, 6th, and 7th days ; less so on Btli ; free from albumin on 9tli and 11th (sodic salicylate was given from the 3d to the 6th). M., 80. 13th. Crisis on night of 15th; resolu- Urine slightly albuminous on 14th tion commencing during the and 15th da,ys; a trace of albumin day. prest^nt on 16tii; none on 17th and 18th. F., 70. nth. Resolution commenced about Urine slightly albuminous on 11th, 12th day. 13th, and 14th days. F., 26. 4th. In resolution on admission. A trace of albumin on 7th. M., 13. 5th. Resolution commenced on 7th Urine highly albuminous on 5th, day. 6th, and 7th days; slightly so on 8th; free from albumin on 9th and 10th. F., 5. nth. Resolution commenced on 12th day. No albumin on 12th or 17th. M., 24. 2d. Resolution commenced on 5th A trace of albumin present on 4th; day. none on 5tli or 12th. M., 27. 5th. No resolution ; death on 10th day. Crisis on night of 7th. Urine loaded with albumin on 8th day. Urine slightly albuminons on 6th M., 39. 5th. day; a trace of albumin pi-esent on 7th; a very faint trace on 8th; none on 10th. M., 4. 5th. Resolution commenced on 8th Urine highly albuminous on 5th day. and 6th days; slightly so on 9th, and on discharge (the face was puffy, and was said to have been so for three weeks before the on- set of the pneumonia). M., 35. 2d. Resolution corDmenced on 7th Much liEematuria on 2d, 3d, and 4th day. days; lesson 5th; little on 6th; a trace of albumin present on 9th; a faint trace on 11th; none on discharge. M., 54. 4th. Resolution commenced on 5th A trace of albumin present on 4th day. day; none on 7th or 9th. F., 22. 5th. Resolution commenced on 8th Urine albuminous on 6th day; free day. from albumin on 11th and 12th. The albumin is often enough to form a bulky coagulum, and it is not uncommon for the urine to contain blood, though not enough to account for the albumin. Epithelial casts are generally to be found. The characters of the urine are such as belong to tubal nephritis, save that, contrary to what occurs in nephritis as an independent disease, the urinary solids, with the exception of the chlorides, appear to be in- 310 ALBUMINURIA IN RELATION TO OTHER DISORDERS. creased. (Edema is practically unknown as a result of pneumonic albu- minuria, tliough Professor Bartels mentions, in Ziemssen's Dictionary, an exceptional instance, in which general dropsy with the ordinary symp- toms of acute nephritis arose in the course of a genuine pneumonia. This patient recovered, and I am not aware that persistent renal disease h;i3 ever been traced to tliis beginning. The albumin either disappears witii the acute symptoms, or withdraws more slowly during convales- cence. There is some variation in the time at which this urinary change presents itself, but it does so in most cases at, or rather before the height of the disease, while tlie hepatization is on the increase, and the febrile disturbance great. The advent of the albumin appears usually to an- ticipate the process of resolution, so that, with our present knowledge, we can hardly adopt the theory which has been advanced that tiie renal disturbance is due to the irritating effect of the pneumonic products es- caping by the kidneys. Nor can we with more probability refer to the dyspnoea as connected with the change of secretion; difficulty of breath- ing when extreme, as from laryngeal disease, may cause the urine to be- come slightly albuminous, but with pneumonia the dyspnoea is compar- atively slight, and the albuminous addition considerable. The hypothesis which of late has gained- most acceptance is that the kidneys are primarily implicated in a general congestion and exudation, of which the lungs afford but the most marked localization; it would seem, however, that the kidneys are usually affected after the lung, and less severely, while the manner of their disturbance is much that which suc- ceeds, obviously as a consequent affection upon many other febrile states. If on such grounds we discard the view that the renal affection is, so to speak, pneumonia of the kidney, we may take refuge in a supposition which seems indeed to spring naturally from the facts of the case. The urine becomes albuminous, and the evidences of tubal nephritis arise at the period in the disease when the essential urinary excreta are in extravagant excess, and the urinary water deficient. The increase relates to the urea, the uric acid, and the sulphuric acid; the urea in particular may be increased beyond the wont of any other disease, excepting, perhaps, diabetes, where the ureal discharge occurs together with a great flow of urinary water. Parkes found between 80 and 90 grammes of urea (be- tween twice and thrice the normal amount) to be secreted daily from the sixth to the tenth days of pneumonia; and other observers bear similar testimony, both as to the enormous amount of urea secreted, and as to the fact that the increase is greater before than during resolution — con- nected, tliat is, witli the febrile state, rather than with the absorption and discliarge of inflammatory })roducts. It is not improbable that the kidneys owe their disturbance to the functional demand thus made upon them, the attendant irritation enhanced possibly by the want of water. Observations are, however, wanted as to the exact relation of the albu- min and the other nitrogenous components of pneumonic urine.' Cases have been reported in whicli, under this disorder, the urea has been less than in health; in them albumin has been either absent or in trifling quantity. That cases of pneumonia in which albuminuria occurs are more fatal than others, does not admit of doubt. Probably this complication is the more apt to occur in the more severe cases, while choking of tlie ' Observations upon the elimination of urea, by S, West, Med.-Chir. Trans., 1874. ^ ALBUMINUKTA IN RELATION TO OTBER DISORDERS. 311 Tiidney can but add to the risk of a disorder which, like pneumonia, is productive of refuse which belongs to this exit. "With regard to cholera also a few words have to be added to what has found place under the heading of nephritis. During the cold stage of cholera, the urine becomes nearly or quite suppressed, and that which is next secreted is albuminous and contains epithelial casts. The kidney itself displays much tubal obstruction and often early fatty change in the epithelium, while by some observers small vascular blockings have been described. Putting aside the latter complication, the condition, clinically and pathologically, is one of tubal nephritis, and has been considered in its place as such. But there are some further points of interest with regard to the way in which this condition is produced. It has been repeatedly asserted that the urine becomes albuminous only in cholera which is truly Asiatic, the presence of albumin being regarded as a pathognomonic symptom in this respect; but albuminuria with English cholera is by no means uncommon; and we have the evidence of Dr. G. Johnson' that, in a large proportion of cases of ordinary summer diarrhoea, the urine first secreted after the se- verity of the attack has passed contains for a few hours albumin and tube casts. Dr. Johnson infers the existence in all cases of a morbid poison by which the kidneys, as well as the bowels are irritated; but the experi- ments of Herrmann,^ of Overbeck,^ and of Cohnheim* enable us to re- gard the matter in a new light, by showing the changes which the renal function undergoes in consequence of the arrest and re-establishment of the circulation. By these experiments, it was shown in the first place wliat is sufficiently obvious, that the renal secretion is suspended when the current in the renal vessels is stopped, whether by compressing the renal artery, or the artery and vein together, or the aorta. The removal of the ligature and the readmission of blood then causes in the dog re- sults which are precisely analogous to those ensuing upon cholera in the human subject. A condition of nephritis comes on, which lasts longer or shorter according to the length of time for which the ligature has been applied. The kidney becomes at once swollen and congested, and the urine bloody; the renal vessels are found to be dilated and liquor sanguinis and corpuscles to have been effused. A similar condition of hyperaemia was produced in other structures — in the ear, for example — by a similar process, so that it could be demonstrated as a law which ap- plied to more than one structure, that re-establishment of the circulation after its arrest is attended with congestive or inflammatory change. As the failure of circulation in the collapse of cholera is general, it may be asked why the subsequent inflammation should be most marked in the kidney; possibly the arrest of circulation may be more complete in this organ than elsewhere, in consequence of the removal of water, which is especially necessary to the renal function, and presumably to its circula- tion. The double system of renal capillaries must be little suited to the transmission of the viscid blood of cholera. Pyrexia has often been referred to, as if this condition, irrespective of its origin, were a cause of albuminuria. It is undoubted that this occurs in many pyrexial states, but it is open to question whether the complication is due to the pyrexia, or to what has caused the pyrexia. ' London Med. Record, vol. i. p. 474. * Year Book of Medicine and Sargeiry, 1862, p. 26. ^ Ibid. 1SG8, p. 28. * Ziemsseii's Dictionary, vol. xv. p. 223. 312 ALBUMINURIA. IN RELATION TO OTHER DISORDERS. Dr. Chaffey, the Registrar at the Hospital for sick children, kindly made at my request at tliat institution some observations which are con- sistent with the supposition that the albuminuria is not due to the tem- perature per se. A comparison of the cases of diphtheria and pneumo- nia with those of high temperature connected with tubercle and local disease shows how much more frequent is albuminuria in the zymotic conditions, if we may include pneumonia under this head, than where no contamination of blood is suspected. It would indeed appear that the urine is albuminous, not as the result of fever, but as the result of febrile poison, or, in the case of pneumonia and cholera, of special influ- ences which have been discussed. Initials of patient. H. M., Feb. F. K. J. i H. J. A. F. E. H. E. E. E. E. B, F. J. J. A. X. E. D. G. L. G. J. E. C. A. A. E A. .\. R. G. F. F. 14, 6 P.M. 15, 6 A.M. 18, 6 a.m. 21, 6 a.m. 24, 6 a.m. 29, 6 A.M. R B C, March 27. 30. F C J B D Trott. . Taylor. R P March 17. " 21 H. S.. Complaint. Diphtheria, before tracheotomy. " after " Gungrenous pharyngitis, diphtheritic. Measles Typhoid Erysipelas Pneumonia, lobar or croupous. of apex. Pleuro-pneumonia. . , Broncho-pneumonia . Bronchitis Empyema General tuberculosis. Phthisis Mesenteric disease. Tubercular peritonitis. Chronic peritonitis. Meningitis Psoas abscess Morbus coxae Abscess. Acute periostitis. . . Abdominal tumors. Tempe- Albumin in rature. urme. 99.8 none 101.6 trace 99.2 '< 99.2 more 98.4 faint trace 99.0 trace 108.4 (( 102.0 none 103.8 <( 102.8 " 102.8 .-race 103.8 a 104.0 n 103.0 it 102.8 faint trace 102.6 bttle 104.8 none 104.6 te 104.0 trace 101.0 << 102.0 none 103.2 (< 101.8 " 101.0 " 104.0 t( 103.6 trace 103.4 none 102.0 <( 102.0 trace 103.0 none 102.0 . ]). 57. ' Diet, de Med. et de Chir. Pratiques, p. 335. 316 ALBUMINURIA IN RELATION TO OTHER DISORDERS. make the urine albuminous. The rapidity, indeed, with which healthy kidneys will discharge any excess of water which is introduced by the stomach, without any accompaniment of albumin, is enough to show that albuminuria from excess of water in the blood has, at least in the human subject, no practical existence. Albuminuria, as connected with intermittent haematuria or haemo- globinuria needs no further notice here. The urine in this condition contains albumin, along with the other matters of the corpuscle, and will even remain albuminous after it has ceased to be colored; this, however, is probably due to the glandular irritation sequent upon the abnormal discharge. Next come conditions of purpura and scurvy. With pur- pura blood is often largely discharged with the urine, and as with inter- mittent hematuria, may remain albuminous after it has ceased to be bloody. It is possible, again, in this case, that some degree of tubal disturbance has been set up by the passage of the blood. It is said that a similar condition of urine sometimes accompanies scurvy; and in the same category, that of albuminuria associated with, and dependent upon, haemorrhage, may be placed those instances in which blood, whether in shape or solution, is discharged with the urine in connection with the more malignant types of small-pox, scarlatina, and other fe- brile disorders. It is said that in such cases the blood is discharged in a state of solution, as with intermittent hsematuria; if in such cases albumin appears without the coloring matter, it must with probability be attributed to the occurrence of such transient nephritis as febrile con- ditions are apt to set up. With regard to the albuminuria of pyaemia and septicaemia, the kid- neys are frequently the seat of pyaemic localizations, and the urine gives evidence accordingly of renal inflammation. As to less definite con- ditions of blood-poisoning to which the term septicaemia has been ap- plied, these are sometimes associated with erysipelatous inflammation and attendant nephritis, and sometimes have a purpuric character, to- gether with Avhich heemorrhagic transudation may take place into the urine. Further than this, Mr. Henry Lee' has drawn attention to the appearance of albumin in the urine often together with the coloring matter of the blood, but without corpuscles, in cases where clot or effused blood has been absorbed after accidents or injuries. We know that blood may be taken up without this result; probably the absorbed matter thus ejected has become, from decomposition or otherwise, unfit for the uses of the system. There are certain observations which would seem to indicate that de- rangement of the liver alone may cause the discharge of albumin by the kidneys. I do not refer to the common albuminuria of jaundice, with which the escape of bile by the kidneys creates an oi)vious condition of tubal nephritis, as evinced by the discharge, together with albumin, of bile-tinted ej)ithelium and tube-casts — this has been considered else- where — but to a possible albuminous discharge l)y the kidneys as a con- sequence of hepatic independently of renal disturbance. ' " On Albumen in the Urine, sometimes in conjunction with the coloring matter of the blood, as a consequence of surgical diseases and operations," by H^ Lee. Lancet, Aug. 21st, 1869, p. 363. CHAPTER XXIII. H^MATUEIA. Blood may become admixed with the urine in so large a variety of circumstances that it may be well to classify them, to name the more important, and to indicate the clinical distinctions by which the classes at least are separated. It is not needful to dwell upon the changes pro- duced in urine by the presence of blood, further than to indicate the differences which attend differences of origin. It is sufficiently known that the color which blood imparts to urine is smoky or brown, if the mixture be acid; pink or reddish, if it be alkaline. Blood-corpuscles, which readily fall to the bottom, and in acid urine long retain an outline which, though possibly not unaltered, is recognizable with the micro- scope, furnish the best test which exists for blood in minute quantity. Small quantities, even, can be discerned by the unassisted but practised eye, as a brown line which the corpuscles present at the bottom of a slowly tilted vessel. The corpuscles may be abundantly evident, while the albumin is inappreciable. Similarly, the color of blood in urine is strongly marked, and is associated with an amount of albumin, suppos- ing the albumin to be only that belonging to the blood, which often falls short of the expectation Avhich the depth of color has raised. It is not necessary to refer to the spectroscope' as a test for ordinary blood in urine, since other means of examination are more easy and more accurate; it has been used with haemoglobinuria to declare its an- alogy with common urinary ha3morrhage or indicate minute points of difference. The results are not very conclusive. The guaiacum test has its uses, the chief of which is the detection, not so much of blood in its entirety, as of the crystalloids, the transuda- tion of which into the urine may precede or stop short of actual haemor- rhage or even of albuminuria. Dr. Mahomed ^ connects the guaiacum reaction with increased arterial tension, and relies upon this test to de- fine a pre-albuminuric stage of albuminuria. If it should prove that this reaction is generally to be recognized before albumin, it would have a practical value which, perhaps, we are hardly yet warranted in assign- ing to it. It is at least evident that the guaicum reaction is more often afforded by albuminous urine, in which case it adds little to our know- ledge, than by non-albuminous. I examined 12 cases of each sort, taken by chance from among hospital patients. None of the non-albuminuric cases gave the reaction in question; it was found in 7 of the albuminu- ' See paper by Drs. Forrest and Finlayson, on " Spectroscopic Examination of Urine in Hsematinuria." Glasgow Med. Joum., 1879. Also the Spectroscope in Medicine, bj' Dr. McMunn. * " Tlie Etiology of Bright's Disease and the Pre-albuminuric Stage," by F. A. Mahomed. Med.-Chir. Trans., vol. Ivii. 318 H.EMATURIA, ric. The non-albnminuric class comprised several varieties of disease of the heart and vessels, pneumonia, bronchitis, pleurisy, asthma, and several forms of paralysis. The albuminuric series included acute and chronic nephritis, the granular and the lardaceous kidney, and albuminuria from cardiac congestion. The reaction was given in"o cases of acute and 4 of chronic disease. It was absent in tiie case of car- diac congestion, and in that of lardaceous disease. The test can scarcely have practical utility except when albumin is absent but expected. The forms of ha^maturia may be first considered in relation to the source of the blood — whether from the kidney, the bladder, or the ure- thra — and, secondly, if it be derived from the kidney or bladder, Avhether it be dependent on local or systemic disease. Blood from the kidney is, as a rule, uniformly mingled with the urine, which is as bloody at the beginning as at the end of micturition. Distinct or tangi- ble dots are exceptional as results of renal haemorrhage, though, in jiar- ticular when the kidney has been lacerated by violence, the urine may exhibit casts of the ureter in coagulum or small clots of indefinite shape. The sediment in general is a brown powder, which presents no shape ex- cept to the microscope. When separate clots are seen, the blood is usu- ally from the bladder, prostate, or outward passages; when they are of large size, it is invariably so. Thus the presence of considerable clots is nearly conclusive against renal hemorrhage, though the absence of clots proves nothing. Blood from the bladder is most abundantly passed at the end of micturition; the first urine may be natural in appearance, the last a mere collection of sanies and clot. Outside the body vesical blood is less intimately mixed with the urine than renal, and preserves a more sanguineous appearance. Blood from the urethra, which has lit- tle importance medically, is, or at least may be, discharged separately from the urine and independently of micturition. These leading dis- tinctions will be assisted by such evidence of renal disease as is afforded by the existence of albumin disproportionately to the blood, or by the presence of blood-casts which may possibly indicate the exact source of the haemorrhage. The vesical or prostatic origin of the blood may be warranted by the urine being ammoniacal, by its depositing triple phos- phatic and tenacious mucus along with the blood, and not least conclu- sively by its displaying " cancer " cells, or cells of the epithelioid type in such abundance as to indicate a growth. " Cancer " cells often come from the bladder, but almost never from the kidney, the growths in which are commonly sarcomas, the cells of which are not shed whole and abundantly as those of carcinoma are apt to be, but come away, if at all, impalpably. I have dwelt chiefly upon the distinctions which may avail when more obvious signs of the nature of the disease are wanting. It may be that local or constitutional symptoms point so unequivocally to one organ that there is no room for speculation. The evidences of acute nephritis, of renal tumor, of stone, intermittent haematuria, purpura, or scurvy may be beyond doubt. Dropsy may be equivocal — either a result of haemorrhage or a sign of renal disease. In a doubtful case it is well to look narrowly for *' bladder symptoms " — vesical tenderness, pain in the bladder or penis, frequency of micturition, or pain after it. The chief varieties of hematuria may be stated in a tabular form, with further reference only to those points of difference and to such cir- cumstances as call for separate mention. im HEMATURIA. 31» From conditions of the kidneys. From conditions of tlie bladder, pro- state, and uri- nary passages. Of uncertain or va- rious seat, or common to sev- eral positions. Dependent on Conditions of the Urinary Organs. { Injuries — bruises and lacerations. Albuminuric changes of any kind, especially nephritis. I Associated with the albuminuria of pneumonia, cholera, and the specific fevers. I Congestion from heart-disease or other mechanical causes. Embolism. Renal pya?mia. Renal disseminated suppuration (surgical kidney), j Tubercle. I Villus. Malignant growths — sarcoma, carcinoma. I Stone. [Strongylus. f Injuries, surgical or accidental, of bladder. Stone. Tubercle. Growths, chiefly carcinoma, papilloma, or villus. V^aricosity or local change in mucous membrane, naeviis. Simple congestion. Cystitis from any cause — gout, paralysis, febrile prostration,, etc. Enlargement or disease of the prostate. [Stricture or inflammation of urethra or use of instruments. ' Simple hsematuria (?). Hagmaturia caused by mental emotion (?). " " " bodily exertion. " " " sexual excess. " vicarious of menstruation (?). " " of haemorrhoidal flux (?). •' due to action of irritant poisons, cantharides, etc. " hydatids. " " bilharzia. " " chyluria (blood in this case probably de- rived from bladder). Dependent on General Cdnditions. f Haemophilia . Scurvy. Purpura. Haamorrhagic condition, sometimes associated with fevers- Associated with -j small-pox, typhus, etc' Relapsing fever. Remittent fever. Ague. [ Intermittent haematuria or haemoglobinuria. Bleeding from the kidney tubes ina}^ occur in connection with any disease of the secreting tissue which gives rise to albuminuria. It is most severe and continued with nephritis, especially from cold. This bleeding, though not of bad omen as regards the result, is often profuse and obstinate; the urine may be nearly black with blood for weeks, and the loss such as much to aggravate the anaemia proper to the disease. But the symptom need not greatly modify the treatment otherwise called for, or give rise to much anxiety. I think, indeed, that with free ' These conditions are commonly associated with nephritis, and appear also in another part of the table. 320 HEMATURIA. bleeding lasting disease is less apt to ensue than "when there is none. The astringent salts of iron are of use, and may be associated with sulphate of magnesia or sulphate of potash, so as to relieve local congestion, and insure free action of the bowels. Haemorrhage sometimes occurs, occa- sionally rather than continuously, with the granular kidney, and is probably a result of intercurrent attacks of nephritis. With lardaceous disease bleeding is less frequent and less profuse. Albuminuric hsemor- rhage is generally easily recognized by the casts which accompany the blood; these will probably contain blood-corpuscles, or will at least dis- play the brown color of blood if not its distinguishing forms. Haemor- rhage of similar origin is sometimes a result of the congestion of heart disease, though in this case it is less persistent. Blood is sometimes found in the urine with all the specific fevers, the more often with the more severe. The hemorrhage is generally renal in origin, and due to inflammation of the kidney or congestion akin to it; occasionally it de- pends on the condition of Idood rather than of structures, and then may proceed either from the kidney or the mucous surfaces. Enough has been said with regard to the nephritis of scarlatina, measles, and erysip- elas, and the hsematuria which so often attends it. Typhus may be similarly accompanied, the kidneys presenting, after death, the appear- ances of acute nephritis. Together with albumin epithelial and blood- casts may have been found in the urine, and even blood in conspicuous amount, the latter addition being, according to Dr. Murchison,' a dan- gerous sign, connected possibly with a state of blood as well as of kidney. The same evidences of renal inflammation are associated, though less frequently, with typhoid, copious haematuria having been met with for the most part in conjunction with other haimorrhages.^ A similar asso- ciation is sometimes, though fortunately not often, seen with small-pox. Often as the urine is albuminous Avith this disease, it is seldom bloody, though it is apt to be so in the malignant form, in which haemorrhages occur from the mucous surfaces and in other situations. Another source of haematuria, as the result of typhus, and possibly also in connection with other fevers, is to be found in cystitis, the result of neglected retention." With yellow fever, as with other specific ' and contagious fevers, al- bumin casts and blood have been found in the urine, apparently in con- nection with associated nephritis. Kelapsing fever is an occasional cause of copious hsematuria. Dr. Murchison" observed the urine to be largely bloody, and to contain albumin and blood-casts, in both paroxysms of this disease, while during the interval it was free from even a trace of albumin. Connected with renal inflammation, though often transient, some- times coincident with a similar condition of the pelvis or some other part of the urinary mucous membrane, is the htematuria of irri- tant poisons, represented by cantharides and turpentine. Bleeding of this origin is apt to occur together with much vesical irritation. It is not necessary to add to what has been said in connection with toxic al- buminuria and abscess from cantharides. ' Treatise on Continued Fevers, 2d edit., p. 156. ^ Ibid., p. 533. ^ Ibid., p. 212. ■» Article on " Yellow Fever," by J. D. Macdonald, M.D. Reynolds' System of Medicine, ed. i., vol. i., p. 669. ^Treatise on Continued Fevers, p. 369. HEMATURIA. 321 Blood in the urine often marks the impaction of an embolic block in the kidney, but neither in this case is it of long continuance. The renal haemorrhages of the greatest practical importance (putting aside for the present that of intermittent hematuria or hsemoglobinuria, which, though renal in source, is not so in cause) are those which belong to stone and tumor. The means of distinguishing tiiem have been de- tailed under the heading of stone (page 1G3). The influence of rest in stopping bleeding from stone supplies the most useful guide. The bleeding from stone is less profuse and more transient than that from tumor, though sometimes, when rest is not attainable, it is such as to cause pallor and call for iron. I may here mention two observations with regard to the bleeding of stone, which have not found place else- where. Though it be brought on by movement, it does not always ensue immediately, but an interval of a day or more may possibly elapse. It will sometimes follow the free use of alcohol ; I have known it to do so with such constancy that an attack could be brought on at option with beer. Growths to bleed must ulcerate into the pelvis. They then cause hemorrhage which is more profuse, persistent, and unmanageable than that from any other cause in which the kidney is concerned ; neverthe- less, it occasionally happens that the discharge will intermit or come to an end spontaneously, or apparently give way to the last remedy. I have seen remission more often sequent upon iron alum or tannate of iron than from ergot or any other styptics. Ergot is of more use with the vessels of a normal structure than with those of a growth. The great thin veins of such sarcomata as belong to the kidney probably have little contractile power. No casts are to be found in blood of this source, but only blood-corpuscles, with perhaps some amorphous powdery sedi- ment. Cancer cells, or morbid cells of any kind, are conspicuously ab- sent ; unlike what occurs when the disease is in the bladder, when they are often abundantly present. The ha?maturia of haemophilia appears to be of renal origin, if pre- ceding pain in the back is to be taken in evidence, and is probably due to some such attenuation of the renal blood-vessels as has been observed in other parts. Whether casts appear in these circumstances, or in what guise the blood presents itself, I have never had an opportunity of ascer- taining. There is at least one instance on record in which this mani- festation of the haimorrhagic diathesis has caused death.' Diseases of the bladder and prostate yield blood to the urine perhaps less persistently, but on occasion more profusely, than to those of the kidney. I think the largest amount of blood I ever knew to be discharged with the urine was in the case of a gentleman whom I saw at Manchester with Dr. Lloyd Roberts, whose bladder, as was ascertained jifter death, was the seat of a ragjied cancerous growth of little thickness, and about two and a half inches in diaiiit-- ter. This gentleman began to pass blood with the water in occasional small quantities, without pain, frequency, or discomfort, rather more than five years before his death. After two and a half years of this he had a sudden profuse haemorrhage, which was followed by retention of urine and much vesical distress, with pain in the penis and perineum. Dr. Roberts passed a catheter, and broke up and evacuated with immediate relief a quantity of coagulum with which the bladaer was filled. At a later epoch a recurrence of similar symptoms made it necessary to repeat this operation. After the first profuse hajmorrhage the at- ' In the case of a boy eight j-ears old, quoted from Grandidier by Dr. Wick- ham Legg. Treatise on Htcinopliilia, p. 5;>. 21 322 H^MATUKIA. tacks were repeated every two or three months — being brought on sometimes by an effort, such as lifting, coming on sometimes insidiously in the night, the pa- tient waking to relieve the bladder, but passing only blood, or what looked like it. The blood was often passed, apparently unmixed, after the urine, which itself had presented a perfectly natural appearance. During tlie attacks there was much vesical irritation, in the intervals none. For the last year the bleeding was nearly continuous. When I visited him two months before his death everj'^ vessel in his bedroom was full of blood or blood-like fluid, with large clots at the bottom of each. The patient described graphically the trouble he liad in expei- Ung these, which were often six inches long, and were shot out only after much straining. Some were so bulky, indeed, that it was difficult to believe that they had passed through the urethra. He was blanched, emaciated, and prostrate, as after such loss of blood he could not fail to be. Under the tannates of iron and alumina, gallic acid and pei'chloride of iron, together with the rest in bed which was now inevitable, the bleeding finally ceased, leaving the urine clear, albumin- ous, and with a plentiful deposit of epithelioid cells, which were presumed to have come from the bladder, but could scarcely have come from it in such abundance but as the results of a morbid epithelial growth. These were of large size, round, pear-shaped, and irregularly elongated and tailed. Without further bleeding the patient gradually sank, death being due rather to the constitutional than to the local consequences of the disease. Such hsemorrhage from any cause is exceptional : from cancer of the bladder it is often scanty, and for long periods absent. As a rule, the bleeding of villous growths which may not be malignant is more profuse, and may be directly fatal, which that of cancer seldom is. Large quan- tities of blood, scarcely changed by the urine, and containing large clots which have formed in the bladder, and often been expelled tlience with difficulty, issue as the result of this condition. Hare as villus is in the kidney, it is common in the bladder. It is readily identified by the find- ing with the microscope of loojjs and filaments of vascular structure often entangled in coagulum. These should be looked for, repeatedly if ne- cessary, in a case of profuse vesical hemorrhage. Villus is almost always of the bladder, though this formation has been known to be associated with solid malignant growths in this situation or in the kidney. Such a concurrence is too rare to form an exception of any practical import- ance to the rule that villus is innocent. And it may be added that it is very amenable to astringents, especially if locally applied. A fat man of 50 was under my care in St. George's Hospital in the year 1867 with profuse hsematuria, vesical in character; the blood was accompanied with large clots, which were expelled, however, without much diflSculty ; and large epithelial cells, such as might have come from the bladder, were found with the microscope. The haematuria was constantly present for rather more than a month, at the end of which he was anaemic to the last degree and oedematous. After one injection of the tincture of perchloride of iron (two drachms to eight ounces of water) the bleeding abruptly stopped, the next urine being free from blood. The heemorrhage reappeared for one day three weeks afterwards, but with this exception remained absent. The patient rapidly regained the ap- pearance and sensation of robust health, and then went his way. Seven years afterwards he had a recurrence of the same symptoms, came again into the hos- pital, was treated again with the perchloride with the same result as regarded the haemorrhage, save that one or two small coagula could still be seen in the urine. But the urine was now albuminous independently of blood, and he died in coma, the result of concurrent kidney disease. A papillomatous growth, which might equally well have been described as villus, was found in the bladder. The readiness of villous growths to be detached gives capriciousness to their course, and adds complication to their symptoms. Portions, or even the whole will sometimes break away, and leave the patient thus cured, or at least completely relieved. A gentleman who suffered from. lI.EMATURIA. 323 an issue of blood of this nature, became the subject of a medical consul- tation. ' During this he had an urgent call to pass water, and discharged in response to it a quantity of nearly pure blood, and with it the villous growth, in regard to which he had sought advice. The riddance seemed complete, and with it the cure; but in ten years the disease returned, aud ended fatally. A brother of this gentleman died of the same disease. I have known a portion of a villous growth to become detached, but re- main in the bladder to become incrusted with phosphates, and set up in- dependently as a stone. I need not dwell upon the forms of vesical haemorrhage which more often come under the notice of the surgeon: those connected with stone and with enlarged prostate are the most common. That from stone is small and repeated rather than profuse; it is often only microscopic in amount. Its obvious dependence upon bodily movement is enough to distinguish the hiemorrhage belonging to stone in the bladder from that due to any other affection save stone in the kidney; and with this it can scarcely be confounded. Enlarged prostate gives rise to more profuse bleeding than any other vesical affection, putting aside morbid growths; large quantities of dark blood, which, as far as I have seen, has less tendency to clot than that derived from cancer or villus, are thrown out from this source in separate outbreaks rather than continuously. The bulk of the blood passes from the bladder with the urine; a few drops usually alone after the bladder is empty. Bleeding of this origin is usually associated with the other concomitants of prostatic disease — ad- vancing age, frequency of micturition, pressure on the rectum — which will be sufficiently significant of its source. I need not dwell upon the treatment of this form of hemorrhage: sulphate of magnesia and other saline purgatives will relieve the congestion on which it depends; ergot may be used with advantage, and ice introduced into the rectum should other measures fail. Among the rarer causes of hfematuria may be mentioned vesical naevus. A child,'' with a malformed bladder and a large "mother's mark " on the pubes, passed blood in its urine. It died eight days after birth, and a number of prominences of vascular tissue like that of a naevus were found upon the vesical mucous membrane. I have lately seen a case presumably of this nature. A gentleman of the age of 38, apparently in robust health, has had, since the age of 16, three or four at- tacks of haematuria a year; the bleeding commonly presented itself with three or four micturitions, and then completely ceased until next time, the urine in the intervals being perfectly natural. The urine which came under my notice, in a fit of unusual severity, in which large clots had been expelled, looked like pure blood; numbers of large spheroidal nucleated cells were seen with the micro- scope, such as might have come from the bladder. There was some uneasiness and tenderness in the vesical region, and a small quantity of blood, unmixed with urine, had often been noticed to leak from the urethra with straining at stool. The bleeding was never brought on, or increased, by even violent exercise. This gentleman has five children, four of whom have external naevi, and it is to be presumed that he has a formation of the same nature in connection with the blad- der or prostate. The bleeding has hitherto stopped spontaneously, or under the influence of styptics, chiefly ergot, by the mouth. The injection of the perchlor- ide is, perhaps, in the future. ' The consultants were Sir W. Gull and Sir Prescott Hewett; the latter my informant. ^ Reported by Mr. T. Holmes, Path. Trans., vol. xvi., St. George's Hospital Museum, series xii., prep. 115. 324 i;.EMATL-KlA. Iltematuria, like most otlier haemorrhages, has been thought to be vi- carious of menstruation, and on doubtful evidence. It has, at least, never been my fortune to trace the urinary flux to this cause. And whether such bleeding is ever vicarious to that of piles may be also taken into question. Tlie bleeding of piles is related to that from the stomach and bowels by a common origin in cirrhosis, and a common source in the portal vein; but the vascular circumstances of the kidney are different, and the connection of renal hemorrhage with that of 2)iles at least remote. A discharge of blood with the urine has been said to supersede asthma and to be caused by mental emotion; of the first I have no ex- perience; with regard to the second, I may mention the case of a skilled medical observer, now in his fifth decade, who attributes the recurrence of small urinary hemorrhage in his own person to excitement or men- tal tension. For twenty-three years he has been liable to occasional bleedings of this sort, about eight attacks in a year at most. These were noticed as occurring with especial frequency after lecturing; in the year of their greatest frequency five of the eight took place immediately upon the conclusion of this effort. It seemed probable, from the char- acter of the hemorrhage, that it was prostatic or vesical. Purpura and scurvy are causes of hematuria, which are generally made clear by the concomitant symptoms. With purpura, blood is often liberally extravasated into tlie renal tissues. I have traced it in cylin- ders, and otherwise between the convoluted tubes, and in the areolar tis- sue, especially that part of it wliich surrounds the pelvis. Blood is sometimes to be traced in such close connection with the pelvic mucous membrane as to suggest that this must have given issue to the discharge, and probably the vesical membrane also may sometimes give exit to it. I have found blood also in the renal tubes and blood-casts in the urine, so that the hemorrhage may present all the characters indicative of its renal origin. The extravasated blood is corpuscular, as a rule, though it is said that, in cases of exceptional severity, both of purjnira and scurvy, it has appeared in the dissolved state to Avhich the term hemoglobinuria has been given. Of this I have had no experience. It may be added, to complete in this place as miich as need be said of renal purpura, that beyond the appearance of blood in the urine, there are usually no symp- toms to point to the local change. A marked example under my ob- servation was in a case of general purpuric extravasation connected with jaundice and obstruction of the common hepatic duct by hydatids. The kidney was deeply yellow and liberally dotted with interstitial ecchy- moses. It is not necessary to particularize the treatment needful for purpuric hematuria, which is that of the primary disorder. Infants who are brought up by hand, especially when milk has been withheld or insufficiently given, are liable, at about the time of teething, to a form of hematuria which cannot be described as otherwise than scorbutic, though the superficial ecchymoses may be slight or even absent, and there be no discharge of blood save with the urine. I have lately been consulted in five such cases, and made aware of a sixth. The children varied in age when attacked from 4i- to 11 months. In all the diet had been conspicuously wanting in fresh milk; the substitutes whicii were employed will be presently indicated. The urine in every case had a full sanguineous color, remained so for many weeks, and ceased to be so under the influence chiefly of milk. The blood in each case was cor- puscular; the urine not albuminoiis, save in one instance, beyond what H^MATUKIA. o'JO was apparently due to the Wood; casts were found in three cases, while in the otliers hirge epithelial cells, with more or less mucus or pus, sug- gested that the blood proceeded from the urinary surface rather than from the kidney substance. The circumstances of these cases, the presence or absence of super- ficial haemorrhages and of changes in the gums, would permit some to be described as simple hannaturia, others as purpura, others as scurvy. It is clear that all were of the same nature, however restricted the symp- toms, and akin rather to scurvy than any other condition. Tiiey suffi- ciently show that Nestle's food and Swiss milk are not to be regarded as substitutes for fresh milk in the process of bringing up by lumd, though as an addition to fresh milk and water Swiss milk can often be advan- tageously used. To allege the occurrence of simple hoematuria, of hematuria unac- companied by any alteration in blood or tissue, is almost to assert the existence of an elfect without a cause. But, nevertlieless, it is matter of experience that the urine will sometimes become bloody, slightly or pro- fusely, and will so remain for a longer or shorter time, and then will cease to be so without our being able to obtain any clue as to the cause, either of the disorder or its cessation. Sometimes such Inemorrhage may be small and transient and apparently connected with some general liability to hemorrhage, as shown by the frequency of slight nose-bleed- ings. In other instances profuse and even dangerous hgematuria has come and gone thus inexplicably. I could mention cases in which free and protracted haemorrhage with the urine has thus come and gone without declaring its nature, either by its characters or its sequelae. Such haematuria, however, is not to be called simple but obscure. A non-malignant bleeding growth is the ex- planation which usually commends itself. Malaria is a fruitful source of hajmorrhage. Whatever processes con- tribute to the extravasation, there is at least one agency, the results of which are simple and obvious, the driving of the blood out of vessels temporarily constricted into others that are not so. If it be that some burst or leak, it is only what is to be expected.' The liver has been found studded with clots of extravasation, the stomacii and bov/els with ecchymoses; extravasations have been found within and upon the walls of the heart, and in connection with the brain and the retina. An amputated stump has been known to bleed periodically under the influence, as was thought, of a previously contracted ague, and to cease to do so under that of quinine.' The association of bloody urine with malaria has long excited notice. Prout regarded this influence as predisposing to urinary hajmorrhage rather than directly inducing it, enhancing the effect of stones and bleed- ing structures, and making profuse what might otherwise be a slight dis- charge. The occurrence of haemorrhage from the kidney during an ague fit is a matter of old, though not frequent, experience. The void- ing of bloody urine, after pain in the loins, at the neck of the bladder, and in the gians, was common with the severe intermittents which gave so large a mortality to the Walcheren^ expedition. I have elsewhere re- ' Retinal Hcemorrhages and Melancemia as symptoms of Ague, by Stephen Mackenzie, M.D. ' Intermittent Hcemorrhage from Malarial Influence, by Surgeon-Major Porter. Med.-Chir. Trans., vol. lix. ^ Dr. J. B. Davis on the Walcheren Fever, p. 37. 326 HEMATURIA. ferrod to the experience of Dr. Elliotsoii upon this point, and tliere Avould be no difficulty in adducing tliat of other observers to the effect that mahirial fevers, whetlier of the intermittent or remittent type, are occasionally productive of this haemorrhage.' A form of malarial hema- turia, after death from which blood is found in the kidney tubes, has been described by Dr. Joseph Jones, of New Orleans, as resembling yellow fever, but distinct from it;^ and we have testimony from Mauri- tius of a "paludal fever "^ which appears to be irregularly periodic, in which the stage of rigor is regularly followed by renal haemorrhage. The attack is accompanied by either a general condition of jaundice, involving the eyes and skin, or else extensive subcutaneous and submucous haemor- rhages of a purpuric character. We are not told whether the blood in the urine in these cases is corj^uscular or disintegrated; but the deficiency is supplied by a case of fatal malarial fever contracted in Minorca, in which the symptoms, inclusive of the subcutaneous haemorrhages and the yellowness of skin, indicate a similar condition. In this instance the urine was loaded with blood which was entirely disintegrated and in all respects characteristic of hgemoglobinuria the malarial origin of which is in question. Such cases, where definite malarial disease is accomj^anied by the typ- ically disintegrated urine, form an inseparable link between the he- maturia of ague and the variously named intermittent hematuria, the recognition and the definition of which depend on the pulverization of the blood-discs. The analogy between the attacks of this affection and of ordinary ague is sufficiently obvious. It is beyond question, as has been shown in another part of this volume (page 276), that a significant proportion of those who suffer from this form of hematuria have either had ague or been notoriously exposed to the malarial influence. The point of inseparability between the two diseases appears to lie between ordinary ague, every recurring fit of which is accompanied by hematuria, and intermittent hematuria, the fits of which recur with regular periodic- it}". If it should prove, as I suspect it will, that the blood passed with ague is generally disintegrated, as in the case which has been cited, then it must be inferred that intermittent hematuria is but a variety of malarial fever. The solution of blood-corpuscles in the body and the exit with the urine of the coloring matter together with albumin is not peculiar to in- termittent hematuria, though charactistic of it; a lesser amount of blood-pigment together with albumin has been found in the urine with various states of septicemia and blood-poisoning, which have been suf- ficiently referred to. It would appear that any of the numerous agencies which tend to dissoh'e or disintegrate the blood Avithin the body may give rise to more or less of this condition. The treatment of hematuria generally resolves itself into that of the diseases on which it depends. When from stone, absolute rest is of the first importance; when from growths, active movement should be avoided, ' See p. 1178. Also Herz on Malarial Diseases, Zieinsseii's Cyclopcedia, vol. ii. p. 641. 'See the New Orleans Med. and Surg. Journ. for February, 1878. "Observa- tions on Malarial Haematuria," by Dr. Joseph Jones, quoted in Lancet for April 20th, 1878, p. 595. ^ "On the treatment of a severe form of Paludal Fever, with Icterus and Renal Haemorrhage," bv J. Labonte, Port Louis. Mauritius. Edin. Med. Journ., May, 1876, p. 1006. HEMATURIA. 327 though rest in bed is attended with little advantage. The kidney is not to be reached by cold superficially applied, or to be directly depleted from the loins; it may be influenced by styptics taken by the mouth, iron alum, tannate of alumina, gallic acid, acetate of lead, Avitch-hazel, and ergot, or by the last of these introduced hypodermically. Local congestion may be lessened by saline purgatives — sulphate of magnesia, perhaps the best for the purpose. This may be given, as a general rule, when the bleeding depends either on albuminuric disease or renal or prostate congestion. Ice, though useless upon the loins, may be of service in the rectum when the bleeding is from the prostate or bladder. For malarial and intermittent ha?maturia, quinine in large doses and long continued is the remedy, often usefully associated with the astrin- gent salts of iron. I need not add to what has been already said as to the necessity of fresh milk with the scorbutic ha?maturia of infants. CHAPTER XXIV. SUPPEESSION OF URIXE. Though suppression of urine as a symptom of renal disease has been referred to in various parts of this work, it ma}' be convenient to phice in juxtaposition the several disorders upon which it ensues, and the circumstances which attend the occurrence. Suppression of urine may be conveniently considered as of two kinds: first, renal suppression, depending on disease of the kidney or of the urinary or vascular channels in immediate connection Avith it; secondly, systemic suppression, in which the gland, though natural in structure, ceases to act in consequence of an intiuence external to itself, which in- volves the whole system in its morbid ojjeration. Rexal Suppression. There are many conditions of kidney which are attended with par- tial suppression of urine; others in which the absence of urine is com- plete. As a rule, partial suppression depends upon disease of the secret- ing structure; total suppression upon a mechanical obstruction in the renal outlet. Partial suppression, or in other words extreme scantiness of urine, sometimes results, as described elsewhere, from disease of the secreting sub- stance of the kidney. With tubal nephritis especially the diminution is sometimes extreme. There is a rapidly fatal form of the disease, consequent upon scarlatina, in which the tubes become early and all at once filled with a fibrinous exudation. The urine is usually free from blood, of a deep yellow color and high specific gravity; it is generally loaded with albu- min, though cases have been known in which under these circumstances albumin has been totally absent; and it abounds with strongly-defined fibrinous casts. This form of scarlatinal nephritis is illustrated in the case of Vallance. His minimum of urine in the twenty-four hours was 45 centimetres, or about an ounce and a half. Sometimes in similar cases the secretion is even more scanty, falling to a few drachms in the day, while less than an ounce daily is passed for several days to- gether. Such cases are usually fatal by way of ura^mic disturbance of the brain, though it may happen that this result is anticipated by one of the forms of acute inflammation, to which children with nephritis are especially liable. The urine may also be remarkably diminished in that highly con- gestive nephritis Avhicli cold sometimes produces in grown persons. Under this condition the urine is always loaded with albumin, and of high specific gravity. It is generally l»lack with blood and full of thick casts. The case of Benjamin Patrick, in which on one occasion SUPPRESSION OF UKINE. 329 only two ounces of urine were voided in the twenty-four hours, may serve as an example of this affection, while a still more striking in- stance is afforded in that of Lord Z 's groom, who passed during the last five days of the disease only three and a half ounces of urine, the quantity for one day and night having fallen as low as five drachms.' This affection, like the scarlatinal form, is rapidly fatal, and as a rule by cerebral urajniia. Such affections of the kidney, much as they may lessen the production of urine, rarely cause total suppression, but it is worth remarking that though the suppression is but partial, death often ensues in shorter time than where as a consequence of me- chanical obstruction the suppression is absolute. Towards the close of granular degeneration the urine may fall considerably below the habitual amount, and may even on the approach of death be absent for many hours. In an advanced stage of lardaceous disease the urine, once super- abundant, may become very scanty; but there is seldom such diminution as has been recorded with other forms of albuminuria. Suppression, for the most part partial, but occasionally total for a short time, may occur when the kidney is the seat of suppuration, whether this be of the limited sort, which is occasionally produced by an extenuil injury, or be disseminated as the result of pyi'emia or of septic urinous absorption. A remarkable instance of disseminated renal sup- puration consequent on scarlatina is related by Dr. Bates,- of New York, in Avhich for the nine days preceding death the total of urine secreted did not amount to half an ounce. An instance of transitory suppression in connection with a traumatic abscess of tlie kidney is given from Rayer at page 2. The urine was absent during one day, the secretion reappearing on the following with the admixture of pus. Suppression in connection with renal pytemia is exemplified in the case of AVil- liam Long, The outset of the pyasmic affection in the kidney was marked by a suspension of micturition for forty-eight hours; at the end of this period five ounces of urine were removed with the catheter, so that the suppression was then only partial. The urine when obtained, and for the rest of the patient's life, was very deeply colored and albu- minous. Blood and pus corpuscles and cells of renal epithelium were seen both scattered and entangled in fibrinous casts. Those cases of renal abscess in which the suppression, though usually incomplete, may for a short time be total, lead us from partial suppres- sion or extreme scantiness of urine to the circumstances in which sup- pression is complete or the secretion totally absent. As a corollary to the suppression of the disseminated suppuration of local origin may be placed the fact that occasionally after catheteriza- tion and operations upon the urethra, the urine has become suppressed and the kidneys have been found intensely congested. It is probable that this condition is but the early stage of the suppurative process, which has been sufficiently dwelt upon, Xephrectomy, ovariotomy, and other operations involving the abdominal and pelvic organs, have been followed by suppression apparently of a different kind, Mr. Godlee * removed by abdominal section a kidney which was the subject of calcu- See case of scarlatinal nephritis reported by Dr. Roberts in the Lancet, 1868» p. 655. '' Med. Record, Oct. UJtli, 1880, p. 431. ^ Clin. Trans., vol. xv., p. 13-1. 330 8DPPRES8ION OF URINE. Ions pyelitis (p. 189). The patient survived the operation for twent}-^- four hours, for the hist twelve of which only an ounce and a half of urine was secreted. The preceding urine was black with carbolic acid absorbed during the operation. The remaining kidney presented a nor- mal appearance to the naked eye, and practically so to the microscope. Mr. Howard Marsh ' (p. 190) removed in })art, tlirough the loin, a sac- culated kidney. Complete suppression of urine followed the operation, and death at the end of thirty hours. The remaining kidney was ''fairly healthy.'^ The capsule Avas adherent, and there were two or three small cysts on the surface, but tliere was nothing to indicate advanced disease. Much temporary diminution of urine has been known to follow ovariot- omy, as in a case recorded by Mr. Thornton.^ How the suppression is produced in the circumstances which have been adverted to is not very clear. It is not from any visible change in the kidney itself. It must be taken into question whether it is to be hypothetically attributed to an inhibiting nervous influence, or, what is more consistent with other ex- perience, to the collapse produced by the operation, or the general fail- ure of function which may precede death. The most striking cases are those which have been described as ob- structive, the suppression being due to a substantial barrier between the mammillary processes and the bladder. Putting aside the rare occurrence of arterial obstruction, and the ob- vious systemic causes of suppression — collapse, intestinal stoppage, cholera, and poison — it is at least of exceeding infrequency to find the secretion of urine arrested for forty-eight hours, and that totally, except there be a palpable obstacle. And where this exists it is due in nine cases out of ten to stone. It is only needful here to recapitulate the general character of the affection and to describe the causes, uncon- nected with stone, to Avhich it may be due. When mechanical ob- struction produces suppression, either both kidneys are simultaneously obstructed, or else, wliat more often happens, the obstructed kidney is the only source of urine, the other having been incapacitated by pre- vious disease. Calculi, for example, may be symmetrically disposed in the two kid- neys; or, on the other hand, one kidney having been sacculated or atro- phied by a past fit of stone, the ureter belonging to the other may be- come occluded by a similar impediment and a total stoppage ensue. Ex- amples of both these occurrences have been related. Suppression of urine may be due to simultaneous sacculation of both kidneys — double hydronephrosis, as it is called — whether due to calculi or to congenital or other obstruction; and it may be produced by morbii growths, which are so circumstanced as to press at the same time upon both ureters. A case of double hydronephrosis has been quoted in which suppression, for the most part incomplete, was succeeded by copious dis- charges of urine and coincident diminution of an elastic lumbar swell- ing. Renal tumefaction lessening suddenly Avith increase of urine may be regarded as characteristic of the affection. The bowels in the same case were obstinately confined, in consequence, as was found, of com- pression of the descending colon by the cyst representing the left kid- ney. From the apposition of the colon and the kidney intestinal 'i7nvy., p. 140. ' Ibid., p. 144. fl SUPPRESSION OF URINE. 331 obstruction may often be suggestive of renal enlargement. These circumstances, together with other evidences of renal tumor, will suffice to distinguish hydronephrosis as a cause of suppression from the other conditions to which the arrest may be due. A further presumption of hydronephrosis in a case of suppression may be found in the recurrence of urinous sweating. Suppression of urine from obstruction, unaccom- panied Avith dilatation of the kidney or vesical retention, does not give rise to this symptom, which, on the contrary, is sometimes strongly marked with hydronephrosis. Urinous exhalations from the skin are generally associated with the accumulation and resorption of urine. It is scai'cely necessary to repeat that to produce suppression hydronephro- sis must exist on both sides, or if it be confined to one, the ureter of the healthy kidney must be obstructed by some other means. Lastly, suppression may result from the consentaneous obstruction of both ureters by a morbid growth. Growths which produce this effect are usually cancerous, and arise in connection, not with the kidney or ureter, but with one or other of the pelvic viscera which occupies the median line. Tumors which originate in the kidney or ureter are usually confined to one side, leaving the gland on the other free to act. When both ducts are occluded the disease has commonly arisen external to and between them in connection either with the bladder or prostate, or with the uterus or vagina. Growths in connection with these organs are apt to start nearly equidistant from the ureter, and, spreading to the right and left, to involve both simultaneously or in succession. Less often both ureters have been known to have become occluded by growths which have begun in the ovary. Suppression of urine may be produced by disease of the bladder itself. A woman died in the obstetrical ward at St. George's Hospital after suppression of urine which was complete, as far as was known, for ten days, excepting that on the sixth day she fancied she passed a little in a bath. It was found that the bladder was the seat of extensive encepha- loid growth by Avhich the orifices of both ureters were obstructed. The growth was primary to the bladder. In cases of suppression from growths the symptoms of the primary disease are usually obvious. Growths cause suppression far less often than calculi. The symptoms of obstructive suppression, putting aside those which are due to the special cause, are much the same whatever be the nature of the obstruction. They have been described in connection with calculi. The urine, if any be passed — and generally some is passed at irregular intervals — is pale, watery, of low specific gravity, and want- ing in urea. The watery character of the urine under these circumstances, with its low specific gravity and want of color, are, as has been shown by Dr. Roberts,' important indications that the secretion has taken place against adverse pressure. In the normal dynamic state of the renal apparatus pressure exists within the blood-vessels, but none in the tubes. This difference of pressure upon the two sides of the membrane between the blood and the urine is, as has been shown by experiment, a condition es- sential to secretion. It has been shown in animals that when the renal artery is narrowed by means of a clamp, so as to lessen the blood-j)res- ' " Paper on Obstructive Suppression of Urine," Manchester Med. and Surg. Beports, vol. i., p. 2:«. 332 SUPPRESSION OF URINE. suro in the kidney, the nrine is diminished ; while conversely a similar result follows when the nrine is made to exert pressure backwards. A column of mercury in the ureter causes the urine to be produced in di- minished quantity and with a diminished percentage of urea, the secre- tion becoming poorer and more scanty with each increase of pressure, and at last stopping altogether. Corresponding changes take place when the ureter is obstructed in the human being. The distention of the pelvis at first retards and then arrests the secretion. Any small quan- tities of nrine which the obstacle permits to escape during the process, having been secreted against pressure, are pale, watery, and deficient in urinary elements. The urine under the circumstances is sometimes, but not necessarily, albuminous. This depends upon the previous state of the kidney, and on the amount of congestion which the arrest of secre- tion has engendered. There is a total absence of dropsy, and unless urine be retained in a dilated kidney or elsewhere, there are no urinous exhalations from the skin or lungs. There is a progressive failure of strengtii, succeeded almost always by twitching of the voluntar}' muscles. The respiration becomes embarrassed and the action of the heart enfeebled. The digestive system is disturbed, as evinced by vomiting, loss of ap- petite, coating and subsequent dryness of the tongue. Sometimes thirst is complained of. The mind usually remains clear, or but slightly af- fected. Occasionally drowsiness, or want of sleep, or distressing rest- lessness supervenes. The pupils, towards the end, become contracted. Sometimes, but by no means constantly, epileptiform convulsion takes place, and more rarely death is preceded by coma. More frequently death takes place in a somewhat sudden manner, apparently from asthenia. Obstructive suppression alfects the heat of the body slightly but with some constancy. In five cases of which I have particulars before me, the highest recorded temperature was 100. U, the lowest 97.0. It is not unusual for there to be a slight febrile disturbance at the outset, indi- cated by the higher temperature : but as the condition continues the temperature usually becomes subnormal, as is the rule with uraemia, whatever its cause may be. Mr. Hutchinson's case of obstruction by cancer appears to be peculiar, insomuch that the temperature rose, instead of falling, as the results of suppression declared them- selves. The duration of cases ending fatally is very variable. Wliere the urine has, before the stoppage, escaped with difficulty and consequent impoverishment, death may occur after a few days only of total arrest. Dr. Eoberts fixes the ordinary duration of complete obstructive suppres- sion at from nine to eleven days. Cases are related in one of which total suppression lasted for twelve days, and in another suppression, total but for one interruption, lasted for twenty-two days. This last case, however, is very exceptional in its duration. In the great majority obstructive suppression proves fatal in the course of the second week. The passage of small quantities of such urine as has been described gives but little protraction. The rare occurrence of suppression of urine m connection with obstruction of the abdominal aorta or both renal arteries completes the enumeration of the circumstances especial to the kidney under which the secretion of urine may be arrested. A case is related by the late Dr. Todd in which suppression, nearly SUPPRESSION OF URINE. 333 complete for five days, accompanied the formation of a dissecting aneu- rism which involved the aorta and probably the renal arteries.' Some interesting illustrations of the effect of obstruction of the aorta upon the urine are given by Dr. Bristowe.'' In two instances, in which the abdominal aorta was suddenly obstructed by coaguluin belonging to aneurisms of this vessel, the uriue was at "^ first suppressed, then scanty, bloody, and highly albuminous. In one of these cases no urine was passed for twenty-four hours after the presumed date of the ob- struction, and then only three ounces, Avliich were albuminous to two- thirds, and contained casts and blood. The return of the secretion after its stoppage is probably due to the re-establishment of the circula- tion by the collateral channels which connect the upper and lower jjarts of the aorta. The kidneys were found in each case to be greatly con- gested, correspondingly with the evidences of nephritis which had been evinced during life. The hyperajmia, or inflammation, might have been partly explained in one instance by the jiresence of blocks, or infarcts, derived from the detached clot, which may have been sources of irrita- tion; but in the other case no such explanation was presented. It is to be observed that other structures in the territory of the obstructed ves- sels — the bladder and rectum for example — were likewise congested and ecchymosed. Thus congestion of some sort, probably venous and by re- flux, may be a late result of arterial stoppage. The congestion about fibrinous blocks is well known; and it is at least of interest to associate with these phenomena the nephritis which succeeds upon the suppres- sion of collapse. Systemic Suppression" of Uriis'e. Suspension of the renal function may occur in connection with cere- bral injury or concussion, or Avith a variety of other morbid conditions, of Avhicli it is to be noted that they are generally accompanied either by universal collapse or by unwonted discharges of fluid from some other exit, or by both these conditions conjointly. Concussion of the brain may be a cause of transient but total suppression. The suspension of nervous function, though chiefly relating to voluntary movements, is not confined to them, as is seen by the embarrassment of respiration sometimes present. The kidney, with its ])neumogastric communica- tions, is especially under the control of the brain, and its action is in- creased, altered, or suspended by cerebral causes. Suppression from concussion is necessarily transient, terminated shortly either by recovery or death. There are general states of system expressed by the terms prostration, collapse, and exhaustion, in which for a time the urine ceases to be formed. The renal is suspended in common with other functions, and is restored with them should reaction occur. The suspension is, in its nature, temporary, the secretion returning as the strength of the circulation is restored and the exhausted vessels are replenished. In some of the conditions in which the urine is thus absent, cholera and some forms of poisoning, at least two causes may l)e supposed to concur — failure of circulating force, with loss of circulating material. But we may consider first a simple relationship which exists, ^ Med.-Chir. Trans., vol. xxvii. 'Three cases of sudden obstruction of the abdominal aorta by aneurism, Lan- cet, 18151, vol. i., p. 133-166. 334- SUPPRESSION OF UKINE. quite independently of depletion or change of blood, between unmixed collapse and suspension of renal action. Suppression from this cause has been frequently observed in connection with perforations of the stomach, of the duodenum, of the jejunum, of the ileum, from typhoid fever or otherwise, and in connection with peneti-ation of the large in- testine. It has been known to folloAV laceration of the bile ducts. Un- der such circumstances death usually comes too rapidly to allow of any very protracted suppression, but it has been noted that as long a time as two days has passed without any secretion. After death it is usually found in these cases that the bladder is empty and contracted; and it Avould seem that not mere emptiness, but unnatural contraction of that organ, has in some instances existed during life, as painful straining, a falla- cious sense of distention, and a resistance to the catheter thought to be unusual, have been observed. The immediate cause of the symptoms in these cases is probably an influence upon the abdominal centres of the sympathetic through irri- tation of the peritoneum by the extruded matter. And it is known that other causes of collapse, acting possibly on other nervous territories, but equally unconnected with any material drain, may also be accompanied by suppression of urine. In collapse, upon whatever it ma}' depend, there appears to be a gen- eral contraction of the arterial system, the blood being driven thence to stagnate in the veins. The left ventricle is, as seen after death, con- tracted to the utmost, the arterial pulse everywhere fails, becoming fee- ble in the large arteries, and imperceptible in the smaller, while the skin is cold and cadaverous, giving in warmth and color no evidence of moving blood. The condition would seem to be one of hindrance in the vessels rather than failure at the heart — arterial closure, not cardiac weakness. The contracted and empty left ventricle, unlike the re- laxed and loaded cavity of asthenia, has done its duty. But the blood, probably from a kind of spasm affecting alike heart and arteries, does not circulate, the absence of circulation being, under these circumstances, more complete than with asthenia, is long compatible with life. With, the absence of circulation the derivatives of blood necessarily cease to be formed, and urine, like other secretions, is in abeyance. Suppression of urine may be produced by certain poisons, especially when their action is attended with collajjse. Corrosive sublimate has, more often than any other poison, been followed by this symptom, though the same result has been known to arise from the mineral acids, putrid animal matter, poisonous fungi, and occasionally from arsenic. With regard to corrosive sublimate, a poisonous dose of this substance produces a condition of collapse which resembles, as Mr. Sedgewick has shown,' that of cholera; the intestinal discharges are usually but not al- ways excessive, and the urine, often for several days, totally wanting. Taylor* relates the case of one John Wright, 38 years of age, who swallowed two drachms of corrosive sublimate, and an hour afterwards was received into Guy's Hospital. It would be easy to collect many other instances of poisoning by cor- rosive sublimate in which there has for many days been a total cessation ' Much information regarding toxic suppression of urine is given by Mr. Sedgewick in a valuable paper on some analogies of cholera. Med.-Chir. Trans., vol. li. p. 1. ^ Guy's Hospital Reports, 1844, p. 24; also Taylor on " Poisons," 2d ed., p. 447. I SUPPRESSION OF UKINK. 335- of the urinary secretion. Mr. Sedgewick, in the paper referred to, quotes the case of a boy who died five days and six hours after taking this poison, where the urinary secretion during the whole time was sus- pended, and the bhidder after death contracted. He mentions also a servant girl, who died from the effects of corrosive sublimate on the eighth day, with whom there was total and permanent suppression ; no urine could be obtained with the catheter, and after death the bladder was empty and contracted. In such cases it would appear that the suspension of secretion is due to the general state of collajise rather than to any change localized in the kidneys. Where the kidneys have been examined, they have been described either as natural, or as presenting only a slight degree of congestion, not enough to add perceptibly to their bulk or materially change their aspect. So slight a local change is totally insufficient to account for the arrest of function. We must, therefore, look for the cause of the cessation in the state of sj'stem rather than of kidney. Two systemic causes of suppression may concur in these cases: first, ex- haustion by profuse discharges, with possible diversion of urinary fluid; secondl}', the restraint of arterial flow which belongs to colla])se. Of these it is probable that want of circulation has more to do with the absence of urine than have the diarrhoea and vomiting. The loss of fluid in these cases is not generally such as would seem to counterbalance the missing secretion, and it may be observed that with poisoning, more especially with nitric acid, Avhere similar suppression follows, the bowels are obstinately confined. We may, therefore, presume that the suppres- sion of corrosive sublimate is a part of the collapse which attends the action of this poison. With poisoning by nitric acid suppression of urine is especially asso- ciated. Extreme collapse is present in these cases. There is vomiting, but no diarrhoea; on the contrary, the bowels are usually confined, and are found after death to be occupied by indurated fa?ces. Suppression has also been noticed in cases of poisoning by sulphuric and hydro- chloric acids. With regard to arsenical poisoning, the urine is suppressed occasionally and for short periods, but not with any regularity. Finally, suppression of urine has been noticed in connection with the choleraic symptoms produced by putrid meat and poisonous fungi. It is probable that in all these cases the suppression is due to the state of circulation which constitutes collapse. It is manifest that the profuse loss of fluid by diarrhoea and vomiting which occurs in some forms of poisoning and in cholera must also tend to diminish the urine. Sup- pression may, therefore, be especially looked for where profuse discharges have produced, or coexist with, a condition of collapse. Cholera and poisoning by corrosive sublimate are the typical examples of this morbid concurrence. The suppression of cholera is complicated, partly systemic and partly renal, arising from general, but frequently protracted by local causes. In the cold stage there is, as a result of the intestinal drain, the gen- eral condition of arterial emptiness, the loss being especially of the water of the blood, which is essential to the solution and elimination of the urinary elements. The rice-water evacuations of cholera' are 1 On the intestinal discharges in cholera, Dr. Parkes, Loud. Journ. of Med., 1849, p. 134. Reports on epidemic cholera, published by the College of Physicians, Path. Report, by Dr. Gull, p. 44. 3:3(1 SUPPRESSION OF URINE. chiefly aqueous, insomucli that on an average 100 parts of rice-water stools contain more than 98 of water, the small amount of solid matter consisting chietly of salts of potash and soda, with only a trace of albu- min. They contain no urea, and of uric acid have given but rare and doubtful indications. They take the water, but leave the renal exere- menta. Tbe blood accordingly becomes viscid; its specific gravity is greatly increased; its water is lessened; the organic solids are propor- tionally raised, after much purging, even to half as much again as in health,' and urea is constantly found. This condition of dehydration, together Avith the failure of circulation which accompanies it, produces a general suspension of all the fluid secretions which are not under the stimulus of the disease. Urine may accordingly be absent during collapse for thirty hours, or even longer. But, though unable to re- spond by secretion, the kidneys, even at this stage, give evidence of ir- Titation,"^ which we must ascribe rather to the urinary elements in the blood than to any direct influence of the cholera poison. The kidneys, if examined during or immediately after the stage of collapse, though not as yet much altered in bulk, are congested sometimes to a general violet tint, some excess and some alteration of epithelium is found in the tubes of the cortex, while those of the cones frequently contain crystals of uric acid or oxalate of lime. 'With these signs of incipient inflammation, the urine as it begins to reappear is scanty, albuminous, sometimes bloody, and loaded Avith casts, usually of the epithelial type. The kidneys may now gradually right themselves, or it may happen that the symptoms and local changes of acute tubal nephritis maydevelop. Early and marked uriemia occurs — it appears, indeed, that what is termed the consecutive fever, or the typhoid strge of cholera, so far resembles uremia in its symptoms that we cannot but regard this condition of blood as one of its pathological factors.' The kidneys under these cir- cumstances are found to be m a condition of tubal nephritis, they are much increased in bulk, weighing, as in a case mentioned by Dr. Gull, 15^ ounces; they are pale, loaded Avith more or less fatty epithelium, and are, in short, in' a tvpical condition of tubal inflammation, not unlike that Avhich results from exposure to cold. The urine is scanty, albuminous, and deficient in urea, and occasionally dropsy ensues._ We thus have in cholera a condition of complete suppression arising in dehydration and collapse, and succeeded by partial suppression depending upon renal inflammation. A cause of transient suppression, connected presumably Avith renal congestion, maybe occasionally found in the so-callea cold stage of ague, under Avhich influence the urine has been known to be absent for a time, to reappear albuminous or bloody. AVe may attribute the accident to the driving inwards of the blood upon the kidneys as upon other inter- nal organs. In cases of intestinal obstruction, the urine is often much dimin- ished, and sometimes entirely withheld. It has been generally stated that the amount of urine formed with intestinal stoppage is a guide to the ^losition of the obstacle — the higher the obstacle the less the urine — the diminution of the secretion depend- ing, as Avas thought, upon the loss of the absorbing surface below loAV the stricture. But as Dr. Brinton has shoAvn, this relationship is by 1 Report on epidemic cholera, published by the College of Phj'sicians, Path. Report, by Dr. Gull, p. 187. SUPPRESSION OF URINE. 337 uo means invariable, copious urine sometimes concurring with a high obstruction, and scanty or temporarily-suppressed urine with a low one. Besides the mere loss of absorbing surface, there are at least two otlier morbid conditions to consider in connection with the renal secretion under these circumstances; first, the drain of fluid by vomiting, which, especially when the obstruction is near the stomach, is profuse, and ap- parently out of proportion to what has been swallowed; and se3ondly, the collapse, so often productive, as has been shown, of anuria, but which has relation to the nature of the lesion rather than to its posi- tion. 22 INDEX. Abdominal tumor from renal disease, 40 tumor simulating renal dis- ease, 44 tumor from hydrone- phrosis, 101 Abscess of kidney, 1 of kidney, pyaemic, 5 of kidney, toxic, 4 of kidney, traumatic, 1 of kidney, uriseptic or surgi- cal, 8 Acids, mineral, for alkalinity of urine, 15, 146 mineral, for phosphuria, 295 Adolescents, albuminuria of, 314 Age of subjects of malignant disease of kidney, 48 of subjects of tubercular disease of kidney, 87 Ague in heematuria, 325 in intermittent haematuria, 276 Albumin, tests for, in urine, 300 peculiar, in urine, 303 Albuminuria of adolescents, 314 alimentary, 315 from blood disorders, 315 causes of, generally con- sidered, 304 classification of, 304 from cholera, 311 with exophthalmic goitre, 313 with hepatic disturbance, 316 of nervous origin, 313 with pneumonia, 307 with pja'exia, 311 relations of, in general, 300 renal diseases as causes of, 306 Alcohol, in causation of intermittent haematuria, 277 Alimentary albuminuria, 315 Alkalies, intolerance of, in pliosphuria, 295 as solvents for stone, 194 Allbutt, Clifford, on albuminuria from mental causes, 313 Ammoniacal urine, 145 Amyloid, see Lardaceous Angioma of kidney, 67 Arteries, renal, diseases of, 224 obstruction of. as cause suppression, 333 of Beale, on chyluria, 256 Bernard, Claude, on albuminuria, 313, 315 Bilharzia haematobia, 337 Bladder, cancer of, 321 disease of, as cause of sup- pression, 331 haematuria connected with, 331 naevus of, 333 villus of, 323 Blood with hajmoglobinuria, 285 in urine, tests for, 317 Blood-calculi, 151 Blood-corpuscles with haemoglobinuria. 385 Bony growths in kidney, 68 Bowel, relation of. to renal tumors, 38 perforated b}' renal tumors, 53 Bronchial tubes, perforation of, from renal calculus, 170 tubes, perforation of, in perinephritis, 24 Calcareous formation in kidney, 68 Calculi, renal, calcic carbonate, 147 renal, cystine, 148 renal, differential diagnosis of. 153 renal, fibrinous, 151 renal, general considerations concerning, 130 renal, geographical distribution of, 136 renal, indigo, 151 renal, insanity and epilepsy with, 176 ' renal, kinds of, 120 renal, modes of death from, 166 renal, in Museums of London, 133 renal, oxalate of lime, 136 340 INDEX Calculi, renal, pathological consequen- ces of, 155 renal, pliosphatic, 141 renal, pyelitis from, 1(58 renal, symptoms of, 157 renal, suppuration from out- side kidney. 170 renal, suppression of urine from. 172 renal, triple x^liosphate, 141 renal, urates, 184 renal, uric acid, 128 renal, urostealitii, 152 renal, water and food in con- nection witli, 127, 128 renal, xanthine, 135 Calculus, renal, treatment of. 177 renal, by operation. 181 renal, by solvents, 194 Cancer cells in urine, 321, 322 Cantharides, as cause of renal abscess, 4 Carcinoma of kidney, 53 Carter, A^andyke, on chyluria, 252 Cartilaginous" growths in kidney, 68 Casts with intermittent hajmaturia 281, 282, 283 Causes of floating kidney, 207 of liEematuria, 319 of hydronephrosis, 95 of intermittent hsematuria, 276 of pyelitis. 16 Chlorate of "potash as cause of haemo- globinuria, 288 Chlorine in intermittent hsematuria, 285 Cholera, albuminuria with, 311 as cause of suppression of urine, 335 Chylorrhoea, 261 Chyluria, 251 pathology of 269 treatment of, 272 Cobbold, on parasites, chap, xviii., 227 Cold, as cause of intermittent haema- turia, 278 Collapse as cause of suppression, 333 Colloid of kidney, 55, 101 Concussion of brain a cause of suppres- sion, 333 Contrexeville water for calculi, 198 Cystic disease of kidney, 109 disease of kidney, congenital, 117 Cystine calculi, 148 Cysts, paianephric, 118 renal, simulating hydronephro- sis. 102 renal, solitary, 118 Davaine, on renal parasites, chap. xviii., 227 Depurative, see Lardaceous Diathesis, cystic, 148 phospliatic, 141 oxalic, 136 Diathesis, uric, 128 Diet in uric acid diatnesis, 133 Discharges of chyle from surface, 261 Displacement of "kidney, 205 Distribution, geographical, of calculi, 126 geographical, of chyluria, 253 Duration of malignant disease of kid- ney, 75 of tubercle of kidney, 92 Earths in urine of phosphuria, 296 Elliotson, hfematuria with ague, 275 Embolism, renal, 33 Encephaloid of kidney, 54 Epilepsy, with renal calculi, 176 Epithelial cancer of kidney, 55 Epitlielium, urinary characters of, in different parts. 19 Ergot in htymaturia, 327 Etiology, see (pauses Excision of kidney, see Nephrectomy of stone, see Lithotomy Exophthalmic goitre as cause of albu- minuria, 313 Fibrinous calculi, 151 Fibrous renal tumors, 60, 68 Filaria, 264 Floating kidney, 205 kidney, excision of, 213 Frank on chyluria, 251 Gangrene, symmetrical, with lijemo- globinuria, 279, 289, 291 Gay Lussac, on solution of calculi. 196 Geographical distribution of calculi, 126 distribution of chyluria, 253 Glandular tumors simulating renal, 43 Globulin in urine, 303 Glomerular nephritis a cause of sup- pression, 329 Graves, on urinary paralysis, 217 Greeve, on Leth- Albumin, 300 Gubler, on chyluria, 252 Gull, on hrematiuuria, 274, 283 on urinary paralysis, 217 Hsematinuria, see Haematuria, inter- mittent Hsematuria, causes of. 319 endemic, 237 generally considered, 317 from improper food with infants, 324 from malaria, 325 from mental emotion, 324 from na^vus of bladder, 333 from purpura and scurvy, 324 INDEX. 34:1 Haematuria, renal, 319 simple. 325 from stone and growths, 163, 163, 321 toxic, 320 treatment of, 326 vicarious, 324 vesical, 321 from villus of bladder, 322 intermittent, 274 intermittent, abortive at- tacks of, 279 intermittent, pathology of, 285 intermittent, rationale of, 290 intermittent, treatment of, 291 intermittent, urine with, 280 Hsemoglobinuria, see Hematuria, in- termittent toxic, 288 Hard water as cause of calculi, 127, 128 Harley, George, on intermittent haema- turia, 275 John, on the Bilharzia, 237, 241 Hassall, on the phosphatie diathesis, 294 Head symptoms with suppression of urine, 332 Healthy epitlielium, microscopic char- acter of, 19 Hepatic disturbance a cause of albu- minuria, 316 Heredity in relation to intermittent haematuria, 277 Hydatids, renal, 927 Hydrsemia as a cause of albuminuria, 315 Hydronephrosis, 94 excision of kidney for, 108 as cause of suppres- sion, 330 Indigo calculus, 151 Insanity with renal calculi, 176 Intermittent fever as cause of haema- turia, 325 fever as cause of hajmo- globinuria, 276 haematuria, see Haematu- ria, intermittent Intestinal obstruction as cause of sup- pression, 336 Jaundice, with intermittent haematu- ria, 279 Jones, Bence, on chyluria, 252 Bence, on phosphatie diathesis, 298 Bence, on peculiar albumin, 301 Kidney in chyluria, 260 Kidney in intermittent haematuria, 285 Lardaceous disease, tubercle of kid- ney with, 91 Leukhaemia of kidnej% 66 Lewis, on chyluria, 252 Lime in urine, 294 water in solution of calculi, 197 Lithia in solution of calculi, 200 Lithotomy, renal, 181 Lymphadenoma of kidney, 66 Mackenzie, morbid anatomy of chylu- ria, 270 Magnesia in phosphuria, 296 Malaria in relation to haematuria. 325 in relation to intermittent haematuria, 276 Malignant disease of kidney, clinical history of, 70 disease of kidney, duration of, 75 disease of kidney, nephrec- tomy for, 76 disease of kidney, treatment of, 76 disease of kidney, urine with, 73 Malpighian bodies in cystic disease of kidney, 113 Marcet, the elder, on solution of calculi, 195 Masturbation as cause of albuminuria, 314 Melanosis of kidney, 60 Mental causes of haematuria, 324 Mineral acids for alkaline urine, 15 acids for phosphuria, 295 Misplacement of kidney, 204 Movable kidney, 205 kidney, treatment of, 212 Moxon on albuminuria of adolescents, 314 Naevus as cause of haematuria, 323 Nephrectomy for hydronephrosis, 108 for malignant disease, 76 for movable kidney, 213 for stone, 181 for tubercle, 93 Nephritis from intermittent haematu- ria, 280 Ord, on indigo calculus, 151 on renal calculi, 125 Owen, on albuminuria in pneumonia, 307 Oxalate of lime calculi, 136 Paralysis, urinary, 215 Paranephric cysts, 118 Paraplegia with hyatids of kidney, 234 with malignant disease of kidney, 72 342 INDEX. Pavy, on paroxysmal hcematuria, 274: Peptones in urine, 8U"3 Perinephritis, 2'S puerperal, 37 Phosphuria, 294 with diabetes, 298 treatment of, 295 Plymouth Dockyard disease, 26 Pneumonia as cause of albuminuria, 307 Potash in solution of calculi, 199 Prout, on chyluria, 196 on haamaturia with malaria, 275 on phosphatic diathesis, 294 Psoas abscess, from perinephritis, 24 Purpura and scurvy as causes of albu- minuria, 316 and scurvy as causes of hasma- turia, 324 Pyaemia of kidney, 5 Pyelitis, 16 from calculi, 168 Pyrexia, albuminuria with, 311 Renal calculi, see Calculi Reynaud's disease with hsemoglobin- uria, 279, 289, 291 Roberts, W., on hydronephrosis, 107 W., on malignant tumor, 49, 51 W., on movable kidneys, 205 W., on solution of calculi, 196 W., on suppression from cal- culi, 173 Sarcoma of kidney, 56 Saundby, on frequency of albuminuria, 304 Sex in relation to floating kidney, 205 Soda in solution of calculi, 199 Spectroscope in haematuria, 317 in haemoglobinuria, 281 Spine involved in renal tumors, 51 Spurious urinary parasites, 249 Stanley, on urinary paralysis, 216 Stephens, Joanna, her stone solvent, 195 Stone, see Calculus Strongulus gigas, 244 Suppression of urine from arterial ob- struction, 332 of urine from calculi, 173, 179, 330 of urine from cholera, 335 of urine from collapse, 333 of urine generally consid- ered, 328 of urine from hydrone- phrosis, 330 of urine from intestinal obstruction, 336 of urine of nervous origin, 333 of urine, obstructive, 330 of urine from poisons, 334 of urine from renal sup- puration, 7, 329 Suppression of urine from surgical operations, 329 Suppuration antecedent to intermittent haematuria, 277 bevond kidney, from cal- culi. 170 Supra-renal tumors distinguished from renal, 43 Surgery of hydronephrosis, 108 of movable kidney, 213 of renal calculi, 181 of renal tumors, 76 of tubercle of kidney, 93 Surgical kidney, 8 Syphilis with intermittent haematuria, 277 Syphiloma of kidney, 67 Temperature of bodj^ with intermittent hgematuria, 279 of body with suppression, 332 Tetrastoma renale, 249 Toxic albummuria, 307 Traumatic abscess of kidney, 1 Tubal nephritis, see Nephritis Tubercle of kidney. 79 of kidney, abdominal tumor from, 89 of kidney, age in regard to, 87 of kidney, causes of, 88 of kidney, clinical history of, 87 of kidney, lardaceous disease with, 91 of kidney, minute anatomy of, 82 of kidney, with tuberculosis elsewhere, 85 of kidney, treatment of, 92 of kidnev, urine with, 91 of pelvis, 84 Tumor, abdominal, from cystic disease of kidney, 116 abdominal, from glandular dis- ease, 43 abdominal, from hydronephro- sis, 104 abdominal, from renal growths, 41, 48 abdominal, from supra-renal growths, 43 abdominal, from tubercular dis- ease of kidney, 89 Tumors, renal, dissemination and spread of, 51 renal, distinguished from those of other organs, 42 renal, general relations of, 37 renal, fibrous, 60 renal, pathological varieties of, 47 renal, primary and secondary, 48 INDEX. 343 Tumors, renal, secondary to those of kidney, 50 Uraemia with obstruction of ureter, 331 Urates, calculi of, 134 Ureter, diseases of, 221 obstruction of, 381 Uric acid diathesis, 128 acid calculi, 128 Urine, with chyluria, 255 with cystic disease of kidney, 116 with hydronephrosis, 104 with intermittent haematuria, 280 with malignant disease of kid- ney, 73 with phosphuria, 295 with suppression, 172, 328 witli tubercle of kidney, 91 Uriseptic abscesses of kidney, 8 Urostealith calculi, 152 Urticaria with intermittent hsematuria, 279 Uterine disease as cause of hydrone- phrosis, 98 f Villusof bladder, 322 of bladder, detachment of, 32S of kidney, 65 Vomiting with calculus, 162 Water, hard, in calculous disease, 127, 128 injection of, as ca ise of albumi- nuria, 315 Waxy, see Lardaceous Xanthine calculi, 135 INDUSTRIAL PRINTING COMPAN STETTINER, LAMBERT A CO., 139 A 181 CROSer 6T., NEW YORK. ■» UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. 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