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 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 VOLUME ex.
 
 SELECTED MONOGRAPHS 
 
 COMPRISING 
 
 ALBUMINURIA IN HEALTH AND DISEASE. 
 
 BY 
 
 Dii. H. SENATOR. 
 
 SOME CONSIDERATIONS ON THE NATURE AND 
 PATHOLOGY OF 
 
 TYPHUS ANI) TYPHOID FEVER. 
 
 BY THE lATE 
 
 ALEXANDER P. STEWART, M.D. 
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 BT 
 
 De. LEOPOLD LANDAF. 
 
 LONDON: 
 THE NEW SYDENHAM SOCIETY. 
 
 1884.
 
 PRINTED BY J. E. ADLAED, BARTHOLOMEW CLOSE.
 
 WS" 
 
 Nlf7?M 
 
 ALBUMINUEIA 
 
 HEALTH AND DISEASE 
 
 WITH TWO APPENDICES 
 
 (1) A CONTRIBUTION TO THE THEORY OF URINARY 
 
 SECRETION. 
 
 (2) THE HYGIENIC TREATiAIENT OF ALBUMINURIA. 
 
 Dß. H. SENATOR, 
 
 PKOFESSOR EXTRAORDINARY OF MEDICINE ; PHYSICIAN TO THE ROYAL CIIAKITB 
 HOSPITAL, AND TO THE AUGUSTA HOSPITAL OF BERLIN. 
 
 with one lithographed illustration. 
 
 translated by 
 Dr. T. p. smith. 

 
 527
 
 jl^bial^it 
 
 HEEE IIUDOLE YIECHOW, 
 
 COMMEMOßATIÜN OE HIS SIXTIETH BIRTHDAY 
 
 AND OF niS 
 
 TWENTY-EIVE YEAES WOEK 
 
 TEACHER IN THE EliEDElilCK WILLIAM UNIVERSITY. 
 
 Uniting, as I do, witli tliat large concourse of your 
 admirers wlio now approacli you witli expressions of gratitude 
 and every good wisli, I sliould like, so far as lies in my 
 power, to bear witness to the fact tliat practitioners also look 
 up to you as their pioneer and master, and that therapeutics, 
 in the strict sense of the term, is not behindhand in 
 gratitude and in the recognition of the enormous obligations, 
 which it, no less than theoretical medicine, owes to you. It 
 does not require my pen to recall these services to the 
 memory of our contemporaries, nor to protect them from 
 future oblivion, for so long as there is a history of medicine, 
 the mighty epoch-forming impulse, which all branches of 
 this science have received through you, will be duly recorded 
 in its pages. I will dwell only upon one point, which, in 
 the abundance of the meritorious services now so vividly
 
 ViU DEDICATION. 
 
 remembered, might be, if not forgotten, at all events too 
 little appreciated. When about three decades ago a new 
 development of medical science took its rise, due in no small 
 degree to the powerful influence of your labours, when new 
 branches shot up vigorously on the old but ever regenerating* 
 tree of medicine, and one branch alone, the oldest indeed 
 — which seldom puts forth true blossoms, but when it does 
 so, brings to maturity precious fruit, blessed by all mankind 
 — remained sterile and, to all appearance, a hard, hopeless 
 twig, when it was a mistake to believe in therapeutics — at 
 that crisis you, most honoured Sir, were not afraid to come 
 forward and avow your participation in this supposed error.^ 
 You had faith in therapeutics ; you considered it to be not 
 a dead branch, all but given up though it Avas by those who 
 were especially called upon to make use of it. Your fore- 
 sight has not deceived you ; with the growth of the tree, 
 so much of which it owes to you, that branch also has 
 received a fresh stimulus, and the indirect effect of your 
 labours and the direct effect of your words, spoken in due 
 season, have been to introduce it to the workmen and the 
 care of which it stood so much in need. Therapeutics has 
 once more become prominent, having received from you both 
 aim and direction. 
 
 In this treatise, which I have the privilege of presenting 
 to you, a place could not be found for therapeutics, for the 
 reason that albuminuria, which is its subject, is upon the 
 whole but little amenable to treatment. But as you have 
 not shown any scepticism on therapeutics in general, when 
 that science seemed all but extinct, so we are not without 
 hope that in this particular case the power of medicine will 
 some day be proved. These pages appear to me to be not 
 unworthy of being dedicated to you, because their contents 
 fall within the lines of "■' pathological anatomy and physio- 
 ^ 'Handb. d. si)cc. ratliol. u. Thcrap.,' i, 1854, Vorwort, S. xi.
 
 DEDICATION. IX 
 
 logy and o£ clinical medicine/' departments to wliich yoa 
 liave given sucli abundant space in your Archives, the 
 imperishable monument of united work in scientific medicine 
 and a motto for all your successors. 
 
 H. SENATOR. 
 
 BeELIN ; 
 
 October, 1881.
 
 CONTENTS. 
 
 PAGE 
 Inteodttction ........ I 
 
 I. The Vaeious Foems in which Albumen is Excreted . 3 
 
 The possible sotirces of albumen in the urine. True and false 
 albuminuria. Albuminuria in the strict sense of the word, 
 or the excretion of albuminous constituents of the blood 
 (serum-albumin and globulin) coagulable by heat. Pepton- 
 uria. Propeptonuria (the excretion of hemi-albumose). 
 Mixed albuminuria. Methods of demonstrating coagulable 
 and non-coagulable albuminous substances. 
 
 II. Albumen as a Constituent of Noemal Ueine . . 15 
 
 Statements with regard to the occuiTence of a ferment-like sub- 
 stance (nephrozymasis) and of albuminous substances proper 
 in normal urine. Physiological albuminuria, its frequency 
 and the difficulties attending its demonstration. The sources 
 of albumen in normal urine are the Malpighian bodies which 
 yield a filtrate, but no secretion. Laws of filtration and 
 transudation. The urine composed of the fluid of filtration 
 and specific glandular secretion. 
 
 III. The Dependence of Albuminueia upon Alteeations in 
 
 THE Blood-peessuee . . . . . -39 
 
 Difficulties in estimating the influence of alterations of pres- 
 sure. Attempts to increase the arterial pressure by irri- 
 tating the spinal cord, by producing dyspnoea, &c., by ligature 
 of the aorta, by dividing the renal nerves, by increasing the 
 bodily temperature, by muscular activity, by the work of 
 digestion, by poisons. Venous congestion due to ligature 
 of the vein, aiiery, and ureters respectively. Differences 
 between long-continued and temporary ligature. Explana- 
 tion of the processes in the various forms of renal congestion. 
 Comparison of the venous congestion experimentally produced 
 with the clinical forms of the same condition.
 
 XU CONTENTS. 
 
 IV. Albuminuria as dependent upon Degeneeation of the 
 
 Renal Epithelium . . . . . -77 
 
 The renal epithelium is considered as a protective against the 
 escape of albnmen. Albuminuria in fatty degeneration of 
 the epithelium (phos])horus-poisoning, pernicious ana3mia), 
 in parenchymatous degeneration and coagulation-necrosis. 
 Origin of albumen from metamorphosed epithelium. 
 
 Y. The Condition of the Blood as influencing the Peo- 
 
 DUCTiON OF Albuminueia . . . . -94 
 
 Quantitative changes in the composition of the blood, especially 
 with regard to the quantity of dissolved albumen, salts, and 
 urea, and their influence upon the filtration of albumen under 
 physiological conditions (albuminuria of digestion). Influence 
 of the same under pathological conditions. Qualitative 
 changes. The appeai'ance of egg-albumen and other soluble 
 albuminous substances in the blood, the occurrence of peptone, 
 propeptone, and dissolved hremoglobin, under physiological 
 and pathological conditions. Influence of increase in the 
 temperature of the blood upon filtration. Condition of the 
 specific secretion. 
 
 VI. Certain peculiar Foems of Morbid Albuminueia . .108 
 
 The impossibility of explaining all forms of morbid albumin- 
 uria. Albuminuria in congestion, convulsions, poisoning. 
 Febrile albuminuria. Albuminuria in cholera and diarrhoea. 
 Albuminuria in the various forms of nephritis, acute and 
 chronic nephritis, and cirrhosis of the kidney. Various 
 differences. Amyloid degeneration of the kidneys.
 
 ALBUMINURIA 
 
 HEALTH AND DISEASE. 
 
 Inteoduction. 
 
 *' History teaches us that the views of modern times constantly revert to 
 those points which were regarded by earlier observers as settled, and thus, 
 particularly nowadays, when so few have leisure for the historical study of 
 science, there is perhaps ample justification for bringing old notions within 
 the intellectual view of a succeeding generation." — R. Virchow's Preface to 
 his ' Gesammelte Abhandlungen zur wissenschaftlichen Medicin,' 1S56. 
 
 I can think of no better introduction to the following 
 treatise than Virchow's words which I have placed at its 
 commencement. For, as holds good with regard to so many- 
 other scientific questions in medicine, so likewise and in an 
 especial manner with reference to the doctrines on albumin- 
 uria, they possess in my opinion complete validity and at 
 present perhaps more than at any previous time. The older 
 views, nowadays if not entirely abandoned, at all events but 
 little regarded, assigned as is well known, various causes for 
 albuminuria, viz. alterations in the circulation in the kidneys, 
 alterations in the membranes placed between the blood and 
 the urine, and changes in the condition of the blood. To 
 ono or other of these three factors was a greater or less 
 .share attributed in the origination of albuminuria, and ac- 
 cording to the existing state of science, attempts were made 
 to determine the influence of each of them. The most ener- 
 getic and successful opponent of these doctrines was J. B. 
 Stokvis, who, supported by extended experimental and clini- 
 
 1
 
 2 ALBUMINUEIA IN 
 
 cal investigations, declared tliat every alteration of tlie cir- 
 culation wliicli checks the afflux of arterial or the escape of 
 venous blood, causes albumen to pass into the urine, but 
 that all other conditions to which the phenomenon had been 
 formerly attributed are to be rejected as ineffectual (i). Ac- 
 cording to this view, the only recognised cause of albumin- 
 uria is a retardation of the flow of blood in the kidneys, 
 for such is the necessary result of every alteration in the 
 circulation, in the sense applied to the term by Stokvis. 
 Only a slight advance was now required in order to deter- 
 mine which of the two functionally different portions of the 
 vascular system of the kidneys was the site of the circulatory 
 disturbance which caused the albuminuria, and the results of 
 the most recent investigations made with the view of deter- 
 mining this question agree in showing that the Malpighian 
 tufts are the portions implicated in the disturbance. Accord- 
 ing to Runeberg, (2) and Posner, (3) with whom Ribbert, 
 (4) and Litten, (§) agree, these vessels are the sole or the 
 only necessary seat of the excretion of albumen ; the cause of 
 the escape of albumen from them is said by Runeberg to be 
 the diminution of the pressure of the blood, while importance 
 is attached to the retardation of the current by Posner and 
 Litten, the latter being supported by Runeberg's views with 
 regard to the effect of the lowering of pressure upon the ex- 
 cretion of albumen.^ Retardation of the current, when pro- 
 longed, changes, as Cohnheim (7) has shown, the condition of 
 the walls of the vessels, inasmuch as it renders them ab- 
 normally permeable by the constituents of the blood and 
 especially by the albumen. Cohnheim himself likewise (8) 
 considers the disturbance of the circulation in the Malpighian 
 tufts to bo the cause of the albuminuria, but the ill effects of 
 this disturbance are of less serious import upon the walls of 
 the vessels than upon the epithelium which covers the glome- 
 rular vessels, for he agrees with Hcidenhaiu (g) in attributing 
 
 ^ It is true that elsewhere Litten has expressed a different opinion, viz. 
 that the epithelium of the convoluted tuhes is concerned in the excretion of 
 albumen, inasmuch as under pathological conditions it does not remove the 
 albumen from the transuded secretion ])ressed through the loops of the 
 vessels of the glomeruli, and which in the normal condition contains 
 albumen (6).
 
 HEALTH AND DISEASE. 3 
 
 to this epittelium tlie retention of the albumen under normal 
 conditions. 
 
 Such then is the shape which in recent years the theories 
 with regard to albuminuria have assumed^ mainly in Ger- 
 many, but also in other countries, as may be inferred from 
 the latest writings of Charcot, (lo) Lepine, (ii) and others. 
 It is obvious that this theory has the advantage of great 
 simplicity as compared with the older views, for all other 
 factors, to which formerly so much thought and investigation 
 were directed, are now held to be inoperative ; they are even 
 scarcely mentioned. Posner, indeed, does not think it worth 
 while to discuss them, for he asserts that they are devoid of 
 any real basis. He goes, however, much too far in his 
 assertions ; for some time past facts have accumulated clearly 
 indicating the dependence of many forms of albuminuria 
 upon alterations in membranes other than those of the Mal- 
 pighian tufts, and yet concerned in the secretion of urine, 
 or upon changes in the condition of the blood. The facts 
 referred to could not therefore bo excluded from a treatise 
 on this subject, and they will be examined in the following- 
 sections after the influence of circulatory changes has been 
 discussed, for to these latter they are undoubtedly subordinate 
 in importance. 
 
 I. The Various Foems in which Albumen is Excketed. 
 
 In calling attention to the older views with regard to albu- 
 minuria, I do not mean that they should be simply received 
 in the somewhat vague and indefinite form in which they 
 have been handed down, but I wish to show that, as com- 
 pared with the most recent, simple, but one-sided doctrines, 
 they make better allowance for facts, inasmuch as they pro- 
 ceed from a higher stand-point and embrace a larger field of 
 view. It is true that even they do not so comprehend all 
 points of view that none are left out ; the circle of possibili- 
 ties may extend itself beyond past and present ideas. How 
 much of them is worthy of consideration, and for what cases 
 the one or the other possibility is deserving of notice will be 
 discussed in the following pages.
 
 4 THE VARIOUS FORMS IN WHICH 
 
 There is one general meeting-point for all received theories 
 of albuminuria, old as well as new, inasmuch as without ex- 
 ception they all place the source of the urinary albumen in 
 the blood, and almost exclusively in the blood of the Mal- 
 pighian tufts. There is a universal absence of doubt on this 
 point, so that the question as to the possibility of any other 
 source of the albumen has never once obtruded itself and has 
 certainly never been discussed.^ But a thorough and un- 
 biassed consideration forces us to acknowledge that the al- 
 bumen may have places of origin other than the blood of the 
 Malpighian tufts ; and as none of the received theories, which 
 make no reference to such a possibility, suffice to explain in 
 a satisfactory manner all the various forms of albuminuria, 
 as further description will show, a discussion of the other 
 ways in which albuminuria may originate does not appear to 
 be superfluous, however little it may harmonise with our or- 
 dinary notions. It is certainly not necessary in discussing 
 the origin of albumen in the urine, to claim as possible 
 sources everything in the kidney that contains or is com- 
 posed of albumen, and this remark is especially true with 
 regard to the constituents of the tissue, such as the inter- 
 stitial connective tissue, the substance of the walls of the 
 blood-vessels and lymphatics, or the basement membrane of 
 the urinary tubes, for only if these tissues were completely 
 destroyed could their albuminous elements pass into the 
 urine. There remains, however, the blood of the interstitial 
 vessels, the lymph and the various epithelial cells of the 
 kidney, all of which might yield albumen to the urine, and 
 there is no reason of any kind for totally excluding these 
 from discussion. On the contrary, there is abundant cause 
 for examining into any possible participation of these tissues 
 in the production of albuminuria, because conjointly or separ- 
 ately they are more or less affected in the processes which 
 lead to albuminuria — in congestion, and in the various forms 
 of inflammation and degeneration of the kidney. 
 
 In the first place it is necessary to form a clear conception 
 
 ' On a former occasion (Virchow's ' Archiv,* Bd. Ix, S. 478, u. 497) I have 
 drawn attention to other possible sources of albumen in the urine, and 
 Bartels has partially assented to my views (in v. Ziemssen's ' Handb. der 
 Pathol.,' ix, I, s. 36, u. 38).
 
 ALBUMEN IS EXCRETED. 5 
 
 of the term " albuminuria," for tlie present limitation of its 
 meaning has become insufficient, owing to the increase of 
 our knowledge with regard to the albuminous substances 
 wbicli are found in tlie urine. Tlie custom has been to 
 distingniisli only '^genuine or true albuminuria" from ''false 
 albuminuria," and to signify by tlie latter term tliose condi- 
 tions in wliicb non-albuminous urine from tlie parenchyma 
 of the kidney subsequently receives an admixture of an 
 albuminous fluid, such as the semen or prostatic fluid, or 
 blood, pus, lymph, or the fluid of disintegrated tissue. This 
 false albuminuria requires no further explanation. In true 
 albuminuria, in which albumen together with other con- 
 stituents of the urine is yielded by the parenchyma of the 
 kidneys, our thoughts are usually directed only to the 
 excretion of albumen coagulable by heat. The property of 
 coagulation possessed by the urine led to the discovery of 
 albuminuria by Cotugno. It occurs in nearly all cases, and 
 harmonises, in a general way, with the idea which regards 
 the blood alone as the source of the albumen. We can 
 therefore readily understand how that at the present day the 
 term " albuminuria " is used in the same sense as it has 
 been for a century past, and that it leads to confusion when 
 albuminous substances, non-coagulable by heat, are found in 
 the urine, even if in other respects they entirely resemble 
 urinary albumen, and that such cases are not regarded as 
 belonging to albuminuria. Coagulation, however, on being 
 heated, is no more a property of all albuminous substances 
 than it is peculiar only to one of them, so as to render 
 it possible for the term " albuminuria " to be limited to 
 the excretion of this one coagulable form of albumen. 
 On the contrary, if we accept the current idea of the 
 origination of the urinary albumen from the blood, it would 
 necessarily follow that more than one coagulable albuminous 
 substance should pass into the urine, for the blood normally 
 contains at least two such substances in solution, viz., the 
 serum -albumin (serine) and the globulin. There is not the 
 slightest ground for the assumption that always, and without 
 exception, only one of these two substances, possibly the 
 serum-albumin, as generally supposed, escapes from the 
 blood ; there is more a prioi'i reason for expecting that, if
 
 6 THE VARIOUS FORMS IN WHICH 
 
 not always, at least in a greater or less number of cases, 
 both, substances escape, though possibly not in equal propor- 
 tions. And the fact accords with our expectation, for in 
 most cases in which coagulable albumen is found on heating 
 the urine, we are able to demonstrate the presence of both 
 serum-albumin and globulin. It therefore certainly appears 
 not impossible that, under certain circumstances only one of 
 these substances should pass into the urine, at least in an 
 appreciable amount, for different as may be the views with 
 regard to the process of excretion of albumen in the kidneys 
 (and these views are by no means clear, as we shall presently 
 see) , they all agree in allowing that the capacity for diffusion 
 and filtration possessed by the various albuminous substances 
 plays a considerable part in their excretion. 
 
 In this respect, however, there is an important difference 
 between the two albuminous substances which normally 
 occur in the blood, for globulin is much more diffusible 
 (possibly also more capable of passing through a filter) than 
 serum-albumin, and therefore much more likely to be found 
 in the urine, supposing that fluid to contain only one 
 albuminous substance in appreciable quantity. If the recent 
 statement of Estelle (12) be verified, which is to the effect 
 that sometimes only the albuminous substance which is preci- 
 pitated by magnesium sulphate (viz. globulin) is to be found 
 in the urine, this theoretical assumption would be thereby 
 remarkably confirmed, and it would be necessary to make 
 use of the term " globulinuria." At present, however, 
 sufficient attention has not been paid to this subject, and the 
 methods in use for demonstrating the presence of globulin 
 are, as Hammarsten (13) has shown, unsuitable for the 
 purpose, inasmuch as they are inexact, and altogether fail 
 for the detection of small quantities. It is therefore to be 
 anticipated that the new method described by Hammarsten, 
 and used also by Estclle, will enable us to detect globulin in 
 the urine, in larger quantities, and more often than at 
 present. That serum-albumin alone should pass into the 
 urine, that is, that a pure " serinuria,'' as it might bo called, 
 should occur, is less probable from the reasons given above. 
 It is true that up to the present time the fact that globulin 
 has not, in all cases, been found associated with the serum-
 
 ALBUMEN IS EXCRETED. 7 
 
 albumin lias rendered probable the existence of a pure 
 serinuria^ but the failure to detect the globulin has been 
 doubtless due to imperfect methods of examination. 
 
 The foregoing statements have conclusively shown that 
 even when the term " albuminuria " is used in its present 
 limited signification, it does not describe the excretion of one 
 and the same albuminous substance. And in addition to 
 this, albuminous substances have been recently discovered in 
 the urine which are deficient in the capacity for coagulation 
 hitherto deemed a distinguishing characteristic. Peptone is 
 the most remarkable example of this kind. Whereas for- 
 merly nothing was known of its occurrence in the urine, and 
 subsequently it was regarded as a doubtful constituent or as 
 a curiosity, quite recently Hofmeister and his pupils have 
 shown that under certain, by no means rare, circumstances, 
 it occurs in the urine in considerable quantities and that this 
 excretion, this " peptonuria " is of scientific and practical 
 importance (14). At the same time it must be remembered 
 that only slight traces of peptone are discoverable in the 
 blood, and that often these are absent. Compared with the 
 current theory of the origin of all urinary albumen from the 
 blood, this might seem very puzzling, did we not possess 
 other experiences which help to solve the mystery. We 
 know that the kidneys by virtue of a peculiar attractive 
 power excrete certain materials in large quantities, and with- 
 draw them from the blood which contains scarcely more than 
 mere traces (as, for example, urea, uric acid, kreatin, &c.), 
 and in like manner Hofmeister explains peptonuria as the 
 result of a specific peculiarity of the excretory elements of 
 the kidneys, inasmuch as he found that after the injection 
 of peptone into the blood, or under the skin, the urine is sur- 
 charged with it, while scarcely an appreciable trace is dis- 
 coverable in the blood. This explanation appears to be very 
 plausible, and is doubtless accurate for certain cases which 
 are analogous to this experimental administration of peptone, 
 as for example, when exudations containing peptone are 
 absorbed, as occurs in pleuritis, pneumonia, and rheumatic 
 arthritis. It is another question as to whether this is the 
 only way in which peptonuria can originate, or whether it 
 may not have other sources. This question appears quite
 
 8 THE VARIOUS FOKMS IN WHICH 
 
 justifiable, as we are taught by recent observations, to the 
 effect that no such sharp distinction exists between albuminous 
 substances proper and peptones, as we were foi'-merly disposed 
 to believe. Not merely as a result of digestion, but likewise 
 in consequence of various influences of a different kind and 
 especially of incipient putrefaction, albumen undergoes 
 modifications which more or less resemble that which we call 
 " peptone." It is quite conceivable that in certain morbid 
 conditions, the ordinary albuminous substances in the blood 
 and the fluids of the body or in the kidneys, become so 
 changed as to lose their coagulability on boiling and their 
 capacity for precipitation on the addition of certain acids 
 and metals. There is indeed no lack of indications of the 
 occurrence in the living body of such processes as can effect 
 alterations in the albuminous substances, similar to those 
 produced by digestion and many fermentative and putre- 
 factive processes. Thus, in these days, the idea has become 
 very familiar to us that in fever certain fermentative pro- 
 cesses take place in the body, and it is in febrile diseases, 
 that the occurrence of peptone-like bodies in the urine has 
 surprised observers more often than was the case in former 
 times. And the processes of tissue-metamorphosis in various- 
 conditions of poisoning, especially in phosphorus poisoning, 
 present numerous analogies with the processes of fermentation 
 and putrefaction, and Selmi (15) has quite recently drawn 
 attention to their similarity, and these again are exactly the 
 circumstances (phosphorus-poisoning being the most remark- 
 able of them all) in which these bodies are to be found in 
 the urine. These examples are sufficient to show that by 
 no means invariably only that form of peptone which is con- 
 tained in the blood and lymph is excreted with the urine,, 
 but that possibly, or probably, changes of combination 
 occurring in the blood, the lymph, and even in the elements 
 of the tissues, may convert the ordinary albuminous sub- 
 stances into peptone-like modifications. We are likewise 
 justified in supposing that certain intermediate products,, 
 which are formed during the transition of the albuminous 
 substances proper into peptone, may occur in the economy,, 
 and are also excreted by the urine, and that there is just as- 
 little reason for maintaining" a strict distinction between
 
 ALBUMEN IS EXCRETED. ^ 
 
 '^ peptonuria " and albuminuria as between peptone and 
 albuminous substances proper. 
 
 Eecent investigations have likewise shown that the con- 
 version of albuminous substances into peptone takes place 
 gradually and in stages^ certain intermediate or transitional 
 products being- formed^ and at least one such product is 
 clearly recognised, analogous in some respects with albumen, 
 and in others with peptone, viz. hemi-albumose or pro-peptone 
 (i6). The most important peculiarity of this substance is 
 that it is not precipitated from its watery solution by boiling, 
 but is precipitated in the cold state by acetic acid and 
 ferrocyanide of potassium, nitric acid, acetic acid and con- 
 centrated solution of chloride of sodium.^ This substance, 
 or one very similar to it, has been discovered by Virchow 
 in the medulla of bones in cases of osteomalacia, and re- 
 cently by Fleischer in the normal bony medulla. An 
 exactly similar substance, or perhaps a mixture thereof 
 with another form of albumen, had been previously dis- 
 covered by Bence Jones in the urine of a patient suffering 
 from osteomalacia. Langendorff and Mommsen made a 
 similar discovery in a case of this nature, although they 
 were not able to demonstrate the presence of any similar 
 albuminous body in the bones after death, and lastly Kühne 
 found hemi-albumose in the urine of a patient the subject of 
 osteomalacia. There are, in addition, a few isolated reports 
 with regard to the presence in the urine of an albuminous 
 substance, non-coagulable by heat, or dissolved by boiling, if 
 precipitated in any other way (17). However, from the gene- 
 rally very meagre character of the statements it is impossible 
 to decide as to how far they always refer to the substance in 
 question. Prout, Gerhardt, Beneke, Fiirbringer, and Gowers 
 make, however, sufficiently definite statements on this subject, 
 and from these we may infer the occurrence of hemi-albumose 
 in various morbid conditions (18). In addition, Stokvis (ig) 
 has found it in the urine of a dog after injecting* it into the 
 rectum ; and finally, Lassar (20) asserts that having rubbed 
 petroleum into the skin of rabbits, he found, after a certain 
 interval, hemi-albumose with all its characteristic peculiari- 
 ties in the urine. On the whole it would appear from thesa 
 ^ For additional reactions I refer to Kühne and Salkowski's statements.
 
 10 THE VARIOUS FORMS IN WHICH 
 
 scanty and not altogether positive statements, that liemi-al- 
 bumose or pro-peptone (pro-peptonuria/ as I shall henceforth 
 call itj) was an extremely rare occurrence in the urine, and 
 unworthy of consideration. My own observations, however, 
 directly contradict such a notion, for they show that though 
 pro -peptonuria is not very common, it is vastly more frequent 
 than current ideas and the literature of the subject would lead 
 us to believe. During the past three or four years I have met 
 with seven cases, one being a man aged forty-four, who had 
 several times been the subject of syphilis, and in the course 
 of years had undergone various courses of anti- syphilitic 
 treatment. When first admitted into the Augusta Hospital, 
 he was fairly well nourished, slightly jaundiced, his liver 
 and spleen were considerably enlarged, and there was pro- 
 fuse diuresis, to an extent of 6000 cctm. daily, corresponding 
 with the somewhat intense thirst. The urine had a sp. gr. 
 of 1004 — 1006, and was free from sugar. It exhibited a 
 decided cloudiness on the addition of acetic acid and ferro- 
 cyanide of potassium, and a similar reaction with the same 
 acid and a concentrated solution of sulphate of magnesia. 
 It remained clear on boiling, and the subsequent addition of 
 nitric acid made no difference. When warmed with solution 
 of caustic soda and a very small quantity of sulphate of 
 ■copper, a red colour was produced. For more minute 
 examination a certain quantity of urine wa,s mixed with 
 about three times its bulk of absolute alcohol, and the preci- 
 pitate, after settling, was mixed with distilled water and 
 filtered. The clear solution became cloudy on the addition 
 of nitric acid, and also when acetic acid was used ; excess 
 of the latter, however, caused the clearness to return ; boiled 
 with nitric acid it became clear and a faint yellow in colour, 
 with soda and sulphate of copper the sohition assumed a 
 beautiful violet, and not a red colour. The urine gave the 
 same reactions on further examination a few days later, but 
 not afterwards, the quantity and specific gravity having at 
 the same time become normal. The patient was discharged 
 
 * The name hemi-albumosc, whicli lias been applied by Kühne to the 
 product of digestion referred to, is older than the term pro-peptone suggested 
 by Schmidt-Miililhcim, but I have preferred the latter as being more 
 ■euphonious.
 
 ALBUMEN IS EXCRETED. 11 
 
 mucli improved after a five montlis' stay in hospital^ and on 
 liis subsequent return on two occasions for short periods and 
 for slight ailmentSj nothing abnormal was discovered in his 
 urine. 
 
 The other cases were as follows : — A man, aged 6i, with 
 right hemiplegia ; a woman, aged 58, with pneumonia on 
 both sides ; a child, with diphtheritic laryngitis, on whom 
 tracheotomy had been performed in the surgical ward ; a 
 man, aged 55, with cancerous stricture of the oesophagus ; a 
 man, aged 26, with pneumonia on the left side ; and lastly 
 a theological student, aged 21, who, as stated by his 
 physician, had suffered four years previously from diphthe- 
 ritic inflammation of the throat, with dysentery and hsemor- 
 rhagic nephritis as sequelae, and lastly from neuritis of the 
 left brachial plexus, followed by paresis and atrophy of all 
 the muscles of the arm. This latter affection had entirely 
 subsided after lasting about a year, so that when I examined 
 him in July, 1 880, the action of the left arm was almost normal, 
 and the limb appeared to be only a little weaker than the 
 right. (Its circumference, as measured at various points, 
 was still .5 — 2 ctm. less than that of the right.) For some 
 time albuminuria had remained as a sequela of the nephritis, 
 and the patient had learnt how to test for albumen by 
 boiling his urine. After about a year and a half had 
 elapsed, during which time the quantity of albumen had 
 gradually diminished, nothing abnormal could be discovered 
 by means of this test ; subsequently, on boiling the urine, 
 albumen was occasionally discovered. When I examined 
 him, only the urine passed after the midday meal became 
 permanently cloudy on long boiling and the addition of acid 
 (see II and V, Albuminuria of Digestion), the urine passed 
 at other times contained no albumen coagulable on boiling, 
 but certainly pro-peptone. It should be remarked that the 
 patient had never suffered from oedema, and in spite of the 
 four years' continuance of the albuminuria there was no 
 trace of any cardiac hypertrophy. He felt also perfectly 
 well, and applied to me only for an explanation with regard 
 to the state of his urine. 
 
 In all cases the test for pro-peptone was that the urine 
 remained clear on boiling, but became cloudy or yielded a
 
 12 THE VARIOUS FORMS IN WHICH 
 
 precipitate with acetic acid and ferrocyanido of potassium. 
 For a further examination, we adopt the method described 
 in the first case, that is, by precipitating by alcohol. It was 
 not always possible to test all the reactions for hemi-albumose,. 
 mentioned by Kühne and Salkowski, partly because they 
 were not known at that time, and partly because the pro- 
 peptonuria had disappeared before the minute and systematic 
 examination could be made. But this much was determined, 
 in addition to the reaction with acetic acid and ferrocyanido 
 of potassium, that boiling alone left the urine clear, that 
 nitric or acetic acid produced cloudiness in the cold urine, 
 and that clearness was restored by heat. Small differences 
 in the behaviour of the urine, and deviations in the reactions 
 of the hemi-albumose obtained during digestion repeatedly 
 occurred, thus in the biuret test violet often took the place 
 of red, or acetic acid and concentrated solution of sulphate 
 of magnesia, or of chloride of sodium, caused no cloudiness, 
 or only a very slight degree of it in cold urine, and still less 
 on boiling. In my opinion much importance need not be 
 attributed to these deviations, for the quantity of saline 
 constituents of tho urine and other admixtures may well 
 account for them. 
 
 It appears more important to call attention to the fact 
 that it is highly probable that cases occur in which hemi- 
 albumose and albumen coagulable by heat (serum-albumin 
 and globulin) occur together in the urine, — cases which can 
 be designated by the term '^ mixed albuminuria." I have 
 repeatedly met with cases, and my experience is certainly 
 not solitary, in which the urine yielded a slight precipitate 
 on boiling, while the addition of nitric acid without previous 
 heat, or of acetic acid and ferrocyanido of potassium, 
 produced a copious precipitate, and further that the precipi- 
 tate caused by the nitric acid was diminished, and not 
 increased on boiling the mixture. I had hitherto always 
 thought that an explanation must be found for this in the 
 variety of the saline constituents of the urine, or perhaps in 
 the fact that in the cold urine uric acid was likewise pre- 
 cipitated, until I closely investigated a case of sub-acute 
 nephritis, in which these reactions were very striking. Tho 
 urine which was very acid was boiled, while a drop of acetic
 
 ALBUMEN IS EXCEETED. 13 
 
 acid was added, a flocculent precipitate was the result ; tlie 
 hot fluid was thrown on a filter and the clear filtrate, mixed 
 with thrice its bulk of absolute alcohol, allowed to stand for 
 twenty-four hours. The white precipitate was readily soluble 
 in distilled water, forming a clear solution, the slightly acid 
 solution remained clear on boiling, but became decidedly 
 cloudy on the addition of nitric or acetic acid, and cleared up 
 completely on boiling, the solution containing the nitric acid 
 becoming yellow, and the cloudiness not returning on cooling. 
 The precipitate caused by acetic acid was soluble in excess, 
 but not so that caused by nitric acid. In the solution, again 
 made clear by excess of acetic acid, ferrocyanide of potassium 
 caused a considerable precipitate. The addition of soda and 
 sulphate of copper produced a beautiful violet colour. The 
 behaviour of this precipitate certainly differs in some respects 
 from that of hemi-albumose and especially in this that the 
 precipitate caused by nitric acid and dissolved by heat does 
 not reappear on cooling, but, on the other hand it differs so 
 essentially from the ordinary albumen of the urine that we 
 can only assume that we are dealing with different albumi- 
 nous substances, or that some modification has taken place 
 as a result of the treatment (boiling and alcohol) to which 
 the urine has been subjected. But inasmuch as ordinary albu- 
 minous urine treated in a similar manner does not become 
 thus modified, the conclusion is perfectly natural that the 
 case is really one of " mixed albuminuria." Additional 
 instances of its occurrence are to be collected. 
 
 The peculiarity of hemi-albumose (pro -peptone), of not being 
 coagulated by heat, certainly accounts for the fact that so 
 little is known up to the present time of pro-peptonuria. 
 For, in the method commonly used for discovering albumen 
 in urine, viz., boiling, and then adding nitric or acetic acid, 
 its discovery is impossible, unless the mixture is set aside and 
 examined when perfectly cold, but this detail is, as a rule, 
 neglected, and if attended to there would be this source of 
 doubt viz., that uric acid and the products of the urinary 
 colouring matters gradually separate from urine thus treated. 
 It has also been repeatedly pointed out that this test is 
 inadequate in other respects, inasmuch as it is not sufiicient 
 for the detection of very small quantities of ordinary albumen
 
 14 THE VARIOUS FORMS IN WHICH 
 
 in the urine. As, however, notwithstanding these drawbacks, 
 the test in question is the only one in common use, it will 
 not be superfluous to give a brief account of far more reliable 
 tests which should be used in doubtful cases, or I would 
 rather say in all cases in future. These are as follows : (i) 
 to acidify the urine with acetic acid, and then add carefully 
 a (concentrated) solution of ferrocyanide of potassium, 
 according to Hofmeister the most delicate of all the tests for 
 albumen, and which precipitates all the albuminous bodies, 
 but not peptone. -"^ 2. The careful addition of nitric acid to 
 the (non-warmed) urine, followed by boiling if any cloudiness 
 results. 3. The addition of a concentrated solution of 
 chloride of sodium, or sulphate of magnesia to urine acidu- 
 lated by acetic or nitric acid. All three tests, or at least 
 the first and one of the others, should invariably be tried. 
 If after applying the second or third, a precipitate which is 
 formed on heating*, entirely or partially disappears, the pre- 
 sence of pro-peptone is indicated. Hindenlang- (21) has 
 lately recommended metaphosphoric acid as a delicate test 
 for albumen and it also precipitates peptone. As far as my 
 present experience goes, and as regards delicacy and con- 
 venience of testing, I can support his recommendation, 
 but for cases where great exactness is required, I would 
 recommend that recourse should also bo had to the other 
 tests, both for the purpose of checking results, and also 
 because when the quantity of albumen is small, the saline 
 constituents of the urino, the presence of other organic sub- 
 stances and other unknown influences arc apt to cause slight 
 differences in its behaviour towards one or other of the 
 reagents. For the discovery of pro-peptone, however, it is 
 necessary to have recourse to one test which is applicable to 
 cold urine and to another which requires the addition of 
 warmth. 
 
 If, as we may assume from Hindenlang's statement, 
 metaphosphoric acid is adopted for the discovery of very 
 small quantities of peptone in the urine, we shall have 
 obtained a very convenient method for the detection of 
 
 1 Salkowslvi states that this test fails only when a large amount of 
 chloride of sodium is present, but the urine never contains this constituent 
 in such quantities as to prevent the precipitation of albumen.
 
 ALBUMEN IS EXCRETED. 15 
 
 jDeptonuria. A precipitate caused by the acid, but not by- 
 acetic acid and ferrocyanide of potassium^ in tlie original 
 urine will indicate peptone to tbo exclusion of other sub- 
 stances. But if the urine gives a precipitate with the two 
 last-named reagents,, it is necessary first to boil and then 
 filter it so as to remove the coagulable albumen (serum- 
 albumin and globulin) ; the filtrate, which must remain clear 
 on the addition of acetic acid and ferrocyanide of potassium, 
 may then be tested with metaphosphoric acid for peptone 
 (and pro-peptone ?). At any rate the filtrate could be con- 
 centrated by evaporation and the precipitate caused by excess 
 of strong alcohol could be mixed with water and tested. As 
 a matter of course the positive results yielded by the tests 
 must be confirmed by other reactions.^ 
 
 The occurrence of such various albuminous substances in 
 the urine, especially of such as are not found in the blood 
 under normal conditions, suggests the idea that changes in 
 the composition of the blood may be concerned in the pro- 
 duction of these peculiar forms of albuminuria. We have- 
 in consequence learnt to recognise an additional factor for 
 the causation of albuminuria and shall therefore have to 
 consider the kidneys, and also changes in the conditions of 
 the circulation and of the epithelium and likewise alterations 
 in the condition of the blood. 
 
 II. Albumen as a Constituent op Normal Urine. 
 
 The question as to whether the urine in its normal condi- 
 tion does or does not contain albumen must always form the 
 starting-point for all investigations with regard to albuminuria. 
 That this question should be raised at all may seem heretical 
 
 ^ The following metliod is recommended by Hofmeister for the demon- 
 stration of peptone for clinical purposes. About one tenth of its volume of 
 concentrated hydrochloric acid is mixed with the urine, an acid solution of 
 the phosphortungstate of sodium is added, and the mixture is filtered without 
 allowing any precipitate to subside. The precipitate is washed with dilute 
 (3 — 5 proc.) of sulphuric acid, placed in a mortar and rubbed up very 
 thoroughly with baryta in substance, then mixed with a little water and 
 warmed for a short time. The fluid filtered from the insoluble baiyta com- 
 pound is then used for trying the biuret reaction.
 
 16 ALBUMEN AS A CONSTITUENT 
 
 to many persons, inasmucli as it is regarded as long since 
 disposed of, and answered in a decidedly negative manner. 
 However, in spite of the fact that the doctrine that normal 
 urine does not contain albnmen, and that albuminuria is 
 invariably a sign of disease, has not yet been exploded, it is 
 nevertheless true that occasional doubts as to its validity 
 make themselves heard with increasing force, and even its 
 most determined supporters, in consideration of the most 
 recent observations, which I shall presently mention, now 
 admit that exceptions exist to a dogma which only a short time 
 ago was held not to admit of them. This change of opinion was 
 •caused by the demonstration that, without any renal disease, 
 small quantities of albumen, formerly overlooked, appeared 
 in the urine, but without assuming significance, in the course 
 of many varying morbid conditions, and in the second place 
 by the discovery of albuminous substances, already referred 
 to, distinguished from the albumen coagulable by heat, 
 ordinarily occurring in the urine, by being imperfectly 
 coagulable, but more soluble and diffusible, and whose 
 escape therefore from the blood must, according to current 
 ideas, seem very obvious. Improved methods of investiga- 
 tion, and the discovery of delicate reactions have further 
 resulted in the discovery of albumen, in very many instances, 
 but in very minute quantities, in the urine of perfectly 
 healthy men, and this albumen, so far as it was possible to 
 judge from these small quantities, differed in no respect from 
 the albumen of the ordinary forms of albuminuria. I make 
 this assertion, because some years ago statements were made 
 to the effect that a substance with properties resembling- 
 albumen or peptone could be found in all specimens of 
 normal urine ; but little reliance was placed on these state- 
 ments, by reason of the defective methods of demonstration, 
 or certain irregular reactions exhibited by the substance 
 demonstrated. Thus, to pass over the statements of earlier 
 observers, Harlcy, but especially Bechamp and after him 
 Foster, Vintschgau and Cobclli have obtained from the 
 alcoholic precipitate of urine a substance called ^^nophrozy- 
 masis," which, however, on account of its diastatic properties 
 was regarded as a ferment, and not as a form of albumen (22). 
 It is not, however, possible to make a complete distinction
 
 OF NORMAL URINE. 17 
 
 between albuminous substances and ferments, even supposing 
 tbat the latter could be obtained in a pure state, inasmuch 
 as Seegen and Kratschmer's (23) inyestigations show that 
 substances unequivocally albuminous may exhibit diastatic 
 properties. Moreover, Leube, who in examining the urine of 
 twenty-one healthy men, found albumen in the alcoholic 
 precipitate in fourteen instances, distinguishes the latter 
 from the diastatic ferment, since in four of those fourteen 
 cases albumen occurred alone, and in seven out of the 
 twenty-one only the fei'ment was demonstrated. In its 
 reactions the albumen resembled paralbumen (24). 
 
 Be this as it may, there are now additional observations 
 with regard to the occurrence of albuminuria in healthy 
 men. That in these cases the substance referred to is 
 albumen in the ordinary sense, there is no room whatever for 
 those doubts which were constantly evinced towards the 
 statements of the older observers, such as Becquerel, Simon, 
 C. Schmidt, and Oanstatt. In recent times such observations 
 have constantly accumulated in proportion as urinary investi- 
 gations have been more numerous, and conducted with greater 
 care and more improved methods than formerly. I have 
 already referred to these methods (see p. 14), and we may 
 with certainty expect that as they become more frequently 
 employed, the discovery of albuminux-ia will become much 
 more common than hitherto. There is^ however, at the pre- 
 sent time a considerable number of observations of a 
 trustworthy character and to a great extent demonstrative, 
 although the most delicate methods have not always been 
 employed, of the excretion of albumen going on in healthy 
 men for a greater or less length of time, no sign of disturbed 
 health showing itself while this was going on, and during 
 an interval of some years. Cases of this kind have been 
 noticed by Frerichs, J. Vogel, Ultzmann, Gueneau de Mussy, 
 Leube, Gull, Moxon, Rooke, Dukes, Saundby, Edlefsen, 
 Marcacci, Munn, Bull, Fürbringer and Kleudgen (25). 
 
 This large number of recent observers, a portion of whose 
 discoveries were made quite accidentally, forbids us to 
 suppose that this albuminuria forms a very rare exception or 
 curiosity unworthy of consideration. Still more cogent in 
 this respect is the jDroportionate frequency discovered by
 
 18 ALBUMEN AS A CONSTITUENT 
 
 certain observers wlio liave specially investigated this sub- 
 ject. According to Leubo albumen was found in tlie urine 
 of 1 9 out of 119 Ileal tliy soldiers^ or in' 16 per cent.; 
 according to Munn in 24 (12 per cent.) out of 200 apparently 
 liealtliy persons wlio presented themselves for examination 
 for life-assurance. Fürbringer found albumen in 7 out of 
 61 healthy children (11 "5 per cent.), Kleudgen in 14 out 
 of 32 healthy nurses, (44 per cent.), and likewise in the 
 others when the urine was concentrated and its specific 
 gravity exceeded 1014. Kleudgen, therefore, thinks that 
 (apart from imperfect methods of testing) the dilution of the 
 urine is the sole cause why, as a general rule, no albumen is 
 discoverable in it. Certainly the dilution of the urine is an 
 element of very considerable importance in the demonstration 
 of its albuminous constituents, a point to which I shall draw 
 particular attention ; but it must not bo supposed that by 
 merely concentrating the urine until its specific gravity 
 becomes very high, albumen previously undiscoverable will 
 be invariably and at once found. This is by no means the case, 
 as wo can convince ourselves by evaporating every specimen 
 of urine which the ordinary tests show to be free from albu- 
 men. The saline constituents, which are thereby increased in 
 proportion, constitute an additional element in reference to 
 the demonstration of albumen, and as these are liable to 
 considerable variations in natural urine and under physiolog- 
 ical conditions, there is at least one obstacle, of a physiolog- 
 ical character, to the discovery of albumen in normal urine, 
 and even though it be of a high specific gravity. On the 
 other hand, in concentrated urine, after a portion of its saline 
 constituents has been precipitated by alcohol, it is certainly 
 easier to discover albumen than it was before. It would 
 appear, however, that other physiological factors are at work 
 in producing the result that albumen is sometimes found in 
 the urine and is absent at others. My own observations are 
 definite on this point. Some years ago I had, in common 
 with other observers, occasionally found albumen in the urine 
 of perfectly healthy persons, but especially in convalescents 
 or in patients sufieriug from ailments of a slight nature and 
 totally unconnected with renal afi^ections. The discovery 
 naturally gave rise to the suspicion that the persons were the
 
 OP NOliMAL UBINE. 19 
 
 subjects of chronic interstitial nephritis (trao atrophy of the 
 kidney, renal sclerosis), but this was not confirmed by further 
 observation. My attention having been aroused by this 
 varying symptom, occurring in myself and my three young 
 colleagues (assistants in the Augusta Hospital), all of us 
 enjoying excellent health, I examined the urine at different 
 hours of the day for a long period, and at one time or other 
 discovered albumen in the urine of each of us, certainly only 
 in faint traces, which might well have been ovei'looked had 
 less delicate tests been employed.^ No definite rule governing 
 its appearance could, however, be discovered, for the urine 
 might be examined for several days without once finding 
 albumen, which would then appear for a day and again vanish 
 as before. In my own case I found it most frequently 
 during the morning (ii — i o'clock), and only exceptionally 
 in the late afternoon after the principal meal. In one of my 
 colleagues it was several times found after dinner, in another 
 likewise during the period of digestion, but only when much 
 meat had been taken ; in the third the urine was examined 
 only a few times, but sufficiently often to show the occasional 
 presence of albumen. 
 
 Many observers have asserted that it is easy to discover 
 albumen in the urine during digestion, others have indicated 
 muscular activity as a factor giving rise to this result. The 
 physiological conditions are, however, by no means exhausted 
 by these statements, as my own observations incline me to 
 suppose, indeed they supply good reason why I should con- 
 sider it not improbable that if we were to examine the urine 
 for long periods at different hours of the 3ay and with great 
 care, we should, sooner or later, find it to contain albumen in 
 the case of every healthy man. If, however, the usual 
 custom be followed, and the total quantity or a large propor- 
 tion of the urine passed in a single day be submitted to exam- 
 ination, the small amount of albumen contained in one portion 
 is still further diluted by mixture with the remainder, and 
 the obvious result is that even after prolonged examination 
 the urine is never, or only exceptionally, found to be albu- 
 
 ^ To avoid any error Tvliicli might be ca'ised by admixture of semen or 
 prostatic secretion, the portions of urine first passed were not use.l for exami- 
 nation.
 
 20 • ALBUMEN AS A CONSTITUENT 
 
 minous. It is much to be desired that the urine passed at 
 different times of the day, by a still greater njimber o£ healthy 
 men, should be subjected to methodical and continuous 
 examination.^ 
 
 There is, however, something- more to be said with regard 
 to the observations that have been made. To take only the 
 smallest of the numerical proportions referred to, if it be true 
 that among eight or nine healthy men, there is one who 
 excretes albumen once or more often in his urine, it is 
 impossible simply to regard albuminuria as a symptom mor- 
 bid in its character under all circumstances ; but the admis- 
 sion must be made that if the occurrence in question does 
 not form the rule, it comes at any rate within the bounds of 
 a physiological condition. It must be admitted either that 
 albumen is present in all urine, but in varying quantities, so 
 that sometimes it eludes observation by the means at our 
 command and sometimes, under certain physiological con- 
 ditions, it can be discovered, or that it is altogether absent at 
 certain periods and appears in the urine only when certain 
 conditions are in existence. The former of these two assump- 
 tions, viz. that the urine always contains albumen but only 
 occasionally in appreciable quantities, appears to me to be 
 the more reasonable and eligible, for the two following 
 reasons. In the first place it cannot be denied that our 
 power of demonstrating albumen in urine has a certain limit, 
 even in cases where there is no doubt as to its presence. 
 The truth of this assertion is supplied by specimens of urine 
 in which no albumen is discoverable by the ordinary methods. 
 For it is well known that all normal urine, after remaining at 
 rest for some time, exhibits a slightly opaque cloudiness 
 (nubecula), which is caused by the epithelium of the urinary 
 passages, and contains albumen, as can be proved by collect- 
 ing it in considerable quantities (i6 a). The objection might 
 ]jc raised that this albumen is mixed with the urine but not 
 dissolved in it, but oven when its solution is effected by 
 adding liquor soda), no reaction due to albumen is shown by 
 the urine, as was likewise the case before the addition of the 
 
 ^ Tlic urine of the animals commonly used for experiment (rabbits, clogs, 
 and cats) very often contains traces, and not seldom considerable quantities, 
 of albumen under conditions of apjiarently perfect health.
 
 OF NORMAL URINE. 21 
 
 soda. We are therefore perfectly justified in stating that our 
 present methods are not sufficient for the detection of extremely 
 minute quantities of albumen in the urine, and that therefore 
 urine in which no albvimen can be found may yet contain traces 
 of that substance. In the second place, it is more in accord- 
 ance with our other experiences and ideas to assume quan- 
 titative oscillations of a function within physiological limits 
 rather than qualitative changes. For example, still to confine 
 ourselves to urine, we daily see that any one of its normal 
 constituents may be excreted in quantities greater or less 
 than the average, but it is a far rarer occurrence, if after all 
 under physiological conditions, for an entirely new substance 
 and one hitherto absent to appear in the urine, unless it or 
 something' from which it could be immediately derived, had 
 been introduced into the blood. Indeed, when something of 
 this kind takes place, i.e. when a substance previously 
 unknown in normal urine is discovered therein, we are, ft 
 'priori and with justice, disposed to assume that it is a normal 
 constituent of the urine, but one which has hitherto escaped 
 recognition, by reason of the minuteness of its quantity or 
 because our methods of investigation were inadequate for its 
 detection. 
 
 Of late years numerous experiences of this character 
 have been aiforded by various constituents of the urine. I 
 refer especially to two of them, viz. grape sugar^ and oxalic 
 acid, because they play in pathology a part similar to that of 
 albumen. How much controversy has taken place as to 
 whether these substances belong to the normal constituents 
 of urine, or whether their occurrence is under all circumstances 
 a morbid phenomenon ! Nowadays we know that they do 
 occur normally in urine, but in such insignificant quantities 
 that a large volume of urine and very delicate methods are 
 required for their demonstration ; and we also know that 
 
 ^ According to the most recent investigations the reactions supposed to be 
 due to the presence of sugar in the urine may depend upon glycuron acid. 
 For our purposes, however, this question is of no consequence, for sugar is 
 referred to here only for the sake of comparison, and besides it and oxalic 
 acid there are several other substances with regard to which the above 
 statements equally hold good. These are hippuric acid, glycerin-phosphoric 
 acid, inosite, xanthin, indoxyl-sulphate of potash (indican), phenol, pyro- 
 catechin, &c.
 
 22 ALBUMEN AS A CONSTITUENT 
 
 sometimes, and even under physiological circumstances, they 
 appear in larger quantities easily recognisable, and that 
 therefore we must admit the existence of a physiological 
 glycosuria and oxalnria. Considering that there are admitted 
 limits to the physiological increase in the normal excretion 
 of sugar or oxalic acid, why should not those cases of the 
 excretion of albumen in healthy men be regarded as exhibiting 
 simply the physiological increase of a normal process ? 
 Nothing prevents us from assuming the occurrence of a 
 physiological albuminuria which takes place just as physio- 
 logical glycosuria, oxaluria, or other physiological increase 
 of those normal urinary constituents, the discovery of which is 
 attended with difficulty, — that is to say, that certain conditions 
 may cause them to make their appearance in larger and there- 
 fore more demonstrable quantities. The conditions with 
 regard to the appearance of albumen are by no means more 
 unfavorable than for that of other substances. 
 
 As regards the origin of the urinary albumen in all these 
 cases, there is no lack of a source extremely rich in this sub- 
 stance. This, as a matter of course, is the blood flowing in the 
 Malpighian tufts, for the blood of the interstitial vascular 
 system, or the lymph, or any other source, under normal 
 conditions, needs not be considered, and this statement 
 requires no further explanation. The albumen therefore 
 must have its origin in the blood of the Malpighian tufts. 
 This statement corresponds, to some extent, with the theory 
 of the excretion of urine, which for some time past has been 
 advanced by Küss (26), von Wittich (27), and Henle (28), 
 but which has mot with few supporters and many opponents, 
 in the first place, because it makes it difficult to explain the 
 absence of albumen in ordinary normal urine, and likewise 
 because it is not altogether in accordance with the fact 
 recently discovered of the slight diffusibility of albumen as 
 a colloidal substance. After what has been stated with 
 regard to physiological albuminuria no importance can be 
 attributed to the first objection, the fact being that normal 
 urine is often found to be alliuminous, if proj^jcrly examined, 
 and all causes may be assumed to account for albumen being 
 a normal constituent of the urine, though its presence cannot 
 always be demonstrated. As regards the other objection.
 
 OP NOÜMAL UBINE. 
 
 the sliglit diffusibility and capacity for filtration of albumen, 
 tliis must, at least to some extent be waived, inasmucb as 
 membranes, permeable by albumen, are to be found tbrougbout 
 tlie body. On tbe other hand, quite recently the belief has 
 arisen that the escape of albumen from the Malpighian tuft 
 is prevented by the epithelial investment of the vessels ; and 
 this theory is now acquiesced in by all those who endeavour 
 to explain the absence of albumen in the fluid which leaves 
 the tuft, this view being adopted especially by Runeberg, 
 Heidenhain, and Cohnheim, as already mentioned.^ Nothing 
 could appear more simple and intelligible than this explana- 
 tion, and it might be adopted forthwith if it could relieve 
 us of any one difficulty, and did not too obviously contradict 
 patent facts. In the first place, it contradicts the well- 
 known fact, insisted upon always, except only upon this 
 occasion, that egg-albumen passes without difficulty into the 
 urine, and, as has been shown by Nussbaum on frogs, and 
 Ribbert on rabbits, through the vessels of the Malpighian tufts. 
 The explanation for this is sought for in the greater ease 
 with which egg-albumen passes through a filter, an explana- 
 tion to which as yet no one has raised any objection, and the 
 same will apply to peptone. This marked capacity for filtra- 
 tion has been incidentally shown on dead animal membranes. 
 It is obvious that, when with regard to these cells, it is only 
 a question of a greater or less capacity for filtration, it is 
 impossible to understand how they can be completely im- 
 permeable for the normal albuminous constituents of the 
 blood. For there is no doubt whatever that these albuminous 
 substances are capable of filtration, especially from saline 
 
 * A different view is adopted by Ribbert in his recent work on ' Nephritis 
 and Albuminuiia ' (29). He attributes no importance in this respect to the 
 epithelial covering of the Malpighian tufts, but thinks that these capil- 
 laries, which, according to him, are almost entirely without nuclei, possess 
 more cohesion than other capillaries, and therefore prevent the escape of 
 albumen. It is hardly possible to take this view even if we choose to 
 admit as correct Eibbert's isolated assertion with regard to the paucity of 
 nuclei of those capillaries. There are, moreover, no capillaries which are 
 impermeable by albumen, and experiments made with this view on kidneys 
 both before and after death have demonstrated that there is no difference be- 
 tween these and other organs in this respect ; and, lastly, the investigations 
 of Frommann and of Eiemer on argyria have shown that solutions of silver 
 pass as readily through the Malpighian tufts as through any other vessel {?,oJ .
 
 24 ALBUMEN AS A CONSTITUENT 
 
 solutions^ sucli as the serum of the blood. We are therefore 
 forced to assume that they also filter through the Malpighian 
 tufts^ but in an extremely minute quantity, corresponding 
 with their small capacity for filtration. 
 
 Let us then consider the epithelium somewhat more closely, 
 as to it is assigned the task of retaining the albumen. This 
 consists, after birth, of extremely flat, thin cells, which 
 most closely resemble the endothelium of serous membranes, 
 " This epithelial investment," says Cohnheim, " is something 
 quite peculiar to the glomerulus, having at the most a distant 
 analogy with the endothelial membrane covering the choroid 
 plexus, the seat of the secretion of tha cerebro-spinal fluid, 
 which is almost free from albumen.''^^ If the analogy 
 referred-to be real though distant, there is clearly one con- 
 clusion to be drawn therefrom, and this is that the capillaries 
 of the Bowman-Müller's tufts permit the escape of a fluid 
 " almost," but not quite, free from albumen. And we are 
 the more justified in arriving at this conclusion, from the 
 fact that it is in complete harmony with what we know 
 regarding other normal transudations (and it may be added 
 abnormal ones also) which pass through capillaries and epi- 
 thelial membranes, and which all without exception contain 
 large and varying quantities of albumen. Not merely does 
 the cerebro-spinal fluid contain albumen, but the transuda- 
 tions of all serous membranes which have an epithelial 
 investment are albuminous, and normally so, as is evidenced 
 especially by the pericardial fluid ; in the majority of the 
 other sacs too little fluid is present for purposes of demonstra- 
 tion. The aqueous humour which transudes in the anterior 
 chamber of the eye, which has a complete epithelial covering, 
 contains albumen, the perilymph and endolymph of the 
 auditory labyrinth, which are certainly separated by epithe- 
 lium from the secreting capillaries, contain albumen. 
 Certainly all normal transudations (to say nothing of 
 abnormal ones) contain albumen ; in whatever part of tlie 
 body fluid escapes from the blood tvithout the interposition of 
 specif c glandular epithelium, it contains albumen, even when 
 it has to pass through an epithelial covering, as well as a. 
 capillary wall. It would therefore be marvellous if the 
 ' This fluid contains albumen in the proportion of "3 — 3 per 1000.
 
 OF NOJiMAL URINE. 25- 
 
 fluid which escapes from the glomerular vessels of the kidney 
 did not contain albumen. 
 
 It is true that we assume that this fluid is in reality only 
 a transudation, that is, pressed out by filtration, but not a 
 product of secretion, and in this we are in complete harmony 
 with the general opinion.^ Qtiite lately Heidenhain alone has 
 expressed a different opinion to the effect that the process 
 which goes on in the kidney is a real secretion, just as that 
 of other glands, since the excretion of water in the kidneys 
 depends upon the functional activity of those cells of the 
 glomerular vessels, the quantity of blood contained in them 
 in a unit of time determining the rate at which the process 
 is carried on. The function of these cells is, therefore, the 
 separation of water (and of the salts by which it is always 
 accompanied) and the prevention of the passage of albumen 
 from the blood. When this function is interfered with, as may 
 occur when the flow of blood through the arteries is checked 
 for a short time, water is separated in smaller quantity 
 and the secretion contains albumen. Heitlenhain himself doe& 
 not attempt to conceal the difficulties connected with this 
 assertion, and, indeed, it is very difficult to attribute the 
 possession of secretory glandular activity to epithelial cells, 
 such as those which cover the glomerular vessels, and are 
 altogether different in their nature from that of all known 
 glandular cells. A greater objection, however, to this 
 assumption is formed by the condition of the secretory func- 
 tion of the kidney, when the blood-pressure is increased 
 without diminution of the flow through the arteries, a state 
 of things which may result from impeded discharge from the 
 veins, the heart's action remaining undisturbed, or from 
 active congestion under conditions of increased afilux without 
 any impediment to the escape of blood. In the first case, 
 the rapidity of the flow is checked, in the second, it is 
 increased. According to Heidenhain the retardation of the 
 
 1 Euneterg, who very justly refers to the fact that all normal and 
 pathological transudations contain albumen, nevertheless asserts, in contra- 
 diction to this statement, that epithelial membranes do not permit albumen 
 to pass through them, and for proof of this he relies upon the tears and the 
 perspiration. Both of these, however, are not transudations, but secretions. 
 It may also be remarked in passing that albumen has been found in both.
 
 26 ALBUMEN AS A CONSTITUENT 
 
 current must produce a disturbance of tlie nutrition and 
 function of those epithelial cells, and as a consequence, 
 diminution of the quantity of urine and escape of albumen. 
 In the second case, increased secretion of urine free from 
 albumen is the necessary consequence. But this is not what 
 really takes place. The first condition, increased pressure 
 with retardation of the current, can be very easily produced 
 by entirely or partially closing the renal vein or the inferior 
 vena cava, but it is difficult to form any definite conclusion 
 with regard to the alterations in the quantity of urine under 
 these circumstances, the only positive fact being that the 
 urine is thereby rendered albuminous. In the human 
 subject, in which it is easier to observe quantitative changes 
 in the urine, occlusions of the renal vein or inferior vena 
 cava very rarely occur, and almost always under conditions 
 in which the arterial blood-pressure is reduced, as takes place 
 in marantic thrombosis, or in occlusion due to cancer, &c. 
 Only in very rare exceptions has arrest of the escape of blood 
 from the kidney been observed in conjunction with well- 
 maintained cardiac activity and normal arterial pressure. 
 For a case of this kind we are indebted to Bartels (31). It 
 was one in which there was impeded escape of the blood of the 
 renal vein, in consequence of thrombosis of the inferior vena 
 cava, occurring in a very robust man, forty-four years of 
 age ; it was, therefore, not a case of ordinary congestion as a 
 result of defective action of the heart, in which there is also 
 diminution of arterial pressure. Now this patient, as Bartels 
 states, passed "enormous quantities" of urine (on an average 
 1640 ccm. daily in spite of most marked oedema), generally 
 containing a considerable quantity of blood, and with a 
 specific gravity varying from I'oii to i '013, and always con- 
 taining much albumen and a sediment of red blood- cor- 
 puscles and epithelial and other casts. This case furnishes 
 evidence of a more decided character than any experiment 
 against Heidenhain's view of the function of these epithelial 
 cells. For in spite of the retardation of the current, which 
 obviously existed, there was no diminution, but a consider- 
 able increase in the quantity of the urine. According to our 
 view, which moreover is admitted as an explanation l)y 
 Bartels, both phenomena, viz. the increased quantity of urine
 
 OF NORMAL UßlNE. 27 
 
 and the escape of albumen and blood, find their inter- 
 pretation in the increased pressure in the glomerular vessels. 
 Heidenhain's supposition is also contradicted by other clinical 
 experiences, not perhaps in such a striking manner as by the 
 above-mentioned case, because the conditions are less simple. 
 They are fully deserving, however, of being mentioned. 
 Thus it is a well-known fact that in certain stages of chronic 
 nephritis and nephro-sclerosis, a very watery and more or 
 less albuminous urine is secreted, whereas the glomerular 
 vessels are in a great degree or almost entirely destroyed, 
 and their epithelial investment has completely perished. 
 Under these circumstances no secretion of water can occur 
 from these parts. 
 
 The second case, increase of blood-pi'essure with accelera- 
 tion of the current, has often been a matter of experimental 
 and clinical observation, and will be thoroughly discussed in 
 subsequent pages. It may here be remarked that under 
 these circumstances, in which there is no kind of question of 
 any disturbance of nutrition and function, albuminuria may 
 occur, a fact utterly irreconciloable with Heidenhain^s view, 
 but perfectly intelligible if we adopt the filtration theory. 
 How it conies to pass that albuminuria is not to be discovered 
 in every case of increased blood-pressure of a like kind, will 
 be discussed later on, when we come to deal with this 
 subject (S. III). 
 
 A consideration of these details will cause us to accept 
 without scruple the generally received view which forms the 
 starting-point of the above description, namely, that the 
 fluid which escapes from the glomerular vessels is a transu- 
 dation, formed in accordance with the laws of filtration, and 
 not a glandular secretion. In this respect I adopt Ludwig's 
 theory of the secretion of urine, but I differ from him in 
 regarding the filtrate as not wholly free from albumen. On 
 the other hand, in another respect, I completely assent to 
 Heidenhain's theory, in so far as he considers that the 
 epithelium of the tubuli uriniferi are actively employed in 
 the secretion of certain specific constituents of the urine. It 
 appears to me that this combination of the two theories 
 satisfactorily gets rid of all the difficulties particularly 
 connected with the simple filtration-theory, and which have
 
 28 ALBUMEN AS A CONSTITUENT 
 
 led Heidenliain to assumo that the epithelial covering of tlie 
 glomerulus is an agent in the secretion of water, as 1 shall 
 show further on. To facilitate the comprehension of what 
 follows, I will now only observe^ that according to my view, 
 the assumption universally received and which forms the basis 
 of every theory, i.e. that tho water of the urine is normally 
 furnished only by the glomerular vessels, is thoroughly 
 untenable, and that we ought rather to assume that the 
 vessels in question supply only a portion, though certainly 
 the larger portion, and that the remainder is yielded by the 
 true secretory elements of the kidney, the epithelium of the 
 uriniferous tubules. This last supposition is based upon the 
 fact that we cannot imagine a glandular secretion without 
 water, unless we picture to ourselves that the whole process 
 consists in nothing else but fatty degeneration of the 
 epithelium, as takes place for example in the formation of 
 the sebaceous secretion of the skin. Nothing of this kind, 
 however, can be thought of in connection with the kidney. 
 Moreover, direct proof that these epithelial cells, i.e. those 
 which invest the tubuli uriniferi, are actively engaged in the 
 secretion of water, has been furnished by Nussbaum (32). 
 The urinary water has therefore two sources, and is partly 
 a transudation and partly a secretion. A firm grasp of this 
 fact is an important aid in explaining the different changes 
 which take place in the urine under various conditions. 
 
 If therefore the fluid Avhich escapes from the glomeruli be 
 a transudation, is there any reason why it should form an 
 exception to all other transudations, as regards the albuminous 
 constituent which is a feature common to all ? Certainly the 
 glomerular vessels arc exceptional in this particular, that in 
 them the lateral pressure is greater than in any other 
 capillary system of the whole body. 
 
 We know, however, that ceteris 'paribus, the quantity of 
 albumen which filters through an animal membrane from an 
 albuminous solution, increases with the increase of pressure, 
 but not in a degree proportional thereto. And in fact this 
 increase is an absolute one, and not relative in proportion to 
 the total amount of the filtrate passing through in a certain 
 unit of time, inasmuch as, with the augmented pressure, the 
 degree of increase of the quantity of water which passes is
 
 OP NORMAL URINE. 29 
 
 greater than that of the albumen. In other words, the 
 greater the pressure under which filtration takes place, the 
 greater the quantity of the filtrate in general, and the 
 smaller its percentage of albumen ; but for all this, for equal 
 periods the total amount of the filtered albumen is greater 
 when the pressure is high than when it is low. It follows, 
 therefore, as regards the glomerular vessels, that they must 
 yield a transudation richer in water, but poorer in albumen 
 than any other set of capillaries in the whole body. 
 
 The investigations which have been carried on in Ludwig's 
 laboratory with reference to the phenomena of the formation 
 and flow of the lymph, which are not influenced merely by 
 changes of pressure, have caused us to regard as inadmissible 
 the application of the laws of filtration, as they are found to 
 apply in the case of animal membranes outside the body, to 
 the processes of transudation which take place within the 
 body. But although the connection between the formation 
 of lymph and transudation from the capillaries is a very 
 close one, yet the lymph which escapes from an opening in 
 a lymphatic trunk cannot be regarded as a simple transudation, 
 and just as little reason would there be in supposing that the 
 conditions of the current in such a vessel were the same with 
 those of transudations from the capillaries, so that our ideas 
 with regard to the one could be simply transferred to the 
 other. The fluid which escapes from a lymphatic vessel differs 
 essentially and in many respects from transudations due to 
 congestion of capillaries. Morphologically, the distinguishing 
 characteristic of " lymph " is the abundance of colourless 
 cells which it contains ; chemically, '^ lymph " and transuda- 
 tions are very dissimilar indeed. It is a well-known fact 
 that '' lymph " coagulates on exposure to air, whereas the 
 real transudations never exhibit this phenomeuou, unless 
 they are mixed with blood, or " lymph,^^ or products of 
 inflammation. The transudations, without exception, contain 
 ■either no potash whatever, or at most only very slight 
 traces, as little, indeed, as the serum of the blood, when this 
 is obtained perfectly free from corpuscles ; the lymph, on 
 the other hand, invariably contains potash in considerable 
 amount, for the analyses of Hensen and Dähnhardt show a 
 proj^ortion of more than three per cent, after incineration (33).
 
 30 ALBUMEN AS A CONSTITUENT 
 
 It miglit Ibe considered, therefore, tliat these differences 
 would suffice to indicate tlie diversity between the two fluids, 
 and to suggest an origin, pa,rtly perhaps, but not altogether iden- 
 tical. Moreover, that observations made upon the discharge of 
 fluid which takes place fi*om an opening in a lymphatic vessel 
 do not justify the conclusion that the process is identical with 
 a transudation, is demonstrated by the fact that the current 
 from such a vessel entirely ceases after a certain time, 
 whereas there is no ground for supposing that transudation 
 has ceased, and besides this, the stagnant current of lymph- 
 can be made to resume its movement, by active and passive 
 movements, such as gentle rubbing, these manipulations pro- 
 ducing no effect on transudation. There is, lastly, this fact, 
 that even the total occclusion of all the lymphatics of a 
 portion of the body is never followed by local oedema (34). 
 If the current in a lymphatic trunk were in complete analogy 
 with transudation from capillaries we should be justified in 
 expecting that occlusion of the former would cause the 
 transudation to accumulate and that oedema would result. 
 But all these facts prove that the lymph-current is altogether 
 unessential for transudation, and observations upon it cannot 
 therefore enable us to draw any positive conclusions with 
 regard to the conditions under which the latter process takes 
 place. 
 
 The function of the lymphatics is that of auxiliaries to the 
 veins. Fulness of the lymphatics indicates inadequacy on 
 the part of the veins for the removal of transudation, but 
 diminution in the current of lymph, so long as the flow 
 through the veins is free, by no means indicates diminished 
 transudation, for the power of absorption and of removing 
 transuded fluids, possessed by the veins, can be increased far 
 beyond the normal amount, as is evidenced by the non- 
 appearance of oedema when the lymphatic current is arrested : 
 the veins can, without aid from the lymphatics, fulfil their 
 task, the removal of the transuded fluids, but the latter cannot 
 thus dispense with the assistance of the former. It follows 
 that the non-appearance of oedema under conditions of 
 increased arterial pressure, the current through the veins 
 being unimpeded, is no proof that the transudation is not 
 increased. There is an increase in this respect, and also in
 
 OF NOKMAL UEINE. 31 
 
 the rapidity of the current and the removal of the transudation 
 by the veins, and only in rare cases, when these means do not 
 suffice, does the current of lymph become more copious (35). 
 
 These are facts the truth of which has been firmly 
 established by experiment, and they are in harmony with all 
 pathological experiences. In addition to this, everyday 
 practice at the bedside clearly teaches us that the formation 
 of transudations, oedema, depends directly upon the pressure 
 in the capillary system, and particularly that the quantity of 
 the transuded fluid rises and falls with the pressure. 
 
 Euneberg's views, put forward some years ago, differ from 
 the above account, and contradict the universal assumption 
 with regard to the cause of the passage of albumen through 
 animal membranes by referring the phenomenon to a diminu- 
 tion of pressure below the normal height. But this theory, as 
 Heidenhain has shown, has its origin in the fact that Rune- 
 berg has misinterpreted his own experiments. Properly 
 estimated, and due care being taken to keep separate the 
 absolute and relative amounts of albumen, they are in com- 
 plete harmony with the law just described, and are as con- 
 firmatory thereof as the recent investigations of D. Newman 
 (36), Gottwalt (37), von Bamberger (38), and numerous 
 clinical experiences, to say nothing of the researches of an 
 older date. If all the clinical facts are not sufficiently clear 
 and simple to be regarded as demonstrative, they are never- 
 theless in complete harmony with our statement ; on the 
 other hand, it is difficult to reconcile them with Euneberg's 
 views, and we can do so only by adopting forced premises, 
 not altogether in harmony with one another. That this is so 
 is best evinced by his attempts to explain by his theory 
 all forms of albuminuria, as will be shown in subsequent 
 pages of this treatise. I may here just refer to the simple 
 and well-known example of ascites, the cause of which is 
 increased pressure in the vena portae, whereas according to 
 Runeberg, it must necessarily occur when the pressure in the 
 vena portte sinks below the normal. This point is passed 
 over by Runeberg, he mentions only the fact that when an 
 effusion has once taken place into the abdominal cavity, the 
 albumen of this transudation increases with the quantity of 
 fluid, the certain result being that the difference between the
 
 82 ALBUMEN AS A CONSTITUENT 
 
 pressure inside and outside the blood- vessels^ and conseqiiently 
 tlie filtration-pressure, become diminished. This pheno- 
 menon, which he regards as supporting his view, has been 
 simply explained by F. Hoppe (Seylei-) as exemplifying the 
 generally received view concerning the influence o£ pressure, 
 that is to say, that with increasing pressure more water is 
 absorbed, the fluid becomes concentrated, and as a matter of 
 course the quantity of albumen is thereby increased (39). 
 
 Notwithstanding the above objections, there is a sense in 
 which we can accept Iluneberg's assertion that albuminuria 
 is caused by diminution of the blood-pressure in the kidney, 
 but we do not agree with him in supposing that the altered 
 circumstances permit albumen to escape in places where 
 hitherto no such passage had occurred, the true explanation 
 being that relatively less water escapes, the quantity of 
 albumen is therefore increased, and the albuminous transu- 
 dation is rendered more distinct — it becomes, that is, an 
 appreciable phenomenon. The diminution of pressure 
 therefore facilitates the discovery of the escape of albumen. 
 In addition to this, the diminished pressure favours the 
 appearance of albumen by reason of the influence it exerts 
 upon the second factor concerned in the formation of urine, 
 viz. the secretion of the epithelium of the uriniferous tubules, 
 a factor altogether neglected by Euneberg, and all others 
 who have endeavoured to explain the phenomena of albu- 
 minuria. We shall explain at length in a subsequent page 
 how albuminuria occurs through the collective effects on 
 both factors, of a reduction in blood-pressure when this is 
 present (S. III). 
 
 Our principal task now is to show how it is that under 
 normal conditions albuminuria, i.e. the manifest presence 
 of albumen in the urine, is not an ordinary occurrence, and 
 with regard to this, the second factor, the secretion of the 
 true glandular epithelium, is of considerable importance. 
 
 This secretion, containing the so-called specific consti- 
 tuents of the urine, dissolved in water, and free from albu- 
 men — a fact requiring no demonstration with such views 
 as are now prevalent — passes into the tubuli uriniferi and 
 mixes with that transudation from the glomerular vessels, 
 which, as wc have seen, is extremely poor in albumen. It
 
 OF NORMAL URINE. 33 
 
 is pretty certain tliat no direct increase of albumen takes place 
 in the further passage through the urinary tubules, and there is 
 no ground for the supposition that, owing to the absorption 
 of water with or without salts, the contents of the tubes 
 become relatively richer in albumen. It is well known that 
 no decision has yet been arrived at on the question as to 
 whether any absorption really takes place from the uriniferous 
 tubules, as is assumed in Ludwig's theory of the secretion of 
 urine, but in opposition to the general and well-grounded 
 opinion on this point. It is, nevertheless, conceivable that 
 absorption might occur, if not in all parts of the urinary 
 tubules, at all events, perhaps, in that portion contained in 
 the renal medulla, which is so copiously supplied with veins 
 and lymphatic vessels, that is therefore in the straight tubes, 
 and in the ascending and descending limbs. But if this be 
 so, we could not expect that albumen actually in a state of 
 solution should be excluded from absorption. For if this 
 latter process involves all portions of the fluid contents of 
 the urinary tubules, it would affect the albumen as one of 
 them ; but if, as Ludwig^s theory requires us to assume, 
 materials are selected for absorption, the specific constituents 
 of the urine being excluded, the albumen must certainly be 
 absorbed. For least of all can the albumen be considered 
 as a specific constituent, and when it is present in a state of 
 solution, and not merely floating about in a fluid, it is 
 constantly taken up wherever absorption is going on. 
 
 The urine, which therefore represents a mixture of the 
 transudation from the glomerular vessels and of the secretion 
 of the uriniferous tubules, is probably on the whole more 
 concentrated, that is, richer in other fixed constituents, but 
 poorer in albumen, than the transudation peculiar in that 
 respect, and whose proportion of albumen must be less than 
 the lowest percentage of any transudation. If we represent 
 the percentage of albumen in the transudation from the 
 glomeruli as a, and the amount of the secretion from the 
 glands which, is added thereto as n, then, if no absorption 
 takes place, the amount of albumen in the urine as a whole 
 
 a 
 will amount only to , ''^ • ^^ ^^t therefore, not hard to 
 
 100
 
 34 ALBUMEN AS A CONSTITUENT 
 
 imagine tliat tlie demonstration of albumen in normal urine 
 is beset with difficulties. It is likewise to be supposed tliat 
 differences may occur even in the normal condition, and that 
 the discovery of albumen sometimes succeeds and at other 
 times fails. Not only does the pressure in the glomerular 
 vessels vary under physiological conditions, a fact which admits 
 of no doubt, the result being that the fluid which transudes 
 from them contains sometimes more and sometimes less 
 albumen, but in addition, that portion of the urinary 
 secretion which depends upon true glandular action, being 
 under the influence of physiological conditions, is sometimes 
 abundant and sometimes scanty. This latter fact is equally 
 certain, and corresponds with our knowledge of all other 
 glands. The more productive the activity of the glandular 
 epithelium, the poorer will the urine bo in albumen, other 
 conditions being equal, and the more difficult the demon- 
 stration, and the reverse. And thus it comes to pass that in 
 consequence of the varying action of the two sources of the 
 urine under physiological conditions, different combinations 
 can be imagined, as a result of which the discovery of 
 albumen may be easy, or difficult, or impossible, that is to say, 
 that albuminuria may or may not be demonstrated, according 
 as both sources either co-operate or act in opposition with refer- 
 ence to the quantity of albumen in the urine. Increase of the 
 pressure under which filtration takes place in tho glomerular 
 vessels, and of the secretion in the epithelium, will cause 
 albuminuria to be absent {i.e. obvious excretion of albumen), 
 diminution of both those factors will produce its appearance, 
 increase of the one and diminution of the other will produce 
 a result dependent upon the influence which preponderates, 
 as will be shown in special cases in subsequent pages (p. 39 et 
 seq.). If to all these considerations we add the individual 
 differences with regard to filtration and secretion, which are 
 properly allowed to play so common a part in the dissimilar 
 reaction of different individuals under physiological and patho- 
 logical conditions, wc shall have scarcely any difficulty in 
 understanding the fluctuations to which physiological 
 albuminuria is subject. 
 
 All this discussion, all the matters of fact and the con- 
 clusions deduced therefrom, are therefore incorporated in
 
 OF NORMAL URINE. 35 
 
 the assumption tliat under normal conditions a fluid 
 extremely poor in albumen transudes into Bowman-Müller's 
 capsules, and that physiological albuminuria is dependent 
 upon the albuminous contents of this fluid. An assumption 
 certainly is not equivalent to a direct proof, but, in the 
 absence of any such, is perfectly justifiable so long as it 
 cannot bo shown that there is any error in the facts upon 
 which it is based, or that experiences and analogies are 
 unjustly brought forward in support, or lastly, until we have 
 direct proof to the contrary. Not long ago it was regarded 
 as impossible, by direct observation or examination, to prove 
 whether the fluid contained in the Bowman-Müller's capsules 
 is albuminous or not. To Posner is due the credit of having 
 indicated a method of directly observing that transudation by 
 an improved method of boiling — and to him we are indebted 
 for the positive proof that in many cases of pathological 
 albuminuria the source of the albuminous secretion is to be 
 found in the glomerular vessels — a fact which until recently 
 could only be guessed at with more or less probability. But 
 Posner has gone further than this, for he believes that he has 
 positive proof for his assertion " that the kidneys under 
 normal conditions are not albuminuric, that is, that no 
 albuminous substances transude from the blood-vessels of the 
 glomeruli." He holds this opinion, because in normal 
 kidneys he has not been able to detect any excretion of 
 albumen in the capsules, but he manifestly over-estimates the 
 efficiency, as a test, of the method of boiling and of the micro- 
 scope. For there is no doubt that albumen may be and is 
 present without becoming visible after boiling.^ I will not 
 discuss the fact that in normal kidneys, even after boiling, no 
 trace of coagulated albumen can be discovered in the lym- 
 phatics, which, according to Ludwig and Zawarykin (40), 
 surround the vessels and the urinary tubules, and, according 
 to Ryndowsky, (41) probably enter the capsules and wind 
 round the glomerular vessels. Can there be any doubt of the 
 presence of lymph and albumen, simply because they are 
 invisible ? But more than this ; albuminuria can be induced 
 in various ways, and the most minute examination may faiL to 
 
 ^ What is true of boiling holds good also with regard to hardening and 
 coagulation by alcohol.
 
 36 ALBUMEN AS A CONSTITUENT 
 
 detect any excretion of albumen in any part^ and especially in 
 tlie capsules of tlie boiled kidney or after hardening by alcohol. 
 This may be very easily and securely effected in rabbits, 
 by rapidly heating them (see page 48), or by injecting a 
 very small quantity of phosphorised oil {^ — ^ cctm. of a 
 solution of one part phosphorus to eighty olive oil) under the 
 skin (see S. IV). Often immediately after a single injection, 
 but always after a repetition on the second or third day there 
 is evident albuminuria, the urine contains finely granular 
 casts and occasionally renal epithelium easily recognisable. 
 After boiling the kidneys and hardening them in alcohol, they 
 exhibit changes corresponding with the degree in which they 
 have suffered. These are sometimes of a transient character and 
 take the form of patches of hyperacmia, minute haemorrhages, 
 swelling of the epithelium, and perhaps coagulated albumen 
 in the capsules alone or in the urinary tubules as well, or 
 there may be nothing remarkable, no albuminous coagula or 
 none at least in the capsules. The same description holds 
 good of albuminuria occurring after rapid heating, and also 
 of the same symptom resulting from the injection of egg- 
 albumen into the blood. Miss Bridges Adams (42), in a 
 series of experiments under Cohnheim and Weigert's direction, 
 noticed albuminuria as a constant phenomenon in six cases 
 in which the injection was made, and in all of them without 
 exception the boiling method failed to detect any albuminous 
 secretion in the capsules. And yet albumen has certainly 
 been present in the capsules, for, as Ribbert has shown, it 
 really escapes from the glomerular vessels and from them 
 alone under those circumstances, and may be seen in the 
 capsules after coagulation. But that it must necessarily be 
 visible under all circumstances is untrue, as the above-men- 
 tioned experiments strikingly show, and as might ä j)'>"i'Ori 
 have been expected. For in the normal condition the glome- 
 rular tuft completely fills the capsule, and is in such close 
 contact with it that even " with a magnifying power of 800 
 diameters applied to very fine sections of a pig's kidney re- 
 moved during life, and placed in a freezing mixture, we are able 
 to distinguish only a scarcely measurable cup-shaped fissure- 
 between the capsular and the glomerular epithelium."^ This 
 ' S. W. Krause, ' AUg. u. mikrosk. Anat.,' 187(1, S. 246.
 
 OF NORMAL URINE. 37 
 
 fissure represents tte space occupied by tlie minimal amount 
 of transudation present at tliat moment, and a consideration 
 of these facts will make it appear quite natural that the infini- 
 tesimally minute trace of albumen contained in this minimal 
 transudation, should remain invisible even after coagulation. 
 To obtain some approximate idea as to how far the minute 
 traces of albumen with which we are dealing are within the 
 limits of vision, supposing that they can be thus included, it 
 is sufficient to take a simple estimate based on the well- 
 known dimensions of a Malpighian corpuscle, and' the 
 thoroughly admissible supposition that the corpuscle is per- 
 fectly globular in form. The diameter of such a corpuscle, 
 and therefore of the Bowman-Miiller capsule, is on an average 
 •25 mm., its capacity is therefore (3^'?'^) •00818 cbmm. 
 If we assume that this space is not, as is really the case, 
 quite completely occupied by the glomerular vessels, but only 
 to three-fourths of its extent, so that a complete fourth of the 
 contents is taken up by the transudation, our supposition will 
 have exceeded the most exaggerated demands. There is then 
 at a given moment "00204 cbmm. of transudation in a capsule, 
 or, expressed in weight — for it is somewhat heavier than 
 water — '00206 milligrammes. This transudation, as we have 
 explained in a previous page, must be poorer in albumen than 
 the poorest normal transudation, than, for example, the 
 cerebro- spinal fluid. But if we here also advance the most 
 -exaggerated assumption, and estimate that the quantity of 
 albumen contained in the fluid of the capsule is equal to that 
 in the cerebro-spinal fluid at its highest amount (see p. 24), 
 that is, 3 per 1000, we should have -00000618 milligrm. of 
 albumen in '00206 milligrm. of transudation. That is the 
 result of a calculation based upon figures exaggerated beyond 
 all belief in order to obtain as large an amount of albumen 
 as possible ; and the most extravagant fancy would find a 
 difi&culty in supposing that this quantity, even when com- 
 pressed into a spot, would be visible under the microscope, 
 to say nothing of its being more or less diffused in the capsule, 
 and therefore necessarily only partially exhibited on a trans- 
 verse section. 
 
 As a matter of course the circumstances are different 
 under abnormal conditions, when more albumen transudes.
 
 38 ALBUMEN AS A CONSTITUENT 
 
 when the transudation is stemmed in consequence o£ impedi- 
 ments to its escape and its albumen is increased owing to 
 the absorption of water, and when, lastly, this stemmed-up, 
 copiously albuminous, fluid compresses the glomerular vessels, 
 and forces them away from the capsule. The albumen thus 
 becomes visible, but by no means always in every capsule, even 
 where they are all involved, though in varying degrees of 
 intensity, in a diffuse process, but it very frequently happens 
 that only more or less of them present traces of albumen, the 
 remainder being apparently free from it, because the accu- 
 mulation has not been sufficient to make itself visible. 
 Yery instructive in this respect is the condition which is 
 produced after prolonged stagnation of urine, the result of 
 applying a ligature to the ureters. Here at a certain period 
 (see S. Ill) we find the urinary tubules and the capsules 
 distended, and in several of the latter the glomerular vessels 
 forced back by coagulated albumen, in others by a more or 
 less broad and clear ring of fluid without any visible trace 
 of coagulated albumen. This fluid must, however, be albu- 
 minous, and it does contain albumen (as appears on examina- 
 tion of the urine obtained immediately after the ligature has 
 been removed from the ureters), and much more than there 
 can possibly be in the normal transudation under the most 
 favorable hypothesis. And as, notwithstanding this, it 
 appears clear and transparent, we cannot expect, as a general 
 rule, to see coagulated albumen, or anything more than a 
 small clear ring, between the glomerulus and the capsule.^ 
 
 It follows, therefore, that there is at present no reason for 
 supposing that microscopical examination can furnish any 
 proof of the presence or absence of albumen under normal 
 
 ^ The application of a ligature to the ureters of rabbits can be so easily 
 and neatly effected, that any one may convince himself without any great 
 difficulty of the correctness of the above statement. The best proof, how- 
 ever, is furnished by a repetition of Posner's own description of the ajipear- 
 ances which the kidneys present after ligature of the ureters for two or four 
 hours, after which we know, and Posner himself asserts, they are in a state 
 of acute congestion, and red blood-corpuscles (?) are mixed with the secre- 
 tion. " On microscopical examination in this initial stage, besides the 
 excessive capillary hyperajmia and partial ha3morrhages, all that is seen is 
 dilatation of the urinary tubules, but there is no coagulable exudation and 
 no unequivocal casts."
 
 OF NOEMAL üßlNE. 39 
 
 conditions in tlie fluid yielded by tlie capsules. We must 
 continue to maintain the assumption, wliich is supported by 
 other considerations, that the transudation which exudes 
 from the glomerular vessels is feebly albuminous in its 
 normal state, and this supposition furnishes us with a means 
 whereby we may explain the presence of the minute proportion 
 of albumen in normal urine, and the occurrence of physio- 
 logical albuminuria, in a manner at once complete and satis- 
 factory (see p. 22, et seq.). 
 
 III. The Dependence op Albuminuria upon Alterations in 
 THE Blood-Pressure. 
 
 Proceeding from the supposition, which we have shown to 
 be perfectly tenable, that the normal fluid in the Bowman- 
 Miiller^s capsules is a transudation yielded by filtration, and 
 as regards its constitution dependent upon the pressure of 
 the blood, many experimenters have endeavoured to produce 
 albuminuria by altering the general blood-pressure of the 
 body, or the pressure in the vessels of the kidney. It is 
 necessary that we should minutely discuss these attempts, on 
 the one hand, because endeavours have been made to obtain 
 conclusions therefrom as to the origin and secretion of the 
 urine and the importance of the blood-pressure in the pro- 
 cess, and secondly, because these experiments have been 
 made to serve as a basis for the explanation of pathological 
 processes. Unfortunately we find many difiiculties in form- 
 ing conclusions as to their value for the above purposes, and 
 these we shall presently endeavour to point out. The con- 
 ditions are not sufficiently simple to justify the expectation 
 that the discovery of albumen in the urine would enable us 
 to decide as to how far its production had been influenced 
 by any possible change of pressure in the renal circulation. 
 For, although we are correct in supposing that the transuda- 
 tion in the Bowman-Müller^s capsules is subject to the laws 
 governing filtration-pressure, we are by no means to conclude 
 that the urine as a whole is placed under the same rules. 
 The urine is, as I have already explained, to be compared to 
 a stream fed by two sources, which differ from each other as
 
 40 ALBUMINURIA DEPENDENT UPON 
 
 regards the quantity of water they yield and other condi- 
 tions^ and are governed by laws not altogether similar in 
 character. The one source, the transudation from the glome- 
 rular vessels, certainly yields more water and contains a 
 little albumen in addition to the ordinary constituents of 
 all transudations ; the other, the secretion of the glandular 
 epithelium in the urinary tubules, is, perhaps, less abundant 
 as regards quantity, is free from albumen, but loaded with 
 the specific constituents of the secretion. The former is, as 
 I have before said, subject to the laws of filtration, whereas 
 the glandular secretion is, as we all know, governed by other 
 influences. In the second place, the fact has been over- 
 looked that, although with increased pressure the quantity of 
 the filtrate becomes augmented, its composition becomes 
 changed, and particularly that the proportion of albumen 
 undergoes a relative diminution, and therefore that increased 
 pressure renders its demonstration more difiicult owing to 
 the greater dilution of the urine. Thirdly, as has been fully 
 recognised since Virchow's investigations (43), the vascular 
 distribution in the kidney is so peculiar in its arrangements, 
 and so different from that of other organs, that alterations 
 of the general blood-pressure, or of the pressure in the 
 principal vessels going to or leaving the kidney, can and 
 must affect unequally the two sources concerned in the secre- 
 tion of urine. Fourthly, as a result of certain changes in 
 the biood-pressure, the nutrition of the walls of the vessels 
 or other membranous structures, and also the epithelium, may 
 become affected, and these may in consequence become abnor- 
 mally permeable for albumen. Fifthly and lastly, the condition 
 of the flow of lymph in the kidneys is also dependent upon the 
 state of the blood-pressure, and is not without influence upon 
 the composition of the urine. The fact must also be men- 
 tioned that, at all events, increase of pressure in the venous 
 system is accompanied by alterations in the purely mechanical 
 conditions of escape, as was shown by Ludwig some years 
 ago (44). 
 
 These facts and considerations teach us how complicated 
 the conditions are, and how difficult it is to estimate the 
 results of experiments upon the changes in the blood-pressure 
 in the kidneys. If we also consider that in certain series of
 
 ALTEEATIONS IN THE BLOOD-PEESSURE. 41 
 
 ■experiments, undesigned and yet potent conditions have been 
 introduced, — conditions frequently overlooked, or their action 
 erroneously interpreted, — we shall not be surprised that some 
 of the experiments with regard to the influence of alterations 
 in the blood-pressure have led to results mutually contra- 
 dictory, while others, even where the results were congruent, 
 as, for example, in venous congestion, have had very discordant 
 explanations attached to them. 
 
 The conditions with regard to the increase of blood- 
 pressure in the arteries are the simplest and plainest of all, 
 yet the influence of this change upon the production of 
 albuminuria has been made the subject of very different 
 statements by the various investigators. It is true that many 
 of the experiments have either been incorrectly performed, 
 or they lead to a conclusion just the opposite to that which 
 their performer deduced from them. If, taking our stand 
 upon pure theory, we ponder over the views developed in 
 the foregoing pages, and reflect upon the necessary conse- 
 quences of the increase of arterial pressure within the kidneys, 
 we find that the result must be a combination of the influence 
 of the increase of pressure upon the transudation from the 
 glomerular vessels, and of the influence upon the secretory 
 elements of the uriniferous tubules. The condition of the 
 transudation may be predicted with perfect certainty, it will, as 
 has been already explained (see p. 28 et secj.), be more copious 
 than under normal conditions, and its percentage of albumen 
 will be diminished. The condition of the proper secreting 
 elements of the kidney cannot be predicted with a like 
 certainty, for they cannot be subjected to a separate 
 experimental test, as is the case with the elements of other 
 glands. Following*, however, the analogy of other glands, 
 especially the liver, we may assume that with the increase of 
 arterial pressure (and of the rapidity of the current) the 
 secretion will, at all events, be increased up to a certain 
 point, and no albumen will appear therein. The result, as 
 regards the urine, will be an increase in its quantity ; on the 
 other hand, it will contain a still smaller percentage of 
 albumen than is assumed to be normally present. If we 
 take, as before, the percentage of albumen in the transudation 
 as a, it will, under the assumed conditions, be a — x, and the
 
 42 ALBUMINUßlA DEPENDENT UPON 
 
 quantity of the secretion yielded by the epitlielium, instead 
 of n, will be rather n + y,&o that now the urine as passed will 
 a — X 
 
 contain only n + y of albumen, always supposing that no 
 
 100 
 absorption takes place from the urinary tubules. 
 
 It follows, therefore, that if the experiments be really 
 successful, and free from all objection, we may expect to 
 find less albumen than normal in the urine ; but simul- 
 taneously with the increase of pressure, other conditions must 
 prevail, which, without causing any other alteration, diminish 
 the quantity of urine, and therefore raise its percentage of 
 albumen, enabling us to demonstrate its presence. 
 
 Let us consider once more the experiments that have 
 hitherto been made, and their results in particular. There 
 are various methods which may be used, and for the most 
 part have been used, for the purpose of increasing the 
 pressure in the arteries in general, or in those of the kidneys 
 only. The greatest increase of pressure in the aorta can be 
 produced with ease and precision by electrical irritation of 
 the cervical spinal cord, by producing dyspnoea, by poisonous 
 doses of strychnia, digitalis, &c. All these means have been 
 employed to produce albuminuria, and it may be asked, with 
 what result ? All observers agree in stating that invariably 
 during the rise of the aortic pressure, and at its height, 
 the flow of urine altogether ceases ; subsequently, when with, 
 the falling pressure secretion is restored and is more copious 
 than before, a (gradually diminishing) excretion of albumen 
 takes place. In the first period there is a general spasm of 
 the small arteries, whicli causes the pressure to rise in the 
 great trunks. The small renal arteries, as Grützner (45) has 
 shown, participate in this spasm, and the natural result is 
 the exhaustion of the flow of urine ; with the subsidence of 
 the vascular spasm, as a matter of course, there is increase of 
 pressure in the arteries and capillaries of the kidneys (as in 
 other organs), and exceeding the original height in a degree 
 corresponding to the previously abnormal increase in the 
 aorta, until the dilatation of the vascular channels causes the 
 normal conditions to be restored. In this period, in which 
 the pressure and the rapidity are both increased, with active
 
 ALTERATIONS IN THE BLOOD-PEESSUEE. 45 
 
 vascular dilatation as a result, the increase in tlie secretion 
 of urine is accompanied by appreciable albuminuria.^ Can 
 we now draw any conclusions tberefrom with regard to the 
 influence of the increased blood-pressure upon the albumi- 
 nuria ? At the first glance, the position of cause and effect 
 seems so clear that this conclusion might be accepted without 
 any hesitation. But there is one important fact of a contrary 
 character, namely, the defective supply of arterial blood 
 while the vessels are constricted. It makes no difference if, 
 as is generally stated with regard to these experiments, the 
 flow of urine altogether ceases during the period of vascular 
 spasm, and the albuminuria consequently afterwards appears 
 with the returning secretion of urine, for undoubtedly 
 this phenomenon is to be referred to the previous period, 
 unless hasmorrhage sets in. We shall see later on that, when 
 the supply of arterial blood is considerably reduced, but not 
 altogether cut off, the secretion of urine continues, and is 
 accompanied by manifest albuminuria, the causes of which 
 will then be described. The only question at present is to 
 establish the fact that even the diminution of the supply of 
 blood, which occurs in the first period, explains loer se the 
 albuminuria, and that, consequently, these experiments are 
 of no force at all as arguments in favour of the influence of 
 increase of the arterial pressure. 
 
 These experiments would have far greater demonstrative 
 force, for or against the existence of this influence, were it 
 possible so to perform them that this effect of pressure, 
 and nothing else, came out as the resultant. The idea 
 formerly was that the pressure in the aorta and other 
 
 * Litten (46), who has performed the above-mentioned experiments with 
 the same result, especially with regard to the alhuminnria, and was disposed 
 to consider this latter as caused by the increase of the arterial pressure, 
 explains this now as the consequence of the dilatation of the vessels and o£ 
 the resulting retardation of the current of blood, and he finds in this a 
 positive confirmation of Runeberg's views, which he had regarded as correct 
 (see pp. 2 and 31). But inasmuch as the condition in question is that of an 
 active dilatation, as a matter of course there can be no retardation of the 
 current of blood, a fact which is also incidentally revealed by the increase in 
 the quantity of urine. It is evident that other conditions prevail when the 
 pressure is raised in consequence of impeded escape from the veins and 
 passive vascular dilatation.
 
 44 ALBÜMINÜEIA DEPENDENT UPON 
 
 ai'teries could be easily raised by placing a ligature on 
 peripheral arteries. Observations witli tlie kymograph have, 
 however, taught us that that idea is erroneous, and have 
 shown that the organism sets in action compensatory arrange- 
 ments whereby, even when large vascular districts are cut 
 off from the circulation, the genei-al blood-pressure is kept 
 at the normal height. The pressure in the aorta can be 
 greatly increased only by ligature of the carotids or, indeed, 
 of one carotid, but, as Nawalichin (47) has shown, this is 
 merely in consequence of the irritation thereby induced in 
 the vaso-motor centre and of the general vascular spasm 
 which ensueSj just as takes place in the first series of 
 experiments which we have already discussed. Without 
 tying the carotids the pressure in the aorta can be certainly 
 and considerably increased only by applying a ligature to 
 the vessel itself below the diaphragm, but above the kidneys. 
 But the obvious consequence of this is that the supply of 
 blood to the kidneys is almost, although not altogether, cut 
 off, and the experiment is therefore useless for our purposes. 
 Ligature of the aorta alone, below the kidneys, causes no 
 increase of pressure ; Litten, indeed, found a slight increase 
 on tying the coeliac and superior mesenteric arteries in addi- 
 tion to the aorta, but this gradually subsided. These facts will 
 cause us to regard the changes which the urine may present 
 after ligature of the aorta below the renal arteries, not as 
 the consequences of the increased arterial pressure, but as 
 due rather to the incidental injuries, unavoidable in so 
 serious an oj^eration, to the pressure to which the kidneys 
 or their vessels have been subjected, and to laceration and 
 injury of the splanchnic nerves, &c. Considerations of a 
 similar character may be raised against those experiments, 
 by which the blood-pressure can be really raised by placing 
 a ligature on the aorta and other arteries. And a review of 
 the results obtained by various investigators will confirm 
 our scruples. G. H. Meyer, who was the first to tie the 
 aorta in order to decide this (][ucstiou, found albumen in the 
 urine passed afterwards, Robinson, on the contrary, found 
 no albumen, Frerichs found traces of it in a few cases, but 
 invariably considerable quantities when he removed a kidney 
 in addition to tying the aorta. The same result was obtained
 
 ALTERATIONS IN THE BLOOD-PßESSüKE. 45- 
 
 by Pb. Muuk. Correnti found albumen after simply tying 
 the aorta ; H. Colin also, but only exceptionally, after 
 removal of one kidney ; Litten, after tying the aorta alone, 
 found no albumen, and lie noticed the same result when 
 both, tlie cooliac and the superior mesenteric arteries were 
 tied, slight increase of pressure being consequently induced. 
 I myself liave twice tied the aorta in rabbits, and subse- 
 quently found the urine to be albuminous, but I also con- 
 vinced myself of the very serious character of the operation. 
 To avoid , injury Stokvis has applied compression, externally 
 through the abdominal wall, to the aorta in rabbits below 
 the kidneys, by means of a belt fitted with a screw ; in two 
 out of three cases the addition of nitric acid to the urine 
 produced a slight cloudiness, which he did not consider to 
 be albumen, but which could not, I think, have been any- 
 thing else. No importance, however, is to be attached to 
 these experiments, for if in reality only the aorta were 
 compressed below the kidneys, we could not, as above stated, 
 expect with any degree of certainty that the blood-pressure 
 in that vessel would be raised. As a matter of fact, how- 
 ever, in these experiments, the pressure in the abdomen 
 generally, and consequently the pressure to which the 
 kidneys are subjected, must necessarily be increased, and 
 must produce considerable congestion of those organs as a 
 result, and we know that this condition is sufficient to cause 
 albuminuria (48). 
 
 What, then, are the conclusions to be drawn from all 
 these experiments ? Without raising the pressure in tha 
 aorta (ligature of the aorta alone) one observer always finds 
 albumen, another never finds it, a third discovers it occa- 
 sionally, and traces of it only ; by raising the pressure 
 (ligature of the aorta and ligature of, or checking the flow 
 through, other arteries), albumen is constantly found by 
 one experimenter and not by another. My own opinion is, 
 that that series of experiments, as a result of which no 
 increase of pressure can be expected, really proves nothing ; 
 and that the albuminuria observed in connection therewith 
 is to be ascribed to the above-mentioned injuries which are 
 incidental to the operation. In those experiments which 
 are attended with real increase of the arterial pi-cssurc, one
 
 46 ALBUMINURIA DEPENDENT UPON 
 
 assertion contradicts the other, and the question still waits 
 decision. At the same time, Litten's experiments, in which 
 no albumen was found, must be allowed to possess the 
 greatest force as demonstrations ; for, though it is easy to 
 understand how in such serious operations the urine becomes 
 albuminous owing to incidental causes, we cannot readily 
 imagine, if the increase of pressure per se caused albuminuria, 
 how this could be accidentally masked, always supposing 
 that proper methods were used for discovering the albumen, 
 of which in this case there can be no doubt. If, therefore. 
 Litten' s experiments be regarded as demonstrative, the result 
 thereof corresponds exactly with our hypothesis (see p. 42) . 
 If albumen is, as a general rule, not to be found in urine, 
 increase of the arterial pressure, unless the quantity of urine 
 be simultaneously diminished, will assuredly not cause any 
 albumen to appear. 
 
 The experiments in which the renal nerves are divided 
 have yielded results more in harmony with each other, mainly 
 because in performing them it is difficult to avoid pressure 
 or injury to the renal vessels. The latter causes can ijer se 
 produce albuminuria, and this fact may explain why some 
 observers, as in recent times von Wittich and Vulpian, have 
 noticed it after dividing the nerves, while others, as M. 
 Herrmann and Knoll, have observed this symptom only after 
 injuries incidental to the operation (49) . Considerable import- 
 ance must be attached to these negative results, for the same 
 reasons as in the experiments in which the aorta was tied. The 
 same thing then occurs as after the division of the nerves, as 
 a result of which the blood-pressure and the rapidity of the 
 current in the kidney arc increased, that is to say, we are not 
 able to discover albumen, because in all these experiments 
 the quantity of the urine is very considerably increased. 
 
 Greater results than those of all these experiments are, as 
 already said, to be expected from a method which increases 
 the arterial pressure, and that alone, and at the same time 
 diminishes the water of the urine so that the discovery of 
 the albumen is facilitated. Such a method we possess in 
 the elevation of the bodily temperature. That this should 
 raise the general blood-pressure can be It priori inferred from 
 the well-known changes which take place in the blood-vessels
 
 ALTERATIONS IN THE ELOOD-PEESSURE. 47 
 
 and in the circulation when the temperature of the body is 
 raised. 
 
 The increased pulsations of the hearty the enlarged calibre 
 of all the arteries, and their greater fulness, the pulsation of 
 small vessels in which no pulse was previously felt, the red 
 and injected appearance of all visible parts, in a word, all 
 those well-known phenomena of " fluxion " as they occur 
 locally or generally after the operation of warmth, are the un- 
 questionable consequences and proofs of the increase of blood- 
 pressure in the arteries (and of the rapidity of the current). 
 At the same time, in the numerous and multiform experi- 
 ments of a bygone and recent date, and performed with a 
 view of measuring the pressure, but little heed has been paid 
 to this condition, and thus it comes to pass that with regard 
 to the direct estimation of the arterial pressure, when the 
 general temperature is raised, we have one solitary incidental 
 communication made by Paschutin (50) when he was investi- 
 gating the lymphatic system in dogs. He found, as a mat- 
 ter of fact, that the pressure was considerably increased. 
 In addition, J. Zadek (51), who performed experiments on 
 men by Basch's method of indirectly measuring pressure, 
 likewise found that the pressure in the arteries becomes ab- 
 normally high when the bodily temperature is increased. 
 These statements are, however, inadequate, and I have there- 
 fore performed a great number of experiments on rabbits, in 
 which the pressure in a carotid artery was measured while the 
 surface of the body was somewhat rapidly warmed. The 
 detailed account and a description of further experiments 
 made at the same time do not belong to this part of the sub- 
 ject and will follow hereafter. I may here just say that, 
 as a matter of fact, when the temperature of the body is 
 raised within certain limits, the pressure in the carotids is 
 increased, and possibly to an extraordinary degree. If, how- 
 ever, the temperature rises above a certain limit, the intense 
 heat produces its well-known effect upon the heart, and the 
 result is that the pressure falls rapidly and far below the 
 normal degree, and death may ensue. 
 
 It is therefore an established fact that, by applying heat 
 to the body, the blood-pressure, and indeed the general arte- 
 rial pressure in the whole body, can be increased. There is
 
 48 ALBUMINURIA DEPENDENT UPON 
 
 no cause for the suspicion tliat^ as occurs in the methods 
 previously discussed^ the pressure in the aorta alone, or th.e 
 pressure in certain portions, is increased at the expense of the 
 pressure in other parts, or that this increase is preceded by 
 a lowering of pressure with diminished supply of blood, but 
 in this method from the very commencement, immediately 
 the warming begins, the superficial and deep arteries and 
 those of the viscera become dilated, — a fact in harmony with 
 our expectations, and of which we may fully convince our- 
 selves by examining any organ we choose and especially the 
 kidneys.^ The first condition for our experiment is there- 
 fore present in a manner which leaves nothing to be desired. 
 There is no difficulty with regard to the fulfilment of the 
 second condition, which is, that the quantity of the urine 
 sbould be diminished. The condition is perfectly fulfilled 
 provided that neither a bath nor a room saturated with mois- 
 ture has been the means adopted for raising the temperature, 
 for the increase of water given off by the skin and lungs 
 causes the urine to become diminished in quantity. This fact 
 is too well known to require me to allude to it any further. 
 
 All that we have to do, therefore, is simply to examine the 
 urine for albumen, before and after heating the animal. I 
 have performed these experiments upon a great number of 
 rabbits. 
 
 As a heating apparatus we use a kind of oven or a drying- 
 closet, made of copper-plate, and such as we find in chemical 
 laboratories, with double walls all round for holding water, 
 except at the side, where there is a door. The water is poured 
 in through an orifice in the upper part. Another opening goes 
 through both walls and reaches into the interior of the oven ; 
 this is designed to admit the thermometer which measures the 
 temperature of the oven. This latter is of sufficient size to 
 allow a large rabbit (and only such should be chosen for the 
 experiment) to sit quite at ease in it. It stands upon a broad 
 tripod, beneath which the heat is applied. Before placing the 
 animal in the oven, its bladder should be emptied by com- 
 
 * It need hardly be said that the heating must he a gradual process, in 
 order that the phenomena may appear in the way above described, and that 
 on the other hand sudden exposure to intense heat acts upon the body as a 
 violent irritant, and coukl only disturb the results of our experiments.
 
 ALTERATIONS IN THE BLOOD-PEESSUHE. 49 
 
 pressing it, and the temperature is to be taken in tlie rectum. 
 As a general rule, in order to save time the oven was first 
 slightly warmed, and after the introduction of the animal the 
 temperature was more or less rapidly increased. In order to 
 give sufiicient air, the door was not quite closed, but left 
 somewhat ajar. When the heat had been applied for a suffi- 
 cient length of time, the temperature in the rectum was 
 taken while the animal remained in the oven, but with the 
 door open, or immediately after removal ; then the bladder 
 was emptied by pressure, and if no urine could be obtained, 
 the animal was placed in a cage from which the urine could 
 escape. Experiments made at the same time with a view of 
 examining the urine as regards its correspondence with the 
 measurements of pressure and its variations, are attended 
 with some difficulty, which, however, may perhaps be over- 
 come by using large animals, such as dogs. For various 
 reasons, however, and for the most part extrinsic ones, I 
 avoid experiments upon large dogs. I have made a few 
 experiments with the view of measuring the pressure in 
 small dogs, but which were not altogether satisfactory on 
 account of the numerous unavoidable difficulties connected 
 with the production of anesthesia in dogs. And in connec- 
 tion with those few experiments in which it was sought to 
 obtain urine from rabbits while estimating the pressure, there 
 was this drawback that the excitement caused by handling 
 the animal was a thing to be avoided ; moreover, in the short 
 interval, urine could not be obtained from the bladder for 
 examination if the organ had been previously compressed. 
 The secretion obtained from the ureters on one occasion was 
 not free from an admixture of blood, which was attributable 
 to the unavoidable irritation and injury of the mucous 
 membrane. 
 
 The result in all cases was, the production of albuminuria 
 when the bodily temperature had been increased by i'5 — 3'oC. 
 with sufficient rapidity, or the heat continued for a sufficient 
 length of time, and where this symptom was normally present, 
 it became more marked.^ 
 
 * I have ah-eadj stated (p. 20) tliat even in animals the urine in the 
 normal condition very often contains albumen. I found it in more than 
 half the number of these I submitted to experiment, and even in those 
 
 4
 
 50 ALBUMINUEIA DEPENDENT UPON 
 
 If the temperature were very rapidly raised to an extreme 
 degree^ blood appeared in the urine^ and in quantities wliicli 
 did not require the microscope for its detection. In addition 
 to this_, and even when no blood-corpuscles were visible, the 
 urine often contained pale hyaline casts, and sometimes 
 finely granular ones, in greater or less abundance. 
 
 That the excretion of albumen, or its excretion in an 
 increased degree, is a direct result of the elevation of tempe- 
 rature, and not a secondary phenomenon manifesting itself 
 while the temperature is falling, is demonstrated by two 
 cases in which the animals passed water while in the hot 
 oven, and a portion was caught for examination. This 
 proved to be albuminous, while the urine shortly before had 
 been found free from albumen. 
 
 We could a priori assume with a degree of probability 
 almost amounting to certainty, that the capsules are the seat 
 of this excretion of albumen. In order to prevent any doubt 
 on this point, I examined the kidneys in many cases with 
 this particular object, killing the animals by cutting their 
 throats immediately after heating them, and then at once 
 removing the kidneys and hardening them by boiling. In 
 proportion to the intensity of the action, there were, in these 
 cases as in those of poisoning by phosphorus (see p. 36), 
 variously strongly marked changes in the kidneys ; in those 
 least affected there was only a very slight deposit of albumen, 
 not visible in all the capsules, whereas in the more violent 
 cases there was not only a marked deposit of albumen, but like- 
 wise ha3morrhages in many capsules and uriniferous tubules, 
 whilst in others there was no abnormality, with the exception 
 of more or less marked hyperasmia. 
 
 With regard to the strictly ultimate cause of this albumi- 
 nuria, we could at once recognise therein a confirmation of 
 the view already unfolded, that with the increased pressure 
 more albumen escaped, and could bo more easily found by 
 reason of the simultaneously diminished excretion of water, 
 if we were quite sure that the purely physical agent, the 
 increased temperature, might not per se, modify the filtration 
 of albumen in this direction. That this is so cannot be 
 
 recently brought to me and kept in tlie open air during the summer. It is 
 true that the albumen was often discoverable only after careful examination.
 
 ALTERATIONS IN THE BLOOD-PEESSURE. 51 
 
 asserted witli our pi'eseut knowledge. "We know from the 
 experiments of W. Sclimidt (52) and Eckhard (53) that the 
 filtration of saline and albuminous solutions through animal 
 membranes goes on with increased rapidity as the tempera- 
 ture is raised, just as Poiseuillo has found to be the case in 
 filtration through glass capillary tubes, but unfortunately, we 
 can draw no certain inference from Schmidt's experiments, 
 which specially related to albuminous solutions, as to what pro- 
 portion the albumen in the filtrate bore to that of the original 
 fluid. If the percentage of albumen increased in the filtrate, 
 this, as a matter of course, would alone suffice to explain the 
 occurrence of albuminuria without any changes of pressure, 
 whereas the latter alone entered into our considerations. I 
 see, therefore, in these heating experiments, no irrefragable 
 proof of the dependence of albuminuria upon an increase of 
 blood-pressure, but certainly a support to this view, and one 
 which taken in connection with other experiments pointing 
 in the same direction give to it a weight by no means in- 
 considerable. In any case, these experiments support the 
 theory, according to which filtration takes place in the 
 capsules. 
 
 There are, however, sundry other conditions which more 
 or less decidedly increase the blood-pressure in the aortic 
 system, and serve as a test for our view — the most important 
 of these is muscular action. Its influence in this respect 
 has been so constantly observed since the introduction of 
 the kymograph by Ludwig that there can be no doubt 
 whatever in regard to it. Its influence upon the production 
 of albuminuria has not, however, so far as I know, been 
 experimentally investigated, but Litten in describing his 
 above-mentioned experiments states that albumen often 
 appeared in the urine as a consequence of the muscular 
 action of the dogs while they were fastened, whereas the 
 urine previously obtained through a catheter was free fi'om 
 albumen. On the other hand, in healthy men frequently 
 after intense muscular exertion, in parturient women as a 
 consequence of difficult labour (without any previous dis- 
 order) filbumen has been found in the urine (see p. 19), and 
 also in pathological conditions, in convulsions of all kinds, 
 but particularly in epilepsy, albuminous urine has been very
 
 52 ALBUMINURIA DEPENDENT UPON 
 
 frequently observed, and its appearance lias been often con- 
 nected with the extraordinary muscular exertion and the 
 accompanying increased arterial pressure.^ That the pressure 
 in the human subject is increased by muscular exertion may^ 
 bo confidently assumed from the analogous effects observed 
 in experiments on animals, and from the condition of the- 
 organs of circulation, resembling as it does that whicb is 
 produced by raising the temperature (see p. 48), and, besides 
 this, positive proof is furnished by the experiments of Zadek, 
 which have been already referred to. He found that active- 
 muscular exertion (running, for example) was accompanied 
 by an increase of the arterial pressure by about one-fourtb 
 of the normal degree. But in addition to this, in all mus- 
 cular exertion of any degree of intensity, as daily experience- 
 teaches us, and as countless experiments have proved beyond 
 doubt, the escape of water through the skin and lungs in 
 the form of perspiration and vapour is enormously increased, 
 and as a result the urine contains less water ; we have, 
 therefore, a perfect combination of the two conditions which 
 we have laid down at the commencement as essential for 
 distinguishing that form of albuminuria dependent upon 
 blood-pressure, that is to say, increase of the arterial 
 pressure and simultaneous diminution of the water of the 
 secretion, and these conditions are fulfilled under the cir- 
 cumstances before us as decidedly as, or even more so than, 
 when the temperature is raised by experiment. For if th& 
 latter could be supposed to be open to any slight objection 
 as to its validity as a demonstration, nothing of this kind 
 can arise with respect to muscular exertion, and I cannot 
 conceive of any well-founded hesitation in accepting the 
 explanation which I have given. But for all this, the 
 attempt has been made to explain the process in another 
 way, and this has been done from the standpoint of Rune- 
 berg^s theory by Edlefsen, who has been followed by Rune- 
 berg himself. Confiding in the correctness of this theor}^, 
 which assumes that the escape of albumen is duo to a 
 diminution and not to an increase of the normal pressure in 
 
 ' To meet any possible objection it may here be remarlved that in the 
 Tnuscular exertion of the healthy subjects, and also in the majority of th&- 
 I)athological cases, there was no symptom of dyspnoea, ("v I'isk of suiTccation.
 
 ALTERATIONS IN THE BLOOD-PRESS [JRE. 53 
 
 the vessels, Edlefseu attempts to prove that during muscular 
 exertion the arterial pressure in the kidneys falls below the 
 normal, and he founds his view upon J. Rankers (54) obser- 
 vations on the subject of the interchange of activity among 
 the organs of the body. According to these observations, 
 during tetanus, the muscles contain more blood, the other 
 organs, and especially the glands, less blood than when the 
 muscles are at rest. But such a conclusion is most assuredly 
 not justified by Rankers observations, for the conditions undor 
 which these were made were fundamentally different from 
 those associated with the muscular exertion of healthy subjects, 
 and those which obtain in the majority of convulsive attacks. 
 Ranke caused tetanus of all the muscles by administering 
 poisonous doses of strychnia or irritating the spinal cord ; or 
 tetanus of single groups of muscles by electrically irritating 
 the nerve trunk of one extremity. In the first form, causing 
 tetanus by acting on the spinal cord, a violent contraction 
 of all the small arteries takes place — a fact to which we have 
 incidentally alluded (see p. 42), and this is least marked in 
 the muscles, the arteries of which, according to Hafiz (55), 
 are far behind those of the skin and the abdominal organs 
 as regards both the degree and also the duration of the con- 
 traction.^ It was therefore that Ranke noticed that little or 
 no blood escaped from the incised vessels of the skin in 
 tetanus, whereas the muscles were full of blood, and bled 
 freely on incision. This fact alone would suffice to demon- 
 strate the difference between the conditions in Rankers 
 experiments and those which obtain in ordinary muscular 
 exertion, even of the most severe character. But in the 
 case before us, are the vessels of the skin abnormally empty? 
 On the contrary, there is visible and marked congestion, 
 that is, an increased supply of blood to the skin, and not to 
 the skin alone, but doubtless to other organs, such as the 
 lungs, brain, &c. The cause of this fluxion, at least an 
 important if not the only cause, is the increase of the bodily 
 temperature which is associated with all muscular exertion, 
 and therefore the conditions, so far as we are concerned with 
 
 ^ The albuminuria wliich is sometimes observed in connection with 
 tetanic convulsions probably depends upon this intense constriction of the 
 renal vessels, as explained above (see p. 42).
 
 54 ALBUMINUßlA DEPENDENT UPON 
 
 them, are in all respects similar to tliose whicli obtain when 
 the temperature is raised by simple exposure to heat. Can 
 there be any doubt that the kidneys participate in the 
 general increase of temperature caused by muscular exertion, 
 and can we possibly conceive that, notwithstanding the 
 fluxion to these organs and the rise in temperature, the renal 
 vessels should be diminished in calibre and receive a smaller 
 supply of blood ? We must reject all previous experience 
 before we can entertain such a suggestion. As far as 
 regards, however, the tetanic irritation of nerve-trunks by 
 means of electricity, we must allow that Heidenhain is 
 correct in the objection he raises, to the conclusions drawn 
 from these experiments, with regard to the activity of 
 glands in muscular exertion, his belief being that the abdo- 
 minal vessels probably become contracted in a reflex manner, 
 just as occurs when the sensory nerves are violently irritated 
 (56). 
 
 The diminution in the quantity of urine and its concentrated 
 condition, which follow muscular exertion, are brought 
 forward by Runeberg (57) as proofs that the pressure is 
 diminished in the renal vessels. We are exempted from 
 any controversy with regard to this view, inasmuch as we 
 have given an obvious and very simple reason why the urine 
 becomes less watery after muscular exertion. 
 
 We may in the last place specify the process of digestion, 
 and certain poisons, as factors by which the arterial blood- 
 pressure can be more or less positively raised, or is perhaps 
 regularly increased. With regard to the former of these, 
 certainly I do not know of any experiments in which the 
 pressure has been directly measured, but Zadek in his re- 
 searches, has indirectly observed that the pressure is increased. 
 Besides this, however, the existence of such increase might, 
 with some probability, be inferred from the fact long since 
 observed by Yierordt and Aberle that the size of the arteries 
 is increased after taking food (58) ; and also, that during diges- 
 tion certain changes take place in the circulation which, at least 
 faintly resemble the condition which follows muscular exer- 
 tion and exposure to heat, and have therefore been designated 
 as "digestion-fever." It is true that this increase of pressure 
 docs not appear to be very considerable as a general rule ;
 
 ALTERATIONS IN THE BLOOD-PRESSUKE. 55 
 
 according to Zadek it amounts to from one-twelfth to one- 
 sixth of the normal degree. It is therefore doubtful whether 
 this increase can exercise any appreciable influence upon the 
 transudation of albumen. Moreover, the albuminuria often 
 observed during digestion cannot be attributed to increased 
 pressure, for, as we know, the urine is increased in quantity 
 while the process is going on. This albuminuria of digestion 
 can be satisfactorily explained in another way, as will appear 
 later on. (See V.) 
 
 No methodical experiments have yet been made with the 
 various poisons which raise the pressure in the aorta, such as, 
 in addition to those previously mentioned (see p. 42) nicotine, 
 Picrotoxin, &c. ; only incidentally has albumen been observed 
 in the urine during the employment of one or other of these 
 remedies. For our purpose we can scarcely expect to obtain 
 any definite explanations from such experiments as these, 
 for when poisons of this kind are administed very different 
 conditions co-operate, which make it difficult to connect 
 causes and effects together. With regard in particular to 
 the increase of pressure and its connection with albuminuria, 
 we must take into consideration the fact that the increase 
 depends upon a narrowing of the vessels when most of these 
 substances are administered, and therefore proves just as 
 little as other experiments based on the same process (see 
 p. 42 et seq.) ; and likewise that these drugs often cause 
 spasm of various groups of muscles, and exercise a disturbing 
 influence upon the nutrition of the tissues, &c. 
 
 A review of the total results of all these numerous expe- 
 riments, having for their object the production of albumi- 
 nuria by increasing the pressure in the aorta, produces the 
 impression that the majority of the experiments have failed, 
 and that the labour devoted to them has been, for the most 
 part, expended in vain. The few trustworthy experiments 
 performed with unequivocal results, and facts of a like im- 
 port, and in harmony with the experiments observed, in the 
 human subject, appear to justify the following conclusion, 
 viz. that the increased arterial pressure in the kidneys j^er se 
 produces, or may produce, albuminuria, if by the removal of 
 water through other channels, the urine is simultaneously 
 decreased in quantity below the normal amount.
 
 56 ALBUMINURIA DEPENDENT UPON 
 
 In venous congestion of the kidneys tlie processes are 
 vastly more complicated and difficult to fathooj. It is true 
 that the experimental investigations on this subject have 
 shown, with a mutual conformity otherwise rare_, that apart 
 from other changes, the urine under these circumstances 
 always becomes albuminous, and with this result the expe- 
 riences of renal cougestion in the human subject seem to 
 accord, so that there has been no hesitation in interpreting 
 in the same sense all the experiments having for their object 
 the arrest of the venous blood ; and in regarding all of 
 them, like the clinical examples, as of equal value. If, 
 however, we look more closely into the matter, we find that 
 there are very important differences among the experiments, 
 and to a greater extent between them and the clinical exam- 
 ples, in spite of the fact that a certain similarity exists. 
 With regard to the clinical examples, we do not require 
 much experience to know that, in the first place, with the 
 exception of those extremely rare cases which have scarcely 
 any clinical significance, the phenomena of congestion in the 
 human subject are induced by conditions which lower the 
 pressure in the aorta, and that in the proportion in which 
 this takes place the congestion becomes increased ; and in 
 the second place, that the conditions generally become deve- 
 loped very slowly, that is to say, in the course of many 
 weeks, or at least days, and hardly ever in the course of a 
 few hours or minutes. In the experimental investigations 
 performed for the purpose of explaining the conditions in 
 the human subject, there is much that contravenes the 
 above experiences. In order to produce congestion, the pre- 
 ference has been given to experiments in which the renal 
 vein is tied, and these have been used for purposes of com- 
 parison, although inasmuch as the arterial supply to the kid- 
 neys continues unchanged, the circumstances are the oppo- 
 site of those of the pathological conditions of the human 
 subject. Moreover, in the majority of cases, and especially in 
 recent times, when these questions have assumed considerable 
 prominence, the effects of the various operations regarded as 
 necessary have neither been gradually induced nor allowed 
 to continue for a brief period, but suddenness and extreme 
 results have been aimed at, and thus, for example, the move-
 
 ALTERATIONS IN THE BLOOD-PRESSURE. 57 
 
 ment of the blood has been completely arrested during many- 
 hours, and indeed, for days. As a matter of fact, the fiual 
 result of all such experiments in which, however mucli the 
 conditions are changed, one at last is always attained — the 
 arrest of the circulation and of tlie renewal of the blood ; I 
 say, the final result of all sucli experiments is, as could be 
 easily foreseen, always the same, namely, the escape of 
 albumen and blood throughout the kidneys, and tliese pass 
 into tlie urine when the secretion is again restored. But 
 that under the various conditions whicli induce congestion, 
 the phenomena should develop themselves in an unequal 
 degree might certainly ä priori be regarded as more pro- 
 bable than the contrary ; it is also certain that these diif er- 
 ences could not be recognised if the cbanges were investigated 
 only after they had become very far advanced, and the mis- 
 chief had thoroughly and universally affected all the various 
 elements of the kidneys ; and in the last place it is no less 
 certain that the course taken by the phenomena may be very 
 different according as the disturbance is a sudden one or of 
 a slow and gradual character. We know that all the organs, 
 and the kidneys are no exception, are very sensitive to dis- 
 turbances of the circulation, but notwithstanding this fact, 
 when the disturbance is of a gradual character, they accomo- 
 date tbemselves very well to the altered conditions, and 
 within certain limits can discharge their functions in a 
 manner approximatively normal. A consideration of all these 
 facts will prevent us from expecting, on the one hand, any 
 uniform course of the phenomena in the experiments on con- 
 gestion, and, on the other, any collective and individual 
 coincidences between the clinical appearances of renal con- 
 .gestion and those experimentally induced. 
 
 If the escape of venous blood be completely prevented by 
 tying the renal vein, or by any other plan whicli does not at 
 the same time arrest the action of the heart, inasmuch as 
 blood will be supplied as freely as before, there must neces- 
 sarily result the fullest imaginable engorgement of the organ 
 with extravasations of blood due to lacerations of the smallest 
 vessels, and the only limit to this engorgement will be the 
 distensibility of the renal capsule. In rabbits, for example, 
 this limit appears to be reached when the escape of blood
 
 58 ALBUMINURIA DEPENDENT UPON. 
 
 has been prevented for from lialf-an-hour to an hour. The 
 kidney is then enormously swollen — to double its normal size 
 or more — and in addition to extravasations varying in size 
 and number^ its entire substance^ cortical and medullary, is 
 turgid with blood. After the organs have been hardened by 
 boiling, according to Posner's method, and then coloured, 
 microscopical examination shows that coagulated albumen 
 and numerous red blood-corpuscles are deposited in the cap- 
 sules and in the uriniferous tubules. The same appearances 
 are found, according to Posner, when the inferior vena cava 
 and not the renal vein is tied, and the same holds good, par- 
 ticularly with regard to the excretion of albumen (to antici- 
 pate further statements on this head), in every form of con- 
 gestion due to other causes, provided only that the condition 
 be of sufficient intensity and duration, stopping short, how- 
 ever, of causing the engorgement and extravasation of blood 
 to attain the same degree. During the existence of such 
 intense congestion, the function of the kidney is almost, if 
 not altogether, in abeyance. In experimenting upon rabbits 
 I could not succeed in obtaining any trace of secretion from 
 the ureter of that side, if, before applying the ligature, the 
 tube had been emptied of its contents. Cohnheim (59) states 
 that immediately after the vein is tied a bloody liquid, highly 
 albuminous, may at first distill from the ureter ; this gradu- 
 ally but decidedly diminishes, until at last the secretion 
 entirely ceases. When the ligature is removed, supposing 
 that it has not been retained for too long a time, the secre- 
 tion is restored, and the fluid, as a matter of course, contains 
 blood and a considerable quantity of albumen. How far this 
 fluid, containing as it does so much albumen and blood, 
 deserves to bo called urine, is a question which may be left 
 undecided. 
 
 An experiment of this kind can, as I have already said, 
 teach us nothing with regard to the order of sequence of 
 the process of the development of the albuminuria, especially 
 upon what it depends. The production of such an intense 
 congestion injures more or less all the elements concerned, 
 the glomerular vessels, the interstitial vessels, the various 
 epithelia, and possibly other constituents of the tissue. With 
 regard especially to the tubular epithelium, it is true that
 
 ALTERATIONS IN THE BLOOD-PEESSURE. 5^ 
 
 no marked changes can be possitively detected under the 
 microscope, but this is clearly no proof that the cells have 
 escaped all injury, for the glomerular vessels appear un- 
 changed, notwithstanding the fact that blood and albumen 
 have escajDed from them in appreciable quantities. 
 
 The appearances are of a different and more simple 
 character when the flow through the vein is checked for a 
 very short pei-iod only, the obstruction being removed before 
 the symptoms have reached their acme. We are indebted 
 to Ludwig, whose studies on the secretion of urine led him 
 to try the effect of these very brief interruptions to the 
 venous outflow, for a knowledge of the very important fact 
 that the closure of the renal vein (the arterial supply con- 
 tinuing unchanged) causes the ui'iniferous tubules of the 
 pyramids and medullary substance to be compressed by the 
 much dilated veins surrounding them, even to the extent of 
 producing complete closure, so that the flow of urine m.ay 
 be interrupted, to be immediately renewed when the blood 
 is allowed to flow. In such a kidney, removed from the 
 body immediately after ligature of the vein, all that can be 
 recognised, both with and without the microscope, is great 
 dilatation of the numerous vessels of the renal medulla, but 
 no excretion of albumen, none at all events in the Bowman- 
 Miiller's capsules. If the vein is allowed to remain occluded 
 for a somewhat longer period, for eight to twelve or at most 
 fifteen minutes, the changes will be found to have advanced 
 a step further — there is now distinct excretion of albumen 
 in the kidney, but this has taken place exclusively, or very 
 nearly so, in the uriniferous tubules, particularly of the medul- 
 lary substance, in the collecting tubes, but not in the capsules. 
 
 The appearances are very beautiful and distinct on sections, 
 doubly coloured with picro-carmine, of the renal tissue 
 hardened by boiling with or without subsequent treatment 
 in alcohol. Everywhere within the tubuli we see the tiny 
 coagula of albumen with shrivelled blood-corpuscles, whereas 
 in the capsules we look in vain for albuminous deposits ; 
 perhaps here and there an isolated specimen may be found, 
 if the experiment has been somewhat more prolonged.^ If 
 the ligature be retained for more than the brief interval 
 
 ' See fis:. i.
 
 •60 ALBUMINURIA DEPENDENT UPON 
 
 mentioned above, the conditions more and more closely 
 approximate to those already described, and the excretion 
 of albumen within the capsules generally is a manifest 
 phenomenon. At the same time, it is important to notice 
 that the epithelial cells of the tubules blocked-up by the 
 masses of albumen are, like the epithelium in general so far 
 as can be recognised, in a perfect state of preservation. 
 When the interruption to the circulation is of such a brief 
 character, no detachment of cells from the basement mem- 
 brane can be made out, but if the congestion lasts a little 
 longer, the epithelium is seen to be removed from its bed 
 by a layer of coagulated albumen. 
 
 No other conclusion can be drawn from these experiments 
 than that the medullary substance of the kidney is that por- 
 tion which is primarily and most seriously affected when the 
 renal vein is occluded, and the flow of blood through the 
 artery allowed to continue ; and that the abnormal excretion 
 of albumen first occurs in the uriniferous tubules of this 
 portion, the visible escape of albumen into the capsules being 
 a subsequent phenomenon. I do not know of any other way 
 of interpreting the appearances before us, for no one can be 
 expected to assume that the albumen is excreted into the 
 capsules, and drains away into the tubules in the course of a 
 few minutes, and to such an extent that nothing beyond a 
 mere trace, if even so much as this, remains behind in the 
 capsules. There is nothing extraordinary in the fact that 
 this conclusion has hitherto not been recognised, or that it 
 should have been repudiated as illegitimate by experimenters, 
 for as I have already said, the experiments hitncrto made 
 have not been properly performed, at least with regard to our 
 present purpose.-^ 
 
 This explanation of the origin of the excretion of albumen 
 when the renal vein is completely occluded for a brief period, 
 during which some amount of circulation is probably kept up 
 by other veins, can also be applied to explain the same 
 
 ' I Lave shown in a former treatise {I. c.) tlmt the process of the excretion 
 of albumen, when the flow through the vein is interrupted, goes on as above 
 described, but I then made no distinction between occlusion of the vein, 
 without any change in the arterial pressure, and the same condition 
 accompanied by a reduction of that pressure.
 
 ALTERATIONS IN THE BLOOD-PEESSUßE. 61 
 
 phenomenon occmn-ing when the renal vein is only partially- 
 occluded or the inferior vena cava is tied, — in either case the 
 escape of venous blood not being interrupted for too long a 
 period. From some statements of Weissgerber and Perls 
 (60), in whose experiments the flow through the vein was 
 thus checked, but for too long an interval for our purpose, we 
 may gather that the excretion of albumen took place primarily 
 and in the most marked degree in the pyramidal portion and 
 medulla of the kidney. For they found the albuminous 
 coagula, which they described as " hyaline cylinders," chiefly 
 and primarily in the pyramids and looped tubules, but more 
 rarely and only sparsely in the convoluted portions. 
 
 A second method of producing congestion consists in 
 cutting off, or reducing, the supply of arterial blood. After 
 a ligature has been applied to the artery for several hours, 
 the macroscopic and microscopic appearances presented by the 
 kidney are, as already mentioned, but little different from 
 those observed when the vein has been similarly treated for 
 an equal period ; the kidney, however, is less swollen, and 
 the engorgement of the medulla as contrasted with that of 
 the cortical portion is more conspicuous ; there is no appreci- 
 able difference with regard to the excretion of albumen. It 
 is no wonder that those who performed experiments of this 
 kind, discovered no sort of difference between the processes 
 of congestion induced in either manner. But the state of 
 the case is different, if the interruption, this time of the' 
 arterial supply, is removed after a short interval, say eight 
 to ten or twelve minutes. Then we see a considerable 
 excretion of albumen, but in the capsules alone, and only 
 after a longer interval in the urinary tubules as well, and 
 then only in a very inferior degree, altogether different there- 
 fore from what takes place when a ligature is kept on the- 
 vein for a short time. A similar result will in all probability 
 be induced, if the artery is not quite closed, but its calibre 
 very much narrowed for a somewhat longer period, as has been 
 done by M. Herrmann and von Overbeck, (61) and resulting 
 in the production, according to their observations, of albu- 
 minous urine, while the afflux of blood continued, though in 
 a reduced quantity, the urine itself undergoing a very 
 considerable diminution before the albumen appeared. I
 
 62 ALBUMINURIA DEPENDENT UPON 
 
 have not made any experiments witli regard to the first 
 appearance of albumen and its distribution under these 
 circumstances. 
 
 With regard to the condition of the urine^ the fact is not 
 without significance that, contrary to what happens after the 
 vein is completely occluded, viz., the almost invariable ap- 
 pearance of blood in the secretion, this, in the case before 
 lis, is only an exceptional phenomenon. Stokvis discovered 
 albumen, but no trace of blood, in the first specimens of 
 urine passed after the circulation in the renal artery had been 
 completely interrupted for a prolonged period. The albumen 
 under these circumstances cannot have been yielded by the 
 remaining healthy kidney, for, as Frerichs, Rosenstein and 
 others have shewn (62) the complete removal of one kidney 
 is not followed by albuminuria. We must, in preference, 
 assume that, when the principal artery of the kidney is tied, 
 the circulation is partially maintained by means of certain 
 small arteries, and that a secretion of urine, certainly abnormal 
 in its characters, goes on. To this category must be referred 
 those instances in which, in consequence of a morbid con- 
 striction of the small arteries, the supply of blood is checked 
 and albuminuria results — conditions which have been observed 
 in the experiments previously alluded to (see p. 42) in 
 which the irritation of the spinal cord, the poisonous effects 
 of strychnia, dyspnoea, &c., were produced — and likewise the 
 albuminuria observed by CI. Bernard (63), when he irritated 
 the peripheral portions of the divided renal nerves. We may 
 fairly assume that, in all these instances, there was an abnormal 
 escape of albumen into the capsule while the spasm of the 
 vessels continued, and that it was washed onwards by the 
 subsequently restored current of blood. Blood may appear 
 in the urine passed under these latter circumstances, just as 
 it may in that which is secreted when the circulation is 
 restored in the artery after complete interruption, for at this 
 period the blood passes under abnormally high pressure 
 through vessels more or less damaged as regards their 
 nutrition, in consequence of the previously defective supply 
 of blood, — conditions under which haemorrhages are prone 
 to occur. 
 
 In connection with the above details we must, in conclu-
 
 ALTERATIONS IN THE BLOOD-rßESSUßE. C3 
 
 siorij allude to those experiments of tying the ureter, wliicli 
 have likewise been adduced in order to explain the alterations 
 of pressure in the kidney. They may be legitimately used 
 for this purpose, provided that the ligature be not retained 
 for too long a period, for in that case the results will tend 
 to produce further obscurity instead of contributing towards 
 an explanation. If the ligature be retained for a very long 
 period, several hours or more, Posner states that the same 
 changes will be produced as are observed after a prolonged 
 occlusion of the vein or artery, viz., marked accumulation of 
 blood, with rupture of vessels here and there, and later on 
 (according to Posner, after the ligature has been retained 
 for three days) albumen in the capsules and tubuli. There is 
 therefore either no difference at all, or only a very slight one, 
 between this form of albuminuria and others produced in 
 other ways, so that Posner in the case before us can discover 
 nothing more than the consequences of acute congestion. 
 The circumstances however, are not exactly similar. In the 
 first place after ligature of the ureter, the blood continues to 
 circulate for at least a considerable time, perhaps not in an 
 altogether normal manner, but without indications of much 
 disturbance, a fact which can be demonstrated by opening 
 the vein. It has been supposed that the retention of the 
 secretion in the urinary tubules would check the flow through 
 the vein, just as obstruction of the latter checks the flow of 
 urine, but this, as Runeberg justly remarks, is a purely 
 arbitrary assumption (64). Certainly no comparison can be 
 drawn between the enormous increase of pressure, the result 
 of occlusion of the vein, and the pressure caused by the con- 
 fined urine, and the uriniferous tubules are very much less 
 distensible than the veins. Granted therefore that the con- 
 fined urine may possibly directly obstruct the escape of blood, 
 the obstacle is certainly not a considerable one and its action 
 is very far indeed behind that of the congestion due to occlu- 
 sion of the vein. 
 
 If the ureter be kept closed only for a shorter period, ten 
 to fifteen minutes, the principal change, and, indeed, the only 
 one when the period is very brief, is marked distension of 
 the uriniferous tubules, to such an extent that even the con- 
 voluted portions present a wide clear lumen, filled with fluid.
 
 64 ALBUMIN ÜEIA DEPENDENT UPON 
 
 and secondly, an enormous dilatation of tlie lympli-spaces 
 (oedema) especially in tlie medullary portion. Tlio intervals, 
 generally hardly recognisable, between the urinary tubules 
 and in the neighbourhood of the vessels, appear as wide clefts ; 
 the adventitia of the small arteries is enlarged to thrice or 
 more times its normal breadth, and its nuclei in consequence 
 are separated from each other by considerable intervals. On 
 sections, prepared as already described, the appearances are 
 very remarkable indeed, and we also noticed that the interior 
 of these lymph-spaces is often filled up Avith a very finely- 
 granular mass (coagulated albumen).'^ Besides this there is 
 congestion, though not of a very marked character, of the 
 medullary veins. When the ligature is retained for a some- 
 what longer period, we find a decided excretion of albumen 
 in the capsules as in the uriniferous tubules. Whether this 
 occurs first in the former or in the latter structures I have 
 not been able to decide, but on the whole the albuminous 
 excretion appears to me to preponderate in the capsules, even 
 when the flow of urine is obstructed for the briefest intervals, 
 so that its appearance is probably earlier and its quantity 
 greater in these portions of the kidney than in the uriniferous 
 tubules." 
 
 The urine secreted after removal of the ligature contains 
 more or less albumen, according to the length of the interval 
 during which the flow of urine has been obstructed. It 
 also contains blood, but always in very small quantity, even 
 when the congestion has been maintained for several days 
 (65). In my experiments, when the ligature had been 
 retained for brief intervals, there was scarcely any trace of 
 blood-corpuscles visible under the microscope. 
 
 These results of all these experiments may therefore be 
 summed up by saying that the various forms of congestion 
 correspond with each other in so far that they all produce 
 
 ' See fig. 2, 
 
 - Posner states that only after three days was lie able to discover marked 
 Alhuminous engorgement of the capsules and tubules. Perhaps the cause of 
 this later appearance, as compared with my experiments, is to be found in 
 the fact that he tied the ureter close to the bladder, whereas I tied it near 
 the Iddney. The ureter is very distensible, and, therefore, more time will 
 l.e required for it to become distended tlironghout to such a degree as to 
 cause the obstruction to be felt in the kidney.
 
 ALTEEATIONS IN THE BLOOD-PRESSUEE. 65 
 
 albuminuria^ but that differences exist not only as regards 
 the degree^ but also as regards the place in which the 
 excretion of albumen occurs. Only after a distinct interval, 
 varying according to the method of experimenting, do these 
 differences become effaced, especially so far as the deposition 
 of albumen is concerned, uniform or nearly uniform condi- 
 tions are then developed in the kidney, all the tissues 
 becoming gradually involved. The albumen escapes most 
 rapidly and abundantly when the vein is occluded, and the 
 escape of blood in considerable quantity is also a regular 
 phenomenon ; cutting off the arterial supply would seem to 
 come next as regards these effects, while confining the urine 
 by tying the ureter occupies the last place. 
 
 What are the causes of the differences in the development 
 of the albuminuria and other changes in the kidney, in these 
 various forms of congestion ? In estimating the processes, 
 we may be guided by the changes of pressure in the blood- 
 vessels and lymphatics, and the disturbances of nutrition 
 which are invariably associated with certain degrees of these 
 changes, since in all cases of congestion, however produced, 
 there is a retardation of the current of blood, with disturb- 
 ance of nutrition as a constant accompaniment as time goes 
 on. These two factors, the retardation of the current and 
 the disturbance of nutrition, must therefore not be separated 
 from each other. It must also be remembered that in the 
 production of urine two factors co-operate, viz. the glome- 
 rular vessels which are governed by the laws of filtration, 
 so long as their nutrition is unaffected, and the glandular 
 epithelium proper, which is subject to influences of a different 
 character, and only partially understood. 
 
 The process takes the simplest form when the arterial 
 supply is interrupted, that is, when the congestion is the 
 result of ischgemia. The natural consequence of this inter- 
 ruption is that the blood-pressure in both capillary systems 
 of the kidney falls below the normal. How the filtration in 
 the capsules will be thereby affected can be stated mth 
 certainty ; there will be a diminution in the quantity of the 
 filtrate, but an increase relatively in the amount of albumen 
 it contains (compare p. 28) ; and this will be decidedly the 
 first direct effect of the diminution of the pressure, and one 
 
 5
 
 6Q ALBUMINURIA DEPENDENT UPON 
 
 ■wliicli must occur immediately, before any possible distur- 
 bance of nutrition can take place, provided tbat any pressure 
 exists and any filtration goes on. The consequences as 
 affecting tlie glandular epithelium of the kidney can be esti- 
 mated only according to the analogy of other glands in 
 which secretion and not merely filtration takes place. It is, 
 however, certain that every secretion becomes more scanty 
 as the blood-pressure diminishes. Whether, in cases of 
 simple diminution of blood-pressure, albumen, previously 
 absent, passes into the secretion, has, so far as I know, not as 
 yet been experimentally determined with regard to the liver, 
 the only gland with a non-albuminous secretion suitable for 
 an experiment of this kind. I should, however, think it not 
 improbable, considering the results obtained by occluding an 
 artery for brief intervals and which have been described in 
 a previous page (see p. 59). The result would be different 
 if the congestion were of long duration. Examination of 
 the kidney in this case furnishes no positive explanation, for 
 deposits of albumen are found both in the capsules and in 
 the uriniferous tubules, but this appearance is no irrefragable 
 proof that the albumen is derived from the interstitial capil- 
 laries, for it may have escaped from the capsules into the 
 tubules. On the other hand, from the condition of the biliary 
 secretion in the human subject, after prolonged congestion, 
 it may be allowable to draw conclusions as to the secretion 
 of the renal epithelium in similar circumstances. In connec- 
 tion with this, much importance is attached to Frerich's 
 statement (66) that albumen has been found in the bile in 
 several cases of passive hypercemia of the liver. It proves 
 that even in this form of congestion, besides the glomerular 
 system of vessels, the secretory apparatus of the kidney may 
 also yield albumen. 
 
 But however this may be, the combined results at any rate 
 of the diminution of pressure upon the two sources which 
 participate in the production of urine, must be a considerable 
 diminution in the quantity of that fluid and an increase in the 
 percentage of the albumen it contains. The percentage of albu- 
 men in the fluid yielded by the capsule will now therefore be 
 a + X instead of a ; the quantity of the epithelial secretion will 
 be represented hy n—y and therefore the percentage in the
 
 ALTEEATIONS IN THE BLOOD-PRESSURE. 67 
 
 a + x 
 urine wlien the arterial supply is diminished will be n—y A 
 
 100 
 
 comparison with the formulae previously given (see pp. 33 
 and 42), for the normal and for the increase of arterial pres- 
 sure^ makes the difference sufficiently obvious. If in this case 
 albumen really appears in the true glandular s-ecretion, we 
 might naturally expect an increased quantity in the urine. 
 
 When the ureter is closed, the action which the confined 
 contents of the uriniferous tubules exercise upon the glome- 
 rular vessels and the secreting epithelium is the factor which 
 determines the result. Runeberg has set forth in a proper 
 light the consequences as they affect the former portions ; he 
 states that the stagnation of the urine causes an increase of 
 the pressure upon the external wall of the glomerular vessels, 
 that the filtration-pressure — that is, the difference between the 
 external and internal pressure — is decreased, always supposing 
 that the current of blood remains unchanged, or at least that 
 there is no increase within the glomerular vessels. That this 
 supposition is perfectly right may be positively assumed only 
 with reference to the first beginnings of the process. As we 
 have already explained (see p. 63), when the ligature is 
 retained on the ureter for a short time only, the circulation 
 is certainly not completely interrupted, and the obstruction 
 which the distended uriniferous tubules cause to the blood- 
 vessels can at first be only very slight, so long as there is no 
 great accumulation of fluid confined within the excretory tubes 
 of the renal medulla.^ A diminution of the filtration-pressure 
 may therefore be admitted to exist in the earliest stage, and 
 the evident deposition of albumen in the Bowman-Miiller's 
 capsules is capable of explanation in accordance with the 
 descriptions already given. It is difficult, however, to make 
 any further statement with regard to the conditions and cir- 
 cumstances of the pressure as the process goes on. It is 
 possible that the blood-pressure within the glomerular vessels 
 may be increased to an extent exceeding that of the external 
 
 ^ Even when there is prolonged and complete occlusion of the ureter, 
 circulation of blood to a sufficient extent may continue, as clinical observa- 
 tion shows. A case o£ this kind, interesting also in other respects, has been 
 recently reported by Schwengers and Leicbtenstern (67).
 
 ,68 ALBUMINURIA DEPENDENT UPON 
 
 pressure to which they are subjected ; in that case the filtra- 
 tion would become almost normal ; or if the preponderance of 
 pressure within the vessels increased, the resulting filtrate 
 would contain more water and would be poorer in albumen. 
 There is also the possibility that, the secretion by the gland- 
 ular epithelium being continuous and actively carried on, the 
 predominance of pressure might become so decided in the 
 uriniferous tubules that the fluid of the capsules might take 
 a backward course, and that absorption might go on until the 
 internal and external pressures became equalised. 
 
 There is no doubt that the secretory epithelium of the 
 uriniferous tubules continues to possess and exhibit its secre- 
 tory activity after the ureter is occluded. That this is so is 
 positively shown by the increasing fullness of the uriniferous 
 tubules, the great dilatation of the lymphatic channels 
 depending upon the pouring into them of secretion not 
 removed in the ordinary way, aiud by the behaviour of other 
 glands under similar circumstances. It is, however, another 
 question whether the secretion is altogether normal in char- 
 acter, and in particular whether it is free from albumen as is 
 normally the case. The liver is the only organ which could, 
 be used to assist in deciding this question, but, so far as I 
 know, no investigations have been made upon its secretion 
 after tying its excretory ducts. But the albuminous deposit 
 which I found in the uriniferous tubules after a ligature had 
 been kept on the ureter for a brief interval (see p. 63), it 
 being impossible that the albumen can have got there by 
 escaping from the capsules, is evidence in favour of the 
 supposition that the real secretion of the epithelium contains 
 albumen, as might be expected with regard to every cedema- 
 tous gland. It is, therefore, highly probable that both the 
 glomerular vessels and the interstitial vascular and lymphatic 
 systems participate in the production of the albuminuria that 
 ensues after the impediment is removed. 
 
 When the escape of venous blood is prevented without 
 interfering with the arterial supply, the circumstances, first 
 and foremost, with regard to the blood-pressure, are very 
 different from those which obtain in the other two kinds of 
 congestion, and especially in that caused by tying the artery. 
 When the supply is cut off, the pressure in the capillaries
 
 ALTEllATIONS IN THE BLOOD-PRESSÜEE. 69 
 
 fallsj as we have said^ below the normal ; if, when the occlu- 
 sion is complete, compensation takes place by a retrograde 
 movement of the blood from the spot where the renal 
 vein opens into the inferior vena cava, the pressure in the 
 radicles of the renal vein will become equal to that in 
 the vena cava, and therefore as a matter of course always 
 lower than the normal degree. The case is, of course, 
 different when the vein is occluded, for then the pressure 
 must reach an abnormal height, the degree varying with the 
 degree of completeness of the closure. In consequence, 
 however, of the peculiarity involved in the fact that the 
 majority of the branches of the renal artery break up into 
 the glomerular capillaries before passing into the interstitial 
 capillary system, the increase of pressure in the various por- 
 tions of the vascular system must differ in amount (68). It 
 will be most marked and its occurrence earliest in the inter- 
 stitial capillary system ; it will appear later and in a less 
 degree in the glomerular vessels. The production of oedema, 
 here as everywhere else, necessarily follows as the second 
 direct effect of occlusion of the vein with unimpeded arterial 
 supply. And thus it iß that this form differs from the 
 ischaemic congestion, which per se does not immediately pro- 
 duce oedema, but which, only after a much longer period, and 
 when in consequence of the deficient supply of blood the 
 nutrition of the tissues has become affected, may be the 
 indirect cause of a dropsical swelling. Thirdly, and lastly, 
 as I have already more than once mentioned, the excretory 
 portions of the uriniferous tubules, especially in the medullary 
 substance, are compressed by the congested veins and stag- 
 nation of urine is the result. 
 
 These three sets of consequences blend with each other 
 and their mutual influence is to some extent contrary, so 
 that it is diflScult to separate their effects, and to determine 
 separately the share which each has in the disturbances they 
 jointly produce. The stagnation of urine in particular 
 counteracts to a certain extent the increase of pressure, as 
 already explained. If we therefore leave this complication 
 out of the question, we shall have less difficulty in estimating 
 the effects of tying the vein upon the two factors concerned 
 in the production of urine, always of course supposing that
 
 '/O ALBUMINURIA DEPENDENT UPON 
 
 the discharge through the vein is not entirely checked, for 
 if it be, the function of the kidney is rapidly extinguished 
 (see p. 60). Cohnheim^s researches upon venous congestion 
 (under conditions, as in the case before us, of unimpeded 
 arterial supply), justify the conclusion that in the parts in which 
 transudation occurs, the glomerular vascular system, there 
 will be an escape of fluid, in quantity exceeding the normal 
 and containing blood. Both of these, the quantity of fluid 
 and the blood, are in direct proportion to the degree in 
 which the pressure of congestion exceeds the normal amount ; 
 and the blood especially is the characteristic which distin- 
 guishes the transudation of congestion from that which is 
 normal, and likewise from that yielded by the kidney when only 
 the arterial pressure is increased ; and whether the blood-cor- 
 puscles escape by diapedesis, or in consequence of rupture 
 of vessels, is for our present purpose a question of no import- 
 ance. 
 
 The condition of the secretory apparatus may also be 
 determined with some degree of certainty, although in this 
 case a comparison with the liver is again wanting. For, so 
 far as I am aware, no observations have been made with 
 regard to any changes which may occur in the bile after 
 ligature of the hepatic vein. But we may regard it as certain 
 that an cedematous gland — and with such we are certainly 
 dealing at present — not only secretes more copiously, but also 
 allows albumen (and probably also blood) to pass abnormally 
 into its secretion, as a matter of course from the interstitial 
 vessels. This is also proved by the discovery of albumen 
 between the epithelium and the membrana propria, an 
 appearance which, in this form of congestion, is speedily 
 produced at a much earlier period than in the other forms in 
 which it may occur after a longer interval. If, however, this 
 hypothesis be rejected, and the albumen in congestion be 
 supposed to escape from a source other than the glomerular 
 vessels, it would then be necessary to interpret these appear- 
 ances by supposing that the epithelium first became detached, 
 and then that albumen drained from the capsules between the 
 epithelium and the membrana propria. It is, however, easy 
 to foresee the relation that would then exist between the 
 basement membrane which had lost its epithelium and the
 
 ALTERATIONS IN THE BLOOD-PEESSUEE. 71 
 
 lympli-current in wliich it is bathed. This thoroughly forced 
 explanation is therefore discarded. 
 
 An abnormally copious secretion yielded by the interstitial 
 vascular apparatus, containing albumen, and possibly blood 
 as well, will therefore be added to the already abnormally 
 copious and blood- containing transudation of the glomerular 
 vessels, and the collective results of the venous occlusion will 
 consequently be the production of urine abnormally copious 
 in quantity and containing albumen and blood. This effect 
 will, however, in part, be weakened by the confinement of 
 the urine within the tubules, wliich is associated with the 
 occlusion of the vein, and which counteracts the pressure in 
 the glomerular vessels. We have already seen that in these 
 vessels the increase of pressure 'per se is less than in the 
 interstitial capillaries, and is also later in appearing, and it 
 follows that the effect of occlusion of the vein upon the 
 glomerular vascular system will be much less and occur later 
 than the same effect upon the interstitial vascular system and 
 the uriniferous tubules. 
 
 So far as any knowledge can be obtained from experiment 
 and clinical observation, they confirm in the most striking 
 manner the correctness of these explanations. It is certainly 
 true that experiments in which the occlusion of the vein is 
 complete and continued for several hours furnish no explanation 
 at all, or none of any use for our purpose. Under such 
 circumstances the function of the kidney scarcely exists, 
 and extravasations of blood and albumen are the general 
 appearances on anatomical investigation. On the other 
 hand, our experiments, in which the vein has been tied only 
 for brief intervals, have really shown that the first effect is 
 produced in the sphere of the interstitial capillaries and the 
 uriniferous tubules (see p. 60). 
 
 As regards the condition of the urine, it is not easy to 
 come to any decision in experiments of such brief duration, 
 for the secretion soon becomes abolished when the closure is 
 complete. In the experiments already referred to of Weiss- 
 g^erber and Perls, in which the vein was completely occluded, 
 but for a longer interval, the special feature was the appear- 
 ance of albumen in the collecting tubes and loops, and only 
 ixy a portion of the cases in the convoluted tubes as well.
 
 72 ALBUMINURIA DEPENDENT UPON 
 
 In five cases it is twice mentioned that the urine contained 
 blood, so that these may be regarded as confirmatory of our 
 explanations. These latter are also supported in a very 
 marked manner by Bartels' case, already referred to (see 
 p. 26), and in many respects so very interesting, of throm- 
 bosis of the inferior vena cava occurring in a robust man, 
 a case presenting precisely the same conditions with those in 
 Weissgerber's and Perls' experiments, viz. obstructed venous 
 outflow with unimpeded arterial supply, and this, moreover, 
 is the only known case of the kind in which any reference is 
 made to the quantity of the urinary secretion. " In this 
 case the result has been," to quote Bartels' own words, ^'not 
 only a profuse secretion of urine, but also the escape of 
 albumen, and even of considerable quantities of blood into 
 the urine, probably in consequence of rupture of several 
 vascular tufts of the glomeruli." If an obstacle to the venous 
 outflow, limited to one renal vein or to the inferior vena cava, 
 is formed in the human subject, the conditions under which 
 this generally occurs do not permit of any comparison with 
 venous occlusion produced by experiment, since the arterial 
 pressure is simultaneously diminished. This is what occurs, 
 for example, in the most common clinical thrombosis of the 
 renal vein of new-born children, for this is always of marantic 
 origin. But even in the very rare cases as well, in which 
 the vein is occluded by tumours, generally of a malignant 
 character, other complications being likewise present, the 
 arterial pressure is usually in a similar condition. Corre- 
 sponding with this, there is in these cases a difference as 
 regards the quantity of the renal secretion. According to 
 the rapidity of the development and growth of the obstacle 
 the urine invariably becomes more or less scanty, and at the 
 same time contains much albumen and blood. 
 
 The admixture of blood distinguishes this urine from 
 that which usually and frequently occurs in congestion 
 in the human subject, this condition of the kidney being 
 the result of diminished cardiac activity. The conditions 
 are different from those of artificial ^enous occlusion, 
 and so likewise are the consequences as regards the renal 
 secretion. The statement so frequently made to the effect 
 that the ordinary urine of congestion in the human subject
 
 ALTERATIONS IN THE BLOOD-PEESSüRE. 73 
 
 contains blood and abundance of albumen, is not at all in 
 accordance with facts, and there is, by no means, the most 
 perfect harmony between clinical observations and the 
 experimental venous occlusion, as is generally pretended. 
 For these reasons it will not be superfluous to describe 
 somewhat minutely the urine of congestion, as it daily 
 comes before us in disease of the circulatory or respi- 
 ratory organs, and such a description will be useful for 
 another reason, viz. because certain changes in the urine, 
 especially with reference to the proportionate amount of its 
 several constituents, and which may be of importance in the 
 explanation of the processes going on in the kidney, can be 
 determined in a satisfactory manner only in the human 
 subject. The first and most constant phenomenon is the 
 diminution of the water, and therefore of the quantity of 
 urine, this being determined by the amount of water present. 
 There is little known with regard to the proportionate amounts 
 of the solid constituents, but the total quantity of these is 
 not diminished in the same proportion as the water. On this 
 account the specific gravity of the urine is increased, its colour 
 becomes deeper, and there is a tendency to the formation of 
 sediments, these being due to the fact that the urates, which 
 are not very soluble in cold water, and uric acid itself, are 
 readily precipitated during cooling from urine which contains 
 less than the normal amount of water. It is, however, more 
 than probable that the solid constituents, or at all events 
 a portion of them, are excreted in diminished quantities, 
 although their diminution does not proceed pari passu with 
 that of the water, and they may therefore be relatively in- 
 creased with reference to that fluid. The urea at least, 
 according to my observations, is always absolutely diminished 
 in quantity, notwithstanding the relative increase, which may 
 amount to three or more per cent»-^ The condition of the 
 uric acid is more difficult to estimate, inasmuch as the respi- 
 ratory troubles almost always present in this form of renal 
 congestion, give rise to complications which apparently exert 
 
 * The absolute diminution of the urea can partly be explained by the fact 
 that less nourishment is taken and absorbed, and partly also by the 
 consideration that the urea finds its way into any dropsical effusions that 
 may be present, and into the discharges from the bowels.
 
 74 ALBUMINURIA DEPENDENT UPON 
 
 some influence on tlie formation of uric acid in the system (69) . 
 At the same time that the water becomes diminished, or 
 shortly afterwards, albumen is often to be found in the urine, 
 but always in small quantity, provided that the condition is 
 that of congestion and nothing more. It would seem that 
 this statement cannot be too often repeated. It is true that 
 when the congestion is of long duration and of great intensity, 
 the quantity of albumen is much increased at a later period, 
 but the consecutive phenomena of the stagnation of blood and 
 lymph (inflammatory processes and conditions of induration, 
 nephritis from passive congestion), have by that time invariably 
 made their appearance. Blood is— and this is a fact which 
 must be repeatedly insisted upon — scarcely ever present in 
 macroscopic quantities, and even with the microscope it is only 
 in a minority of cases that we are able to detect isolated red 
 blood-corpuscles, and generally a few colourless cells. It 
 appears to be doubtful whether, in such cases, this slight 
 admixture of blood has its origin always in the renal paren- 
 chyma, rather than from the mucous membrane of the bladder, 
 ureter, or pelvis of the kidney ; for, as a general rule, the 
 mucous membrane of these parts is the seat of more or less 
 marked hyperemia which, as in other mucous membranes, 
 may give rise to more or less considerable hsemorrhage. Pale 
 (hyaline) casts are often found associated ^vith the albumen. 
 We have thus given the details of the ordinary kind of 
 renal congestion with which every physician is familiar. 
 Another circumstance, equally well known, may be added, 
 viz. that so soon as the heart recovers its power, the urine 
 very rapidly returns to its normal condition. I need only 
 refer to the action of digitalis in cases of mitral deficiency. 
 In its origin and the way in which it becomes developed, 
 this form of renal congestion obviously most resembles that 
 which is induced when the arterial supply is cut off for a 
 brief interval or in an incomplete manner, for in both cases 
 diminution of the arterial pressure within the kidney is the 
 first thing that happens. In the experiment certainly, 
 in order to produce the most striking phenomenon in the 
 brief period of observation, the arterial pressure is very 
 considerably reduced, or perhaps altogether abolished, a 
 condition not belonging to the pathological examples. The
 
 ALTERATIONS IN THE BLOOD-PRESSURE. 75 
 
 case before us, however, differs from the experiment in 
 which the artery is tied, in the fact that an obstacle is 
 introduced in the direction of the current of venous blood, 
 the pulmonary vessels and the right side of the heart being 
 engorged with blood. The effect, therefore, with regard to 
 the difference of tension between arteries and veins, which 
 is the main point in the question, maybe exactly similar: in 
 the experiment, in consequence of the marked diminution of 
 the arterial pressure, the flow through the vein being unim- 
 peded : in the pathological conditions, in consequence of a 
 smaller diminution of the arterial pressure, but with a co- 
 existing impediment to the escape of blood through the vein. 
 It comes to pass, therefore, that there is an anatomical 
 resemblance in the main feature between the kidney in the 
 ordinary state of congestion and in that due to cutting off 
 the arterial supply, any difference being due only to the fact 
 that in the human subject death does not result as soon as the 
 congestion begins, and that this latter condition is of longer 
 duration, time being thus afforded for the development of 
 those consequences of stagnation which have been already 
 mentioned. There is seldom an opportunity, except in cases 
 of sudden suffocation, to examine kidneys in a marked state of 
 venous congestion of recent origin, and in which, when death 
 took place, the congestion had rapidly advanced so far as to 
 produce albuminuria. In the few cases which have come 
 under my notice, and which to some extent coincided with the 
 requirements, a very moderate increase in the size of the 
 kidney was the only thing to be observed ; but this did not 
 even approximately resemble that enormous increase which 
 took place in a rabbit's kidney after tying the vein, and 
 never even once reached the degree attained in cases of 
 recent inflammatory swelling of the kidney. The congestion 
 presented the usual appearances, being most marked in the 
 pyramidal portion in which veins are numerous, but less 
 prominent in the Bowman-Müller's capsules. Under the 
 microscope a deposit of albumen was not always to be founds 
 at least not in every section ; where, however, it was present, 
 it was contained almost invariably in the capsules alone. 
 
 The results, therefore, of clinical observation coincide, in 
 a manner practically complete, with what follows when the
 
 7C ALBUMINURIA DEPENDENT UPON 
 
 arterial supply is artificially cut oS, and are most satisfac- 
 torily explained by those processes wliicli are induced by this 
 experiment, as above described (see p. 63). These are, the 
 great diminution of the water as the aggregate result of de- 
 crease in pressure upon the filtering and secreting apparatus, 
 the diminution of the specific constituents of urine as repre- 
 sented by urea, the small proportion of albumen present, the 
 total absence of blood, or its presence in very minute quan- 
 tities. Considering the experimental and clinical facts, it is 
 not necessary to discuss the influence of an alteration in the 
 nutrition of the epithelium and vascular walls upon the com- 
 mencement of the process, even when the arterial supply is 
 completely cut off, and it is still less necessary to do so 
 when the supply is reduced but not entirely abolished. M. 
 Herrmann as well as v. Overbeck noticed the appearance of 
 albumen in the urine a few seconds after they had tied the 
 renal artery, and they also observed that it disappeared after 
 a very short interval, even within half-an-hour. It has been 
 already mentioned that the circumstances are often very 
 similar in the human subject, and that the urine changes, 
 so to speak, at once when the circulation becomes regu- 
 lated, being more abundant in quantity, and exhibiting no 
 trace of albumen. It would be necessary to magnify con- 
 siderably our notion of disturbed nutrition and to regard 
 every disorder of the circulation as coming within this cate- 
 gory, if in cases like these we attempted to attribute the 
 rapidly appearing and transient albuminuria to deranged 
 nutrition of the elements of the tissues. It is, moreover, 
 difiicult to reconcile the scanty excretion of albumen and 
 the very slight admixture, if any, of blood in the urine, with 
 the assumption that there is any disorder of nutrition in the 
 glomerular vessels or their epithelial investment. 
 
 It would, however, be improper to deny that, as time goes 
 on, disturbances of nutrition become a prominent feature in 
 the congestion we are now discussing. It is certainly 
 difficult or even impossible to specify the degree to which 
 the arterial supply must be reduced in order to cause 
 nutritional disturbances, and therefore in forming an estimate 
 of this influence considerable latitude must be allowed to 
 individual discretion. According to the stand-point which an
 
 ALTERATIONS IN THE BLOOD-PRESSURE. 77 
 
 observer takes up witli regard to th.e effect of mere changes 
 of pressure, will lie be inclined to claim tlie right of laying 
 stress upon the influence of derangement of nutrition, at an 
 early or late period, for the purpose of explaining the disturb- 
 ance of function. It is only in estimates of extreme con- 
 ditions that certainty can be attained, and we shall not go 
 wrong in laying down the two following propositions : 
 First, that no considerable disturbance of the nutrition of 
 the tissues can take place if the supply of blood be inter- 
 rupted for a very brief period only, say for a few seconds, 
 and during no portion whatever of the time in a complete 
 manner ; or if a retardation of the circulation be moderate in 
 extent and slow and gradual in its development, so that, as 
 already mentioned (page 58), the tissues accommodate them- 
 selves to the diminished blood-supply. Secondly, that if the 
 circulation be completely interrupted for several hours or 
 days, severe disturbance of the nutrition of the tissue must 
 necessarily ensue. 
 
 The third form of renal congestion, viz. that which is due 
 to impeded escape of urine, occurs in the human subject, 
 though less frequently than the other forms. A comparison, 
 however, cannot be so freely instituted between the sym- 
 ptoms at the bedside in these cases and those produced by 
 experiment, because for the most part only one kidney is 
 affected, so that the urine, secreted by the healthy kidney 
 alone, either presents nothing abnormal, or, if, the discharge 
 from the affected kidney be not completely suspended, the 
 result is a mixture of normal with abnormal urine. Another 
 fact which affects the comparison is that the obstacles to 
 escape of urine are usually of such a character that abnor- 
 mal admixtures, e.g. albumen or blood, become superadded 
 to the fluid after it has left the kidney. Instances of this 
 kind are, among others, the obstacles due to concretions 
 which irritate the mucous membrane, tumours in the urinary 
 passages, &c. We have also no knowledge of the anatom- 
 ical appearances of the human kidney from the very first 
 stages of the process involving complete stagnation of urine, 
 which can be compared with the result of tying the ureter ; 
 we likewise know nothing as to the part in which albumen 
 is deposited in these kidneys.
 
 78 ALBÜMINÜEIA DEPENDENT UPON 
 
 lY, — Albuminuria as Dependent Upon Degenitration of the 
 Renal Epithelium. 
 
 Of the tissue-elements, otlier tlian those of the vascular 
 system, which compose the renal parenchyma, the epithelium 
 alone remains for consideration in our study of albuminuria. 
 The most important are the epithelial cells of the uriniferous 
 tubules, next come those of vascular tufts, and in the third 
 place, though these are not so directly concerned, the epi- 
 thelial cells which line the internal surface of the Bowman- 
 Müller's capsules. In former times the epithelial cells were 
 credited with the possession of a considerable amount of 
 influence in the causation of albuminuria, but this was 
 attributed only to those of the first class, the existence of the 
 others not being recognised. Two principal ideas prevailed 
 on this subject. It was supposed that in morbid states of 
 the epithelium, the albumen which normally transuded 
 through the glomerular vessels, to be taken up and assimi- 
 lated by the epithelium, no longer underwent this process, 
 but escaped by the urinary tubules ; or, secondly, that the 
 albumen passed into these channels from the blood-vessels 
 by which they are surrounded, because the epithelial cells 
 having undergone nutritive derangement, were unable to 
 discharge their normal function of preventing such escape 
 from taking place. Modern theories pay little attention to 
 this question, but they usually cut the matter short by 
 asserting that in fatty or other degeneration of the epithe- 
 lium, as in phosphorus-poisoning, in severe anaemia, and 
 severe febrile infectious diseases, no albumen is found in the 
 urine, and therefore the epithelium can have no share in the 
 production of albuminuria. And yet these very theories are 
 based upon the doctrine that the epithelium prevents the 
 escape of albumen from the blood, and that normal urine is 
 therefore free from this constituent. The contradiction 
 stares us in the face ! At all events those who assume that 
 the albumen is retained in the blood by the agency of the 
 epithelial investment of the glomerular vessels, must allow 
 the possibility of albuminuria being caused by derangement of
 
 DEGENEEATION OF THE EENAL EPITHELIUM. 79 
 
 the nutrition or destruction of this epithelium in particular. 
 The other epithelial cells^ especially those o£ the uriniferous 
 tubules, of the proper glandular elements, are either not 
 mentioned at all, or else they are expressly alluded to as 
 altogether unconcerned in the production of albuminuria. 
 
 It is well known that some of the secretions proper, that 
 is, the sole products of really secreting glandular epithe- 
 lium, are albuminous, while others are free from that con- 
 stituent. The products of the former, which are the more 
 numerous class, owe their albumen to the constant metamor- 
 phosis and separation of the cells which mix with the secre- 
 tion ; the other glands yield a product which is non-albumi- 
 nous, because according to the general and almost sacred 
 theory, their epithelium does not decay under normal con- 
 ditions, and their products consist only of definite matters 
 which they take up from the vessels or prepare within them- 
 selves, but not of albumen. Whether these epithelial cells 
 really continue without any change during the whole period 
 of life, or whether they undergo an imperceptible metamor- 
 phosis, similar to that which is constantly taking place in 
 the organism as a whole, are questions with which we are not 
 concerned at present. It is enough for our purpose that the 
 normal function of its epithelial cells is assigned as the 
 reason for the absence of albumen in the secretion of the 
 liver, the most prominent of the second class of glands, and 
 likewise in the secretions of the perspiratory and lachrymal 
 glands, supposing it to be the case that these latter secre- 
 tions in their pure state are really non-albuminous. If the 
 urine be regarded simply as a true non-albuminous glandular 
 secretion, the epithelium must be credited with the function 
 of preventing the escape of albumen from the blood ; but if 
 my view be adopted, and the urine be regarded as a mixture 
 of a transudation with a glandular secretion (see p. 33), the 
 latter at least being the produce of the epithelium of the 
 uriniferous tubules must for the same reason be considered 
 to be non-albuminous, whatever view may be entertained as 
 to the presence or absence of albumen in the transudation 
 from the glomerular vessels. The conclusion is forced upon 
 us that, when their nutrition and functions are disturbed, or 
 when t.he epithelial cells of the uriniferous tubules are in a
 
 80 ALBUMINURIA DEPENDENT UPON 
 
 state of complete decay, albumen will escape from tlie blood 
 and lympb and show itself in the urine hitherto apparently 
 non-albuminous, that is, that albuminuria will become deve- 
 loped. Observations which are alleged to prove the contrary 
 must be based upon error or defective investigation, for if 
 not, all our doctrines with regard to specific glandular secre- 
 tion must be thrown to the winds. 
 
 Fortunately, there is no such discord between observation 
 and theory in the case before us. It is well known that 
 fatty degeneration of the epithelium, of the most intense 
 character, is induced in acute poisoning by phosphorus and 
 with arsenic acid, and a few other toxic agents, and phos- 
 phorus-poisoning, the type of this class, is adduced as 
 evidence against the theory of the participation of the 
 epithelium in albuminuria, because little or no albumen 
 appeared in the urine in cases of this kind. So far as I 
 see, this entirely erroneous view owes its existence to the 
 statements of Stokvis and Kohts (70), who, as a result of 
 their experiments with this poison, felt bound to adopt the 
 conclusion that no connection existed between albuminuria 
 and fatty degeneration, whereas up to that time the observa- 
 tions of Ph. Munk and Leyden (71) had been taken as 
 evidence that albuminuria is an almost constant symptom of 
 poisoning by phosphorus. But in reality the experiments 
 of Stokvis and Kohts do not contradict the hypothesis of a 
 connection between albuminuria and phosphorus-poisoning. 
 As far as Stokvis's experiments are concerned, in the first 
 place he employed as tests nitric acid or acetic acid and 
 boiling, all of which were at that time considered to be 
 sufficient for demonstrating the presence of albumen, though 
 now we know that such is by no means the case (see p. 13 
 and 14). In the second place, even with these not very 
 delicate tests, he discovered the presence of albuminous 
 substances, viz. serum-albumen and hemi-albumose (propep- 
 tone), in three out of his four experiments, and in the fourth 
 experiment the attempt at poisoning appears to have been 
 altogether unsuccessful.^ With regard to the hemi-albumose, 
 
 * In the notes of his experiments, published by Stokvis, we find as follows : 
 — Exp. I. A rabbit poisoned by phosphorus. Death on the second day. 
 The urine during this time without any trace of albumen. The bladder
 
 DEGENERATION OP THE RENAL EPITHELIUM. 81 
 
 tliese experiments permit us to infer its presence, or at least 
 they do not prove that it was absent, inasmuch as the addi- 
 tion of acids caused a precipitate or cloudiness which disap- 
 peared on heating, and which Stokvis, without further 
 testing, referred to the presence of fat or of fatty acids. 
 But since we now know that peptone-like substances fre- 
 quently occur in the urine in cases of phosphorus-poisoning, 
 there is quite as much probability in the former assumption, 
 viz. that they were present in these experiments, as that the 
 reactions manifested were due to the presence of fat. 
 
 Kohts has performed eight experiments with poisonous 
 doses of phosphorus — six on dogs, two on rabbits. With 
 the exception of the case of one dog, which died suddenly on 
 the second day, and one rabbit, the reports of all the other 
 experiments state that, after the poisoning took place, albu- 
 men invariably appeared once or several times in small 
 quantity, and that in one rabbit the quantity was consider- 
 able. No mention is made of the methods used for its 
 detection, but we may suppose that the ordinary means were 
 employed, viz. boiling and nitric acid. It follows that the 
 sentence with which Kohts concludes his report, that ''no 
 albuminuria appeared in any of the animals experimented 
 on, with the exception of one rabbit," directly contradicts his 
 own observations. 
 
 Investigations on this subject have been very carefully 
 
 contains clear, acid urine, which is rendered slightly turbid on the addition of 
 nitric acid, excess of which causes the turbidity to disappear. The same degree 
 of cloudiness is obtained when the urine is heated with a little acetic acid. 
 This can be only serum-albumen, which Stokvis's own experiments show 
 to be soluble in excess of nitric acid, in cold urine, Exp, 2. A dog poisoned 
 with phosphorus. Death on the fifth day. The urine on the last day con- 
 taining biliary colouring matter, and rendered turbid by nitric and acetic 
 acids, but not by heating ; urine found in the bladder exhibiting the same 
 reactions. Exp, 3. A dog poisoned with arsenious acid. Death on the 
 fourth day. Urine of the last two days turbid on addition of nitric and 
 acetic acids ; the turbidity disappears on heating, and does not return on the 
 addition of sulphate of soda ; urine in the bladder gives similar reactions. 
 Exp, 4. Dog poisoned with ai'senious acid ; killed on the eleventh day, 
 though then appearing pretty well (!) The report on the urine simply states 
 that there was no trace of albumen, but only a few epithelial cells in a state 
 of fatty degeneration. Nothing found post mortem, but very slight (!) fatty 
 defeneration of the organs.
 
 82 ALBUMINUEIA DEPENDENT UPON 
 
 made by Schultzen and Ricss (72). In six dogs poisoned 
 with pTiosphorus, tliey found more or less .albumen in the 
 urine in every case. 
 
 The statements, however, of Stokvis and Kohts, cast some 
 doubt upon the subject, especially with regard to the appear- 
 ance of albuminuria in rabbits, and I therefore performed four 
 experiments with phosphorus upon as many animals of this 
 kind, all previously healthy and vigorous. A solution of phos- 
 phorus in oil was injected under the skin. Albuminuria was 
 the result in all four cases, or where there were previous evi- 
 dences of albumen (see page 20, note) its quantity was found to 
 be increased. I append brief details of these experiments. 
 
 I. March 20, 1880. — A largo vigorous rabbit, fed on oats. 
 Urine passed on compressing the bladder, acid, clear on filtra- 
 tion. The addition of acetic acid and of ferrocyanide of 
 potassium causes a slight cloudiness ; the same appearance 
 results on adding acetic acid and concentrated solution of 
 sulphate of soda to the cold urine, the cloudiness remains on 
 boiling. Nitric acid produces a slight cloudiness. On subse- 
 quent boiling, the colour becomes so deep that it cannot be 
 ascertained whether the cloudiness has disappeared or not. 
 Three-quarters of a cubic centimeter of a solution of phos- 
 phorus in olive oil (i to 80) are injected beneath the skin. 
 
 March 21. — The rabbit is pretty lively. Its urine is 
 acid, clear on filtration, and gives a decided precipitate with 
 acetic acid and ferrocyanide of potassium ; with acetic acid 
 and sulphate of soda, marked cloudiness, increased by heat ; 
 with nitric acid, marked cloudiness, and on subsequent 
 boiling the urine becomes very dark and a precipitate 
 gradually falls. Another injection as before. 
 
 March 23. — The rabbit died early this morning. The 
 urine previously voided gives same reactions as yesterday. 
 Under the microscope, sediment is found to contain very 
 finely granular casts, and a few renal epithelial cells in a fair 
 state of preservation. 
 
 II. March 23, 1880. — A large rabbit, fed on oats. 
 Urine acid, clear on filtration ; yields a doubtful trace of 
 albumen with the three tests above-mentioned. Injection of 
 half a cubic centimeter of the phosphorised oil. 
 
 March 24. — The rabbit's bladder contains a large quantity
 
 DEGENERATION OF THE RENAL EPITHELIUM. 83 
 
 of urine, when as recently passed has an acid reaction and is 
 found to be pretty strongly albuminous with all the three 
 tests. Only a few finely granular casts in the sediment. A 
 portion boiled with acetic acid and sulphate of soda, and a 
 precipitate formed. The filtrate gives no peptone- (or biuret-) 
 reaction. Rather more than half a cubic centimeter of the 
 phosphorised oil injected. 
 
 March 25. — Urine copious, paler than yesterday, acid, 
 contains more albumen than before as shown by the three 
 tests. No peptone-reaction in the precipitated urine. The 
 sediment contains a good many coarsely granular casts and 
 a few renal epithelial cells in a state of fatty degeneration. 
 1^0 injection. 
 
 March 26. — Death early this morning. The urine pre- 
 viously voided is very pale, acid, and very highly albuminous, 
 as shown by all three tests. The sediment contains coarsely 
 granular short casts and isolated epithelial cells in a state of 
 disintegration. 
 
 III. March 28. — A very large rabbit, fed upon oats and 
 turnips. Urine abundant and acid, clear on filtration ; no 
 cloudiness with all the three tests for albumen. Injection 
 of half a cubic centimeter of phosphorised oil. 
 
 March 29. — Urine acid. Acetic acid and ferro-cyanide of 
 potassium added to the clear filtrate produce slight cloudi- 
 ness ; the same result on boiling with acetic acid and 
 sulphate of soda. Nitric acid alone causes no decided tur- 
 bidity j boiling causes the urine to become so dark that 
 nothing can be recognised. Injection of half a cubic centi- 
 meter of phosphorised oil. 
 
 March 30. — Urine acid, yields a clear filtrate which is 
 shown to be decidedly albuminous by the two first-mentioned 
 tests ; nitric acid causes slight cloudiness, which seems to 
 become more marked on boiling, so far as can be made out 
 in the dark discolouration which appears in the urine. 
 
 March 31. — Rabbit found dead. Urine by mistake not 
 examined. 
 
 IV. April 2. — A medium-sized rabbit, kept in a cage 
 since the day before yesterday, and fed upon oats and 
 turnips. The urine obtained by compressing the bladder is 
 acid, somewhat gelatinous, semi-fluid, but yields a clear
 
 84 ALBUMINURIA DEPENDENT UPON 
 
 filtrate in whicli a slight cloudiness after long standing is 
 produced by acetic acid and ferrocyanide of potassium alone ; 
 the other two reagents cause no alteration. 
 
 April 3. — Urine clear, acid ; the clear filtrate free from 
 albumen with all three tests. Three or four drops of 
 phosphorised oil injected. 
 
 April 4. — Urine acid ; acetic acid and ferrocyanide of 
 potassium added to the clear filtrate cause slight cloudiness ; 
 no effect with other two tests. Half a cubic centimeter of 
 phosphorised oil injected. 
 
 April 5. — Urine acid; the filtrate slightly albuminous 
 with all three tests. 
 
 April 6. — Urine acid ; the filtrate highly albuminous with 
 all three tests. The rabbit died this evening. 
 
 The condition of the kidneys^ which in the first two cases 
 exhibited macroscopic fatty degeneration of their parenchyma 
 at various points, has been already briefly alluded to in the 
 discussion of the question as to how far albuminous excretions 
 in the kidneys can be detected under the microscope (see page 
 36). The kidneys were first examined just as taken from 
 the body, and subsequently one half was hardened by 
 boiling and the other in strong alcohol. In the two first 
 cases, in addition to haemorrhage in several capsules and 
 uriniferous tubules, we could distinguish deposits of coagu- 
 lated albumen, some finely granular, others rather hyaline, 
 in the tubules and capsules ; in the third and fourth cases, 
 on the other hand, besides slight fatty degeneration of the 
 epithelium, there was only very moderate hyperaemia of the 
 cortical substance, but no sign of albuminous excretion in 
 the capsules or the uriniferous tubules could be recognised. 
 
 The perfectly harmonious results of these four experi- 
 ments rendered it unnecessary to pursue the subject any 
 further in this way, for I regard the conclusion to be 
 deduced as absolutely positive, viz. that albuminuria is 
 produced in rabbits as well as in dogs by very small doses 
 of phosphorus, which disturb the general health only to an 
 almost imperceptible degree, and, with the exception of fatty 
 degeneration of the elements of the tissues, cause no remark- 
 able changes in the kidneys ; certainly no visible evidences
 
 DEGENERATION OF THE EENAL EPITHELIUM. 85 
 
 of inflammation. That tlie albuminous excretion in tlie first 
 two cases was visible in the capsules, and not merely in the 
 uriniferous tubules, is a proof that phosphorus, as we might 
 ä priori expect, acts injuriously, not merely upon the epithe- 
 lium of the uriniferous tubules, but upon that of the glome- 
 rular tufts as well, and possibly upon these vessels them- 
 selves. The last supposition is borne out by the fact that 
 effusions of blood appeared in the capsules. No fatty 
 degeneration within these parts could be detected under the 
 microscope, because the poisonous doses of phosphorus were 
 very small, but in one case of poisoning by this agent in a 
 girl, I noticed that the glomerular vessels were in a state of 
 profound fatty degeneration. 
 
 The clinical observations of cases of phosphorus-poisoning 
 are in complete accordance with, the experimental results, 
 and it therefore appears extraordinary that the absence of 
 albuminuria sliould be described as a normal occurrence in 
 poisoning of this kind. The truth is that albuminuria is 
 the rule, and its absence the exception in such cases. la 
 1S64, at a time, therefore, when phosphorus-poisoning first 
 began to attract general attention, Meischner found albumi- 
 nuria seven times in a collection of ten cases, and in a 
 recent treatise Hessler tells us that he found this symptom 
 twelve times in fifteen cases (73). We are justified in sup- 
 posing that in the cases in which it was absent, its non- 
 detection was possibly due to the fact that only the usual test, 
 viz. boiling, was tried, and the more so, since in phosphorus- 
 poisoning, as I have already mentioned, peptone-like bodies 
 appear in the urine (see pp. 8 and 81). It almost appears as if 
 the albuminuria in these cases had been disregarded for the 
 sake of certain theories, or, possibly, the cause of the disre- 
 gard may be found in the fact that the quantity of albumen 
 was so insignificant. But to my mind this is a proof that 
 the fatty degeneration of the epithelium, and especially that 
 of the uriniferous tubules, as the anatomical examination 
 shows, is the real cause of the albuminui'ia ; and that this is 
 not due to other complications, such as acute inflammatory 
 processes, for as a result of these latter, the urine always 
 contains a very considerable quantity of albumen. On the 
 other hand, in mere fatty degeneration of the epithelium, it
 
 86 ALBUMINUIilA DEPENDENT UPON 
 
 may easily be supposed that but little albumen is allowed 
 to escape abnormally into the secretion^ for there is always 
 the basement membrane to be traversed^ and more than this^ 
 the epithelial cells do not all at once completely lose their 
 functions. The secretion of the liver would furnish the 
 desired analogy^ but, unfortunately, we have no definite inves- 
 tigations with regard to its condition. Many years ago two 
 statements were made, from which, if they were sufficiently 
 minute, we could conclude that albumen is really found in 
 the secretion when the glandular epithelium is in a state of 
 fatty degeneration. Thus Thenard states that he found 
 albumen in the bile in five out of six cases of " fatty liver," 
 and Lehmann makes the same statement witb regard to twa 
 cases of " fatty granular liver " (74). But even without these 
 statements, what we have previously adduced definitely 
 proves that albuminuria occurs in fatty degeneration of the 
 renal epithelium following phosphorus-poisoning, and this 
 latter should certainly no longer be adduced as evidence 
 against the dependence of albuminuria upon fatty degenera- 
 tion of the epithelium, for it is evidence of an opposite 
 character. It is not denied that other factors may co- 
 operate in the production of albuminuria in cases of phos- 
 phorus-poisoning. 
 
 Almost equally indefensible is the statement that the 
 absence of albuminuria in various conditions of anasmia is evi- 
 dence against the connection of the former symptom with 
 fatty degeneration of the epithelium. It is certainly true that 
 no albumen can be found in the urine in many cases of ansemia, 
 but it is also indisputable that fatty degeneration of the 
 renal epithelium does not accompany every form of ana3mia, 
 even when of a very severe type — I need only refer to chlo- 
 rosis. There are in particular certain pernicious forms of 
 anaemia which lead to fatty degeneration, but the insignifi- 
 cant amount of albumen excreted in these cases has caused 
 its appearance to be disregarded. But albuminuria though 
 trifling is a real symptom, and as deserving of notice as the 
 albuminuria of congestion, which is likewise trifling as a 
 general rule. The amount of significance to be attached ta 
 the " absence of albuminuria " in pernicious anaemia is 
 shown by the single circumstance that, while from the stand-
 
 DEGENERATION Ofc' THE RENAL EPITHELIUfil. 87 
 
 point of one observer peculiar emphasis is laid upon tlie fact, 
 another regards the occurrence of albuminuria in ''^progressive 
 pernicious anaemia ^^ as evidence in support of his own different 
 view (75) . As a matter of fact albuminuria occurs sufficiently 
 often in severe forms of anaemia, in which fatty degeneration 
 of the epithelium may fairly be supposed to exist or is found 
 after death ; and if some regard it as a rare phenomenon, a 
 more uncommon one than my experience compels me to con- 
 sider it, this difference is probably due to the fact that in 
 such cases the quantity of albumen contained in the urine 
 is certainly inconsiderable, provided that other morbid con- 
 ditions are absent, and is often enough overlooked when the 
 customary but not very reliable test by boiling is applied. 
 And if the albuminuria is not an invariable occurrence, and 
 even fails to appear in the majority of cases, we are not jus- 
 tified in concluding that the condition of the epithelium is of 
 no importance ; for the extent to which its function is dis- 
 turbed, and whether this impairment has reached such a stage 
 as to become manifest and capable of demonstration, are doubt- 
 less dependent upon the intensity of the degeneration. We 
 must abstain from drawing general conclusions as to the im- 
 portance, or unimportance, of disturbances which perhaps 
 occur with a certain amount of regularity, but differ as regards 
 their intensity and therefore, perhaps, as regards their impor- 
 tance. It is a well-known fact, for example, that fatty 
 degeneration of the epithelium of the gastric glands is a 
 regular occurrence in phosphorus-poisoning, and this is ob- 
 served even when the drug is not administered by the 
 stomach ; and yet the evidences of disorder in this organ 
 are often altogether inconsiderable, or at least in no way 
 marked, especially when the poison is introduced into 
 the system in some other way. Are we then justified 
 in cbaracterising the condition of the peptic glands and of 
 tbeir epithelium as of no consequence so far as the function 
 of the stomach is concerned j but must we not rather assume 
 that in such cases the degeneration is not sufficiently intense 
 for the production of manifest disorder ? We are compelled 
 to adopt this assumption, because we know from other 
 sources how important are the peptic glands for the discharge 
 of the functions of the stomach. The case is a parallel
 
 88 ALBUMINURIA DEPENDENT UPON 
 
 one with regard to tlie epithelium of the uriniferous tubules. 
 We ascribe to these cells, aud to these alone, the power and 
 the task of preventing the albumen of the blood in the inter- 
 stitial vessels, and of the lymph, from escaping into the uri- 
 niferous tubules, and we must therefore infer that when their 
 degeneration, fatty or otherwise, has reached a certain degree, 
 the fulfilment of their task will become impossible. Cer- 
 tainly, it is said, when they are in a state of fatty degenera- 
 tion, but not in that of fatty infiltration ! It would scarcely be 
 necessary to advert to the difference between these two con- 
 ditions, were it not for the fact that the physiological occur- 
 rence of epithelial cells, containing fat, in the kidneys of 
 several animals, e.g. dogs and cats, has been referred to as 
 evidence of the insignificance of fatty changes (76). But in 
 these instances the condition is that of fatty infiltration, and 
 no demonstration is requisite to show that the absorption of 
 fat by otherwise healthy cells is one thing and the conversion 
 of the substance of the cell into fat is quite another thing, 
 and that the fatty changes in the two cases are of entirely 
 different import as regards the function of the cell. It may 
 bo remarked that a " physiological albuminuria " often 
 enough occurs in dogs and cats ; this, however, has nothing 
 whatever to do with any fatty contents of the renal epithe- 
 lium, but is dependent upon other causes (see note, p. 20). 
 Fatty degeneration of the renal epithelium occurs in animals 
 after long-continued exposure to excessive heat. The urine, 
 however, becomes albuminous very soon after the heat is 
 applied, long before any fatty degeneration can be demon- 
 strated, and, as before shown, this result is due to other 
 causes (see p. 47). When, however, in the further course 
 of such exposure, albumen occurs in the urine — a fact of 
 which there can scarcely be any doubt, though I have no 
 knowledge of this subject — a share at least in its causation 
 must be attributed to the degeneration of the epithelium, 
 and the more so since that cause to which the appearance 
 of albuminuria at the commencement of the exposure to 
 heat must be ascribed, viz. the increased blood-pressure, 
 ceases to operate with the continuance of the abnormally 
 high temperature and of its deleterious effects upon the 
 muscular tissue of the heart.
 
 DEGENERATION OP THE RENAL EPITHELIUM. 89 
 
 Another kind of degeneration of tho epitlielium, the 
 parenchymatous degeneration, is a well-known phenomenon 
 in febrile infectious diseases. It is also well known that these 
 diseases are characterised by the presence of albuminuria, to 
 which the epithet " febrile " has been attached, and there is 
 a point of resemblance between it and the albuminuria which 
 occurs in phosphorus-poisoning and pernicious aneemia, namely 
 this, that though as a general rule it is more marked than in 
 these latter conditions, it is usually not a prominent symptom, 
 especially when compared with the albuminuria of nephritis 
 or of amyloid degeneration of the kidneys. On this account 
 it was unknown or disregarded in former times, and only 
 recently has it been considered worthy of consideration, but 
 tho instances of its occurrence become more and more 
 numerous the greater the care bestowed upon its discovery. 
 Whereas a few years ago tho term " febrile albuminuria '^ 
 was scarcely heard of, the condition is now universally 
 regarded as an ordinary symptom. It is, however, difficult 
 to estimate the share taken by the parenchymatous degener- 
 ation of the epithelium in the causation of this albuminuria, 
 because a series of other conditions invariably co-operate 
 therein, and to which, even more than to the degeneration 
 of the epithelium, a certain influence must be ascribed, as 
 will be shown in a subsequent page (see Section VI) . 
 
 It remains now to allude to a peculiar form of degenera- 
 tion of the epithelium, viz. the coagulative necrosis, types 
 of which can be artificially produced by the administration of 
 certain poisons, especially chromic acid, and likewise by 
 petroleum, croton oil, and cantharidin. Albuminuria speedily 
 follows the administration of these poisons, as Gergen has 
 found in experiments with chromic acid. Lassar has discov- 
 ered a marked peculiarity with regard to petroleum poisoning, 
 viz. that a stage of propeptonuria precedes the excretion of 
 the albumen which is coagulable by heat (serum-albumin, 
 and globulin), that is, albuminuria proper (see page lo). 
 Weigert (Kabierske) states that in animals poisoned with 
 chromic acid salts, after some hours interval, only the epithe- 
 lium of the convoluted uriniferous tubules is involved in the 
 degeneration, whereas the glomerular vessels, the interstitial 
 tissue, and the epithelium of the straight tubes remain intact.
 
 90 ALBUMINUEIA DEPENDENT UPON 
 
 A similar description is given by Lassar of tlie condition of 
 the kidneys in poisoning by petroleum. This author and 
 Kabierske have experimented with injections of indigo-sul- 
 phate of soda, which, when sviitable methods are adopted, as 
 Heidenhain has shown, is well known to be excreted only by 
 the epithelium of the uriniferous tubules ; and they wore able 
 to convince themselves of the destruction of these cells as a 
 result of the administration of chromic acid and petroleum, 
 and that all the other elements of the tissue remained appa- 
 rently unaffected. Nevertheless, it must be assumed that the 
 mischief is not confined exclusively to those epithelial cells 
 and to the proper secretory apparatus, for, according to Pos- 
 ner, Yoorhoeve, and Kabierske, the microscopical examination 
 of kidneys after the administration of chromic acid shows that 
 albumen is deposited not merely in the uriniferous tubules, 
 where it has separated the epithelial detritus from the base- 
 ment membrane, but in the Bowman-Miiller's capsules as 
 well. And a similar description is given by Browicz and 
 Voorhoeve in cases of poisoning with cantharidin, but with 
 this addition, that inflammatory changes were also indicated. 
 In this instance, therefore, as in phosphorus-poisoning, it 
 would appear that the albumen is derived partly from the 
 interstitial vascular system and partly from the glomerular 
 vessels, which, together with their epithelial investment, have 
 likewise become affected (though to an extent not perceptible 
 under the microscope), since in these cases there are manifest 
 extravasations of blood in the capsules and uriniferous 
 tubules (77). 
 
 The conclusion to be drawn from the above statements is 
 that albuminuria occurs with a certain amount of regularity 
 in all forms of degeneration of the epithelium, and especially 
 of that of the convoluted tubules, and likewise that, under the 
 same circumstances, the appearance of peptonuria and of pro- 
 peptonuria takes place, a symptom which, as Lassar has shown, 
 (and as otlier experiences prove to be not improbable, see page 
 12), may pass into albuminuria proper, though the presence of 
 these substances is liable to be overlooked when the ordinary 
 methods of investigation are employed. Whether it will hence- 
 forth be regarded as proved that the degeneration of the epithe- 
 lium alone, in the sense in which we have explained it, is or is
 
 DEGENERATION OP THE EENAL EPITHELIUM. 91 
 
 not the cause o£ the escape o£ albumen^ will depend entirely 
 upon the degree of credit which is attached to the evidence 
 yielded by the microscope. He who steadfastly refuses to 
 recognise any lesion unless it can be demonstrated under the 
 microscope, will be forced to regard the connection between 
 albuminuria and epithelial degeneration as proved beyond 
 doubt, for the appearance in question is all that the most 
 expert microscopists have been able to discover. I for my 
 part do not adopt this stand-point, which is based upon an 
 over-estimate of the capacity of the microscope, as is also 
 evidenced in the attempt to procure microscopical demonstra- 
 tion of the albumen contained in the normal transudation of 
 the capsules (see page 35, et seq.). I am, therefore, very far 
 from wishing to discover in all the cases which have been 
 adduced, a rigid proof of the dependence of albuminuria upon 
 degeneration of the epithelium, but I see in them evidence of 
 a very strong character against the assertion that the condi- 
 tion of the epithelium of the uriniferous tubules is a matter 
 of no importance with reference to albuminuria. There is 
 still less evidence in favour of this assertion. On the other 
 hand, so low an estimate will hardly be formed of the value of 
 microscopical investigation as to cause it to be rejected as 
 altogether worthless. In the albuminuria in question, the 
 microscope shows us intense degeneration of the uriniferous 
 tubules as a constant appearance, but no other striking alter- 
 ation. Neither more nor less can be detected. It is there- 
 fore extremely probable, as a result of this investigation, that a 
 connection exists between the two conditions, and that at least 
 a considerable share in the causation of the albuminuria is to 
 be attributed to the destruction of the epithelium. This con- 
 clusion is convei'ted into a certainty by the fact that these obser- 
 vations only conjEirm the proposition which the theory of glan- 
 dular secretion, and of the function of glandular epithelium, 
 has laid down by anticipation as a necessary postulate, namely, 
 that when these epithelial cells are destroyed, the obstacle to 
 the escape of albumen from the interstitial vessels is broken 
 through. 
 
 A peculiarity exhibited by the albuminuria which is con- 
 nected with the various forms of epithelial degeneration be- 
 comes intelligible from this point of view. In fatty degene-
 
 92 ALBUMINURIA DEPENDENT UPON 
 
 ration, as in phosphorus-poisoning, or in pernicious anasmia, 
 the excretion of coagulable albumen is, as I have already 
 stated, as a general rule only slight ; on the other hand, in 
 the coagulative necrosis due to chromic acid salts or petro- 
 leum, the urine contains large quantities of albumen. In 
 the former instances the degeneration is the result of the 
 conversion into fat of the protoplasm of the cells, which, 
 however, usually remain connected with each other and 
 occupy the same position when death occurs ; in the latter 
 case, as Weigert expresses it, destruction goes on rapidly 
 and the cells become detached to a considerable extent. It is 
 evident that in this last-named lesion, the rapid destruction of 
 the entire epithelial investment must be followed by total, or 
 almost total, abolition of function, and the disturbance at any 
 rate must be far more serious than in that slighter form of 
 degeneration in which, so to speak, the obstacle to the escape 
 of albumen is certainly damaged, but is not entirely 
 removed. This at least is the rule, for it is perfectly clear 
 that even fatty degeneration may finally lead to complete 
 disintegration and detachment of cells, and consequently in 
 exceptional cases to a more intense degree of albuminuria, 
 just as in such cases the detachment of these cells in a state 
 of fatty degeneration and their passage into the urine, simul- 
 taneously with the albumen, will induce a form of chyluria — 
 a chyluria the result of phosphorus-poisoning, which has really 
 come under observation (78). 
 
 We are thus led to consider the possible occurrence of 
 a form of albuminuria, as a simple result of the passage 
 into the urine of detached epithelial cells belonging to any 
 portion of the renal parenchyma. For some years past, I 
 have drawn attention to this possibility, and it must, I think, 
 ä priori, be admitted, without any scruple, that when epithe- 
 lium becomes detached, it is not merely the fixed and 
 therefore undissolved albumen contained in the substance of 
 the cells which finds its way into the urine ; for this is a 
 matter of course, unless all the cells separately and 
 collectively were converted into fat; but a portion of the 
 protoplasm, in a state of disintegration and passing into a 
 tiuid state, may become dissolved in the neighbouring 
 current (79). There can bo no dispute on this point, and
 
 DEGENERATION OF THE EENAL EPITHELIUM. OS- 
 
 HO dispute has arisen, but a process of this kind has been 
 thought unworthy of consideration, as appears from the- 
 notion expressed by Bartels (80) to the eifect that these 
 admixtures of albumen can amount only to very minute- 
 quantities, a notion which, as in phosphorus-poisoning and 
 other forms of albuminuria, has led to the error of totally 
 disregarding this symptom. But even so slight an albumi- 
 nuria as this may be, is a real albuminuria; and it is tho 
 more remarkable that it has attracted no sort of attention^ 
 when it seems as though sufficient consideration could not be- 
 attached to the excretion of albumen in cases of renal venous 
 congestion, amounting as it does (and as Bartels himself so 
 justly remarks) ^'rarely to more than o*i per cent.'^ of the 
 urine. If an excretion of albumen, amounting within, 
 twenty-four hours at most to half-a-gramme or a gramme, 
 as is common in renal venous congestion, be not so minute as 
 to be unworthy of consideration, it follows that albuminuria, 
 as a possible result of disintegration of the epithelium, has 
 certainly some claim upon our notice. But why must this 
 latter form be so insignificant a symptom ? Is it the case 
 that all the epithelial cells which may decay and become 
 detached, — the epithelium of the capsules, of the glomeruli, 
 and of all the other portions of the uriniferous tubules, — are 
 not in sufficient quantity to yield a daily supply of half a 
 gramme to a gramme of albumen, even if all these epithelial 
 cells do not simultaneously perish? In my opinion a positive 
 presumption is abundantly justified by estimating how much, 
 of the weight of the renal parenchyma is made up by the' 
 aggregate of these epithelial cells. 
 
 If, therefore, no objection can be raised against this view — 
 and I can think of none that is really tenable — it must be 
 admitted that the disintegration and detachment of cells may 
 give rise to the appearance in the urine of albuminous sub- 
 stances, differing from the albumen of ordinary albuminuria. 
 As a general rule the cell-protoplasm appears to contain albu- 
 minous substances (vitellin and myosin) resembling globulin, 
 and which as such, or in some other stage of transformation,, 
 may find their way into the urine ; indeed, according to Gott- 
 walt's observations, the kidneys free from blood contain from 
 seven to eight times as much globulin as serum-albumin (81)..
 
 ^4 ALBüMINUlilA DEPENDENT UPON 
 
 We know that globulin along with scrum-albumin is 
 found in the urine in very variable quantities, so that we 
 might perhaps suppose that, according as the albumen of the 
 renal parenchyma is mixed with the urine, this latter secre- 
 tion will contain more or less globulin in proportion to the 
 serum-albumin. Our defective insight into the chemical pro- 
 cesses of living and decaying cells does not allow us to 
 do more than indulge in guesswork on this point. But 
 it appears justifiable to mention it, for it is in these 
 forms of albuminuria which are connected with rapid and 
 severe epithelial decay, that the albumen exhibits several 
 reactions differing from those ordinarily met with. This 
 is, however, not the only possible means of explaining the 
 occurrence of unusual forms of albumen in the urine, for 
 there is another and a more probable explanation, viz. that 
 the substances in question may be conveyed to the kidneys 
 with the blood, in consequence of some change in the com- 
 position of that fluid. We shall now discuss this subject, 
 so far as the change alluded to has any influence in the pro- 
 duction of albuminuria. 
 
 V. The Condition op the Blood as Influencing the 
 Production op Albuminuria. 
 
 That albuminuria is caused by an abnormal condition of the 
 blood, is the oldest view, and the same which Cotugno, the 
 discoverer of albumen in the urine, suggested, and which his 
 contemporaries and immediate successors adopted and dis- 
 seminated ; and this theory necessarily remained unshaken so 
 long as observers wei'C ignorant of the connection between 
 albuminuria and dropsy and renal disorders. But the views of 
 physicians were dominated by this theory even for some time 
 after the connection between these conditions was discovered 
 by Dr. E,. Bright ; subsequently, however, it lost its promi- 
 nence, as the progress of investigation led to the discovery 
 of various disorders of the kidney in states of disease 
 accompanied by albuminuria, while little or no further 
 knowledge was gained with regard to the supposed alterations
 
 THE CONDITION OP THE BLOOD. 95 
 
 in the blood. These changes in the blood were supposed 
 to be due to a morbid condition of the albumen^ which, in 
 consequence, diifering from the normal albumen of the blood, 
 passed into the urine ; and the cause of this morbid condition 
 was sought for in some abnormal process of digestion or of 
 tissue-change, or in the retention of excrementitious matters, 
 &c. But all that could be brought forward in support of 
 these theories resolved itself into more or less obscure suppo- 
 sitions or arbitrary assumptions, and consequently it was only 
 to be expected that the theories which attributed the causa- 
 tion of albuminuria to the condition of the blood — the theories 
 of a haematogenous albuminuria — would bo set aside in favour 
 of a nephrogenous albuminuria, so that at the present day the 
 former views have very few adherents (82). Moreover, 
 it has been shown by the very ingenious experiments of 
 Stokvis, that at least in ordinary cases of albuminuria and 
 dropsy, or of so-called " Bright's disease '' and amyloid dege- 
 neration of the kidney, the albumen does not, certainly as a 
 general rule, possess the power of inducing albuminuria in 
 healthy kidneys. Albuminous urine, or the blood-serum of 
 patients suffering from albuminuria, was injected into the 
 blood or under the skin of healthy animals, and in twenty- 
 one out of twenty- three experiments of this kind no albumen 
 was found in the urine. In the two cases in which albumin- 
 uria occurred, it was very remarkable that the urine used for 
 injection had been taken from a patient suffering from 
 albuminuria without demonstrable renal disease. The very 
 cautious conclusion drawn by Stokvis is, that in the majority 
 of cases a modification of the albumen of the blood is not the 
 existing cause of the albuminuria, but that it must be left 
 for further experiments to decide whether such may be the 
 case under exceptional circumstances, as it is not improbable 
 from a iwiori considerations (83). My opinion is, that this 
 conclusion must be adopted in its entirety ; it corresponds 
 even now, after nearly a decade and a half, with the actual 
 state of our knowledge of the subject. That view especially 
 must be rejected which attributes the occurrence of albumin- 
 uria in renal diseases to changes in the blood, particulai'ly in 
 the conditions, including amyloid degeneration and conges- 
 tion, formerly, and to some extent also nowadays, classified
 
 96 ALBUMINUEIA DEPENDENT UPON 
 
 under the name " Briglit's disease/^ There is no doubt that 
 a cause for the symptom in question is to be found in a renal 
 lesion. This latter certainly may (and this view is highly prob- 
 able) often originate in a morbid condition of the blood, 
 which may therefore be fairly described as the indirect cause 
 of the albuminuria in these cases. 
 
 It may be difficult to explain the occurrence of albuminuria 
 in those much rarer cases in which no lesion of the kidney 
 exists. For it is beyond doubt that there are such cases, and 
 that albuminuria is not always symptomatic of a nephritis or 
 of some other demonstrable kidney-lesion. I need only 
 refer to the detailed description already given (see page 15, 
 et seq.) of albuminuria as occurring in perfectly healthy men, 
 or to the albuminuria in patients who show no other indica- 
 tion of kidney-disease, and in whom when death occurs from 
 some other cause, the most careful examination fails to detect 
 any abnormality in the kidney, any trace of degeneration of 
 the epithelium, any swelling and cloudiness of the parenchyma, 
 appearances which are yet regarded by many indeed as devoid 
 of significance with regard to albuminuria. We have become 
 acquainted with the existence of circumstances which, in 
 certain conditions of the circulation, may give to albuminuria 
 in the absence of any disorder of tissue in the renal paren- 
 chyma ; but not in all cases of this nature can the circulatory 
 changes be positively demonstrated or even assumed as prob- 
 able, without straining the interpretation of the symptoms. 
 It appears to me that for such cases, probability must be 
 admitted for the theory that the albuminuria is due to changes 
 in the composition of the blood. I say designedly '^ changes 
 in the composition of the blood," and not " changes in the 
 albuminous substances in the blood " as is usually expressed 
 by those who make use of the term " haematogenous albumin- 
 uria." Not that I consider an abnormal condition of the albu- 
 minous substances as impossible ; on the contrary, I regard 
 it as not only possible but even not improbable, so far as 
 many cases are concerned, and I will soon give my reason for 
 so doing ; but I think it is at least as probable that 
 other changes in the composition of the blood, having no 
 connection with any abnormal condition of the albumen, may 
 induce albuminuria, and I am alluding not to hypothetical
 
 THE CONDITION OP THE BLOOD. 97 
 
 clianges of composition but to such as can be demonstrated 
 beyond possibility of doubt. 
 
 The urinary secretion in great measure depends, as has been 
 already sufficiently explained, upon filtration from the plasma 
 of the blood, that is, from a saline albuminous solution ; and 
 in accordance with the numerous experiments which have 
 been performed with regard to the filtration of such fluids, it 
 can be regarded as quite certain that the quantity of 
 albumen contained in the filtrate is, cajteris paribus, dependent 
 upon the quantity of albumen and salts contained in the 
 original fluid. The more albumen the latter contains, the 
 more of this constituent, cseteris paribus, will be found in the 
 filtrate, though this latter quantity does not rise and fall in a 
 degree exactly proportionate to the amount contained in the 
 original fluid. As regards the influence of the saline con- 
 stituents, the results of the investigations of Hoppe- Seyler, 
 V. Wittich, and Nasse, notwithstanding a few differences in 
 •details, practically agree in showing that the quantity of 
 albumen which passes through the filter increases with the 
 increase of the saline constituents of the fluid. This is espe- 
 cially the case in regard to chloride of sodium, with which 
 the majority of the investigations were made, but it is also 
 true in the case of other salts (nitre, chloride of calcium) ; 
 and it is important to observe that it holds good with respect 
 to urea, the influence of which in facilitating the passage of 
 albumen through a filter has been observed by Hoppe- Seyler, 
 and recently by Newman (84). 
 
 In face of the above facts there is no reason to refuse to 
 ■accept the theory of a hsematogenous albuminuria, as is now 
 ■almost universally the custom, for there cannot be a moment's 
 doubt that, under multiform normal and pathological condi- 
 tions, both the dissolved albumen and the salts of the blood 
 may become increased, and further, that such increase really 
 takes place. After every meal, which does not contain too 
 great a proportion of water or an unusually small quantity of 
 albumen and salts, the composition of the blood may become 
 altered in the manner described, and may be a cause of albu- 
 minuria, in so far as more than the normal amount of 
 albumen transudes through the glomei'ular vessels. As a 
 matter of fact, with healthy kidneys, the occurreuco of 
 
 7
 
 98 ALBUMINURIA DEPENDENT UPON 
 
 albuminuria during digestion lias been noticed by numerous 
 observers (see page 19), and to it, tlierefore, a peculiar name, 
 " digestion-albuminuria ^' (albuminuria alimentaria) , has been 
 attached. That likewise, in the ordinary forms of morbid 
 albuminuria, an increase in the excretion of albumen is a 
 frequent result of digestion, altogether independently of 
 other conditions, is a fact already noticed by Parkes and 
 Gubler (85), and one that has been minutely investigated by 
 Brunton and Power (86) , and confirmatory evidence of which 
 abounds on all sides. Moreover, in addition to the increase 
 of albumen and salts, the above-mentioned investigations of 
 Hoppe-Seyler and Newman show that regard must be had 
 to the increase of the quantity of urea in the blood, which 
 occurs some time after the digestion of albuminous food, and 
 manifests itself in the increased excretion of urea. It is 
 well known, on the other hand, that the urine becomes 
 increased in quantity while digestion is going on, and such 
 increase is in a measure independent of the process of 
 filtration, and is in excess of the activity of the latter, inas- 
 much as the glandular secretion proper is at the same tim& 
 augmented, owing to the infl.uence of the urea, the salts, &c. 
 These facts, as we have already explained (see pages 28, 40), 
 constitute a reason why in most cases the discovery of the 
 quantity of albumen of the urine is rendered difficult. For 
 if a fluid containing much albumen transudes through the 
 glomerular vessels, and receives in addition, a greater 
 quantity of non-albuminous fluid, consisting of the secre- 
 tion of the glandular epithelium, the quantity of albumen in 
 the urine as a whole may be very small, and may pro- 
 gressively diminish until it reaches the proportion observed 
 when no digestion is going on, or even falls below it. 
 The concurrence of particularly favorable circumstances is, 
 therefore, required for this '' digestion-albuminuria " to make 
 its appearance, and it may be soonest expected after a meal 
 containing much albumen but very little water. Food con- 
 taining much saline matters will be less favorable in this 
 respect, for the ordinary salts may act in two directions, 
 since on the one hand they facilitate the filtration of albumen 
 in the glomeruli, but on the other, the secretion of water by 
 the glandular epithelium. This purely theoretical deduction
 
 THE CONDITION OP THE BLOOD. 99 
 
 is confirmed by experience, for the diet after which 
 '^ digestion-albuminui'ia " is noticed is usually one in which 
 animal food largely preponderates. Christison has noticed 
 temporary albuminuria in persons who had eaten much 
 cheese (87). I have already (page 19) alluded to the same 
 symptom occurring in an otherwise perfectly healthy physi- 
 cian, after almost every meal consisting largely of meat, 
 and many similar cases are recorded in the literature of this 
 subject. I am now referring not merely to the instances in 
 which albuminuria occurred after eating eggs, for these are 
 only partly traceable to the same cause, and in the main a 
 different explanation is to be found for them (see page 100). 
 It is extremely probable that under pathological conditions 
 similar changes take place with regard to the quantity of 
 albumen and salts contained in the blood, and especially in 
 the direction of an increase, whether of an absolute or of a 
 relative character. But this assumption is based only upon 
 theoretical considerations, for we have at present no obser- 
 vations which would j^rove its truth. Only in the case of 
 cholera, and other conditions associated with profuse watery 
 evacuations, we know from C. Schmidt's classic investiga- 
 tions that the albumen of the blood becomes relatively 
 increased and that the saline constituents are similarly 
 affected for a very brief interval (88) . We know somewhat 
 more with regard to the increase of urea in disease. Gscheid- 
 len (89) has sbown that the quantity of urea contained in 
 the blood becomes increased in the febrile state, and the 
 same thing will take place in all those conditions in which 
 increased disintegration of albumen is accompanied by dimi- 
 nution of the urinary secretion, as in phosphorus-poisoning, 
 according to Storch, Bauer, and Cazeneuve, and, according to 
 A. Fränkel, as a result of insuflScient supply of oxygen (90). 
 In all these cases there will be an abnormally large forma- 
 tion of urea which will be excreted with the urine, but the 
 amount excreted may easily be less than the excessive for- 
 mation, since, for reasons which we need not here discuss, 
 there is a considerable and simultaneous depression of the 
 renal activity. The result, therefore, in such cases may be 
 an accumulation of urea in the blood, whereas in other cases 
 in which the increased formation of urea is met by a corres-
 
 100 ALBUMINURIA DEPENDENT UPON 
 
 ponding increase in the secretion of urine and urea^ as, for 
 example, in diabetes, no accumulation can be supposed to 
 occur. An accumulation of urea in the blood has been 
 clearly demonstrated in disease of the kidney itself, simply 
 as a result of impeded excretion, and always associated with 
 diminution of the quantity of urine. 
 
 There is, therefore, in all these cases in which the albumen 
 or the urea, and possibly also the salts, are increased in quan- 
 tity, a certain factor present, endued with the power of 
 causing a much increased transudation of albumen, and con- 
 sequently albuminuria. But it is by no means a single 
 factor, for a number of more or less active influences, capable 
 of producing the same effect, come into play in the above- 
 mentioned instances. Thus in phosphorus -poisoning, there 
 is the degeneration of the epithelium, and the diminution in 
 the quantity of urine consequent upon diminished arterial 
 pressure ; this latter is also pi'esent in cases of profuse 
 watery evacuations, in cholera, violent diarrha3as, &c., while 
 in fever, of which we shall presently speak particularly, 
 many other factors co-operate, by which the albuminuria may 
 be explained. 
 
 While, therefore, there is a positive basis of facts for the 
 assumption that quantitative changes in the composition of 
 the blood may, under certain circumstances, cause albuminuria 
 to appear, or increase this symptom if already existing, the 
 other assumption, hitherto maintained only by the supporters 
 of a hsematogenous albuminuria, to the effect that the sym- 
 ptom in question has its origin in qualitative changes in the 
 albumen of the blood, can claim no equally definite and 
 positive facts as a foundation but only sundry reasons which 
 invest it with a certain amount of probability. This, how- 
 ever, holds good only with regard to the pathological 
 albuminuria, for there is a certain kind of physiological 
 albuminuria which is doubtless a result of qualitative 
 changes in the albumen of the blood. This is the albumi- 
 nuria which occurs after the introduction of egg-albumen 
 into the blood — and not merely after the immediate introduc- 
 tion or its injection under the skin, as often done in experi- 
 ments, but likewise after its introduction into the stomach. 
 Many observers, namely Tegart, Brown- Sequard, Becquerel,
 
 THE CONDITION OV THE BLOOD. 101 
 
 and Barreswil;, Hammond, CI. Bernard, J. Clir. Lehmann, 
 and Stokyis, have observed albuminuria after eating many 
 eggs, or a long-continued diet of this character, the experi- 
 ments being performed on themselves, or on other persons, 
 or on rabbits and dogs (91). As a general rule, this albumi- 
 nuria is explained as due to the readiness with which egg-albu- 
 men passes through a filter ; it is consequently supposed to 
 traverse the glomerular vessels more readily than is the case 
 with the normal albuminous substances of the blood ; and I 
 have already drawn attention to the fact (see p. 23) that 
 this generally received explanation involves a recognition of 
 the theory according to which the albuminous substances 
 really do pass through those vessels, though in quantities 
 varying according to the capacity for filtration possessed by 
 each. The investigations of Lehmann, Stokvis, and Creite 
 (92), show beyond doubt that egg-albumen is really excreted 
 as such, and that in the majority of cases the albuminuria 
 disappears with its excretion. It must, therefore, be assumed 
 that in those cases in which a large number of eggs are in- 
 troduced into the stomach, a portion at least escapes the 
 action of the gastric juice and passes unchanged into the 
 blood ; and this theory is supported by the fact that Stokvis 
 failed to produce albuminuria in rabbits when he introduced 
 coagulated albumen into the stomach. The portion really 
 digested may, however, by increasing the quantity of normal 
 albumen in the blood, have contributed to the production of 
 albuminuria in the way just described (see page 97, et seq.) . 
 It appears, however, as if the admixture of dissolved egg- 
 albumen might lead to the production of albuminuria in 
 yet another way, for both Lehmann and Stokvis several times 
 observed that a long-continued albuminuria was the result 
 of injecting the albumen in question into the blood, and that 
 more albumen (in one of Stokvis' s experiments, four times 
 as much) was excreted than was injected. In these cases, 
 therefore, the presence of an extraneous albuminous substance 
 in the blood must have set up, probably in the kidney, some 
 kind of process which led to the production of albuminuria 
 in the strict sense of the word — that is to say, to the excretion 
 of coagulable albumen of the system itself. Here we are re- 
 minded of the fact that Creite often witnessed the occurrence
 
 102 ALBUMINURIA DEPENDENT UPON 
 
 of albuminuria without admixture of blood, in rabbits, as a 
 result of the injection of the blood-serum of animals belong- 
 ing to different species. To explain this we must assume, 
 either that the albuminous substances of these kinds of 
 serum more readily filter through the kidneys of rabbits than 
 through those of the animals to which they belonged ; or that 
 extraneous serum of this kind induces serious derangements, 
 with albuminuria as an accompaniment. Taking into con- 
 sideration the effect, presently to be discussed, of the serum 
 upon the blood-corpusclos of other animals, it must bo 
 admitted that the latter assumption is the more probable of 
 the two. 
 
 Nothing certain is yet known as to the effect produced by 
 the injection into the blood of other soluble albuminous sub- 
 stances, peptone chiefly excepted. J. Chr. Lehmann observed 
 no albuminuria after injections of Lieberkiihn's albuminate 
 of soda, of solutions of syntonin, myosin, and fibrin, whereas 
 Runeberg witnessed the occurrence of albuminuria after the 
 injection of an albuminous substance, which he obtained by 
 dissolving in soda casein precipitated from milk by means 
 of acetic acid, but not when he injected pure milk or milk 
 mixed with soda (93). The former fluid possessed great 
 capacity for filtration, and the question arose whether the 
 albuminous substances made use of by Lehmann were less 
 adapted for that process, for solubility alone is no measure 
 of the capacity for filtration. 
 
 The other albuminous substances, distinguished by their 
 capacity iov diffusion and filtration, with which we are 
 acquainted, are peptone (probably also propoptone) and 
 haemoglobin. No experiments in this direction have as yet 
 been made with propeptone, but it may with certainty be 
 assumed that its behaviour is the same with that of the 
 other two substances, which, introduced in a state of solu- 
 tion into the blood, are, in accordance with theory, readily 
 excreted in consequence of the marked capacity for filtration 
 which they possess. With regard to peptone we know that 
 it may find its way into the blood by injection, or by the 
 absorption of exudations in which it is contained (as in 
 pleurisy, pneumonia, and rheumatic arthritis), and that 
 peptonuria then makes its appearance. The same origin
 
 THE CONDITION OP THE BLOOD. 103 
 
 may Ibe assumed in the case of propeptonuria. It is well 
 Icnown that the colouring matter of the blood is dissolved, 
 not merely as a consequence of the injection, but likewise 
 under various circumstances, as a result of the destruction of 
 the red corpuscles in the blood. In this way its excretion 
 takes place, and thus we find hEemoglobinuria (methEemoglo- 
 binuria, hgematinuria) as a result of various poisons, and in 
 certain states of disease (periodic hfBmoglobinuria, severe in- 
 fectious conditions) , and, as Creite, Landois, and Ponfick have 
 observed, after the introduction into the circulation of blood, 
 or only blood-serum, of an animal belonging to a different 
 species (94). The excretion of the hsemoglobin, however, 
 appears to take place not only by filtration through the 
 glomerular vessels, but besides this, as is the case with 
 other colouring materials, in a specific manner through the 
 epithelium of the uriniferous tubules (95). 
 
 This, then, is almost all that is known with certainty witli 
 regard to the dependence of albuminuria upon qualitative 
 changes of the blood, and particularly upon alterations of the 
 albuminous substances. All the results of experiments in 
 reference to this question amount apparently to this, viz. that 
 albuminous substances, normally not dissolved in the blood, 
 appear in solution in that fluid, and that they are excreted by 
 the kidneys in proportion to their capacity for filtration, just 
 as was to be anticipated from the views we have developed 
 with reference to the filtration in the glomerular vessels. In 
 consequence of the greater capacity for filtration possessed 
 by these substances a larger amount passes through the 
 glomerular vessels than in the case of the normal albuminous 
 substances of the blood ; it therefore follows that the former 
 will be more easily discoverable in the urine than the latter, 
 and the albuminuria is mainly accounted for by this fact. It 
 would, moreover, appear that abnormal excretion of the 
 ordinary albumen may be induced as a result of extraneous 
 admixtures of this description. 
 
 It might be thought that these facts amounted to sulE- 
 ciently presumptive evidence in favour of the view that 
 many forms of albuminuria are dependent upon qualitative 
 changes of the blood, and particularly of its albuminous 
 ■constituents. It is true that this view has met with but
 
 104 ALBUMINURIA DEPENDENT UPON 
 
 little acceptance of late years, but for a reason Avliich, if 
 carefully scrutinised, "will be found to be -strictly of an 
 extrinsic and formal character. The invariable custom is ta 
 include in the term albuminuria nothing but the excretion of 
 coagulable albumen from the blood, and, as before noticed,. 
 to consider that the excretion of other albuminous substances 
 is not comprehended under the same term. In this sense 
 the only recognised albuminuria, which assuredly depends 
 upon a qualitative change in the blood, is that which is 
 caused by the introduction of egg-albumen ; but this i& 
 usually considered as devoid of significance in a clinical 
 respect. And it is quite true that up to the present time 
 our knowledge of this albuminuria has been derived from 
 experiment and not from clinical observation. It is indeed 
 possible that that which is brought about in a healthy man 
 or animal by the ingestion of an excess of egg-albumen, may 
 become developed in a diseased organism, especially in one 
 which possesses abnormal capacity of digestion, by a 
 moderate or even small amount of such food, and in that case 
 this excretion of egg-albumen would certainly possess a 
 clinical significance as well — the same significance as may 
 perhaps be assigned to the ingestion of amylaceous food by a 
 patient suffering from mild diabetes, who, when he avoids 
 such food altogether or limits its quantity, excretes no sugar, 
 and in a general way shows no symptom of disease. It is 
 well known that even healthy persons may be made to 
 excrete sugar (glycosuria alimentaria) by feeding them upon 
 large quantities of sugar and starch, and since this fact 
 does not induce us to remove the so-called mild form of 
 diabetes from the category of pathology, there is no greater 
 amount of objection to regarding this excretion of egg- 
 albumen as devoid of significance in a pathological respect. 
 The question would be to determine the boundary between 
 moderation and excess of supply — obviously a difl&cult task. 
 With regard to the other albuminous substances which 
 occur in the urine, not merely in the course of experiments, 
 but likewise under purely clinical conditions in various forms 
 of disease, we are quite justified in separating hasmoglobi- 
 nuria from albuminuria proper, inasmuch as the haemoglobin, 
 as well as the colouring matters derived therefrom, does not
 
 THE CONDITION OP THE BLOOD. 105 
 
 belong to the albuminous substances properly so-called. On 
 the other hand^ no strict line of separation can now be drawn 
 between " peptonuria/' " propeptonuria/' and albuminuria, 
 for the two former occur alternately with albuminuria in the 
 strict sense of the word, and also combined with it (see p. 
 g, et seq.). If, however, they must be considered as be- 
 longing to albuminuria in the wider sense of the term, this 
 view involves the admission that forms of albuminuria exist 
 which are dependent upon qualitative changes in the albu- 
 men of the blood, for I scarcely know what other form of 
 albuminuria could be expected to arise from such qualitative 
 changes, and otherwise we should find ourselves in an end- 
 less circle of terms. If coagulable albuminous substances 
 are excreted, and albuminuria in the ordinary strict sense 
 therefore exists, the substances in question must necessarily 
 be invariably regarded merely as serum-albumin or as globu- 
 lin (we can disregard egg-albumen, as that appears only 
 after introduction from without), and it will therefore be 
 needless to assume the existence of any qualitative change, 
 or of any modification of the albumen of the blood. If, 
 however, one of the substances, in other respects resembling 
 albumen, but wanting in coagulability, is found in the 
 urine, if, therefore, some modification be present, this is 
 set aside as " peptonuria or propeptonuria," and is re- 
 garded as something peculiar. But in this way it will 
 scarcely ever be possible to prove or disprove the exist- 
 ence of albuminuria due to changes in the condition 
 of the blood. For the distinctions once considered impor- 
 tant aids towards demonstrating modifications of albumen in 
 the urine, and consequently in the blood, are of quite subor- 
 dinate significance if we take into consideration the facility 
 with which the several albuminous substances undergo con- 
 version; and all the experiments, especially those performed 
 some years ago, with the view of demonstrating the presence 
 of morbid modifications of albumen by the variations in the 
 diffusion of albuminous urines, are of little value, because 
 such variations are caused by alterations in the quantity of 
 the saline constituents, the urea, &&. 
 
 Much more value would be attached to a physiological 
 experiment which would demonstrate a property of the
 
 106 ALBUMINURIA DEPENDENT UPON 
 
 albumen contained in the urine or tlie blood in cases of 
 albuminuria, that is, if it could be shown that this albumen 
 injected into the blood or subcutaneously, was, like egg-albu- 
 men, capable of producing albuminuria. It is true that, con- 
 nected with this subject, we have a single isolated statement 
 by Stokvis, which has been already incidentally referred to 
 (see p. 95). As an exception to, and differing from, the 
 great majority of his other experiments in this direction, he 
 found that the albuminous urine of a patient, free from any 
 manifest disease of the kidney, produced albuminuria in one 
 dog and one rabbit, the symptom disappearing in a few days. 
 We cannot suppose that this extraordinary result was due. 
 to any oversight or confusion; had any such existed, Stokvis 
 must have discovered them, for these two experiments 
 are inconsistent with the conclusions warranted by all the 
 others, and must therefore remain as unexplained exceptions. 
 For the present, however, it will be well not to invest them 
 with any great amount of significance, but to regard them 
 only as an index for further researches in this direction. 
 Until the time comes that they are confirmed, the question 
 as to the existence in diseases of a modification of the albu- 
 minous substances, capable of producing an albuminuria not to 
 be designated peptonuria or propeptonuria, must be regarded 
 as unsettled. 
 
 In like manner the question as to the means whereby any 
 modification of albuminous substances of the blood takes 
 place, must be considered as still awaiting solution. There 
 are many possibilities, but at present there is no theory which 
 can be proved and certainly none which can bo disproved. 
 It is therefore possible that, in accordance with the theory 
 especially favoured by Prout among English observers, ab- 
 normal processes of digestion are responsible for the passage 
 into the blood of an albumen differing from the normal sub- 
 stance ; or that under the influence of some kind of morbid 
 condition in the blood and fluids of the body, such altera- 
 tions take place ; as the old doctrines of crasis were always 
 ready to assume. Inasmuch, however, as we are not as yet 
 able to recognise with certainty any single morbid modifi- 
 cation of albumen in the blood and fluids, we ought in this 
 matter to assume an attitude of reserve, if not of incredulity.
 
 THE CONDITION OF THE BLOOD. 107 
 
 Among the alterations in the condition of the blood, we have 
 finally to notice one which contrasts with the above-described 
 deviations which concern only the chemical composition. 
 The alteration in question is of a physical character, having 
 perhaps the power of increasing to an abnormal extent the 
 transudation of albumen until albuminuria is produced. I 
 refer to an increased temperature. We have already alluded 
 to the fact that filtration of albuminous solutions is facili- 
 tated by increase of temperature, but we do not know what 
 proportion the albumen contained in the filtrate bears 
 to that of the original solution {conf. page 51). We must, 
 therefore, be satisfied with having drawn attention to tbis 
 point which may, among other things, be of unmistakable 
 importance in reference to the albuminuria of febrile dis- 
 orders. There is also another point, possibly connected witb 
 this one just mentioned, but to which in the present state of 
 our knowledge we can make only a passing allusion, viz. that 
 with the elevation of temperature the molecular composition 
 of the albuminous substances becomes so changed, that they 
 pass more readily through a filter than is the case in their 
 normal condition. On this subject conjectures have been 
 hazarded from many quarters, but nothing certain is known, 
 and, in accordance with the explanation already given, the 
 occurrence of such a change under the influence of increased 
 temperature, may be capable of recognition only because the 
 coagulablc albuminous substances are converted into peptone 
 and propoptone. 
 
 As far as we have gone at present in our description of 
 the influence of modified conditions of the blood upon the 
 production of albuminuria, we have referred only to the pro- 
 cesses of filtration going on in the kidneys, but we have said 
 nothing about the process of secretion proper, because, to all 
 appearances, this latter, in the majority of cases, is only 
 indirectly concerned. I know of only one instance which 
 supports the view that true glands may allow the abnormal 
 escape of albumen, when extraneous albuminous substances 
 are present in the blood, one of these substances being allowed 
 to escape. This observation, likewise made by Stokvis, 
 refers to the case of a strong dog, in which egg-albumen 
 was subcutaneously injected, with the result that the secre-
 
 108 CEETAIN PECULIAR FORMS OF 
 
 tion from the parotids,, previously filtered and found perfectly 
 non-albuminous, now contained a marked proportion of egg- 
 albumen. If it be desired to draw any conclusion from this 
 observation, it may be assumed as probable, that not only the 
 glomerular vessels, whose action in this respect has been 
 proved, but likewise the interstitial vascular system parti- 
 cipates with the epithelium of the uriniferous tubules in the 
 excretion of egg-albumen in the kidney. Besides, the latter 
 portions of the kidney may, as already stated, in consequence 
 of morbid changes in the condition of the blood, indirectly 
 contribute towards the production of albuminuria, inasmuch 
 as the latter gives rise to derangement of nutrition and 
 degeneration of the epithelium, conditions which, in the way 
 already described, lead to the excretion of albumen. 
 
 VI. Certain Peculiar Forms op Morbid Albuminuria. 
 
 In the foregoing sections we have become acquainted 
 with so many varying conditions which may assist in the 
 production of albuminuria, that we cannot agreo with the 
 attempts which have been made to attribute to a single 
 cause all those forms of albuminuria which do not originate 
 in the coarser disorders of the kidney. How the conditions 
 which are submitted to our consideration, viz. the state of 
 the circulation and of the blood-pressure, the condition of 
 the membranes concerned in the secretion, and the state 
 of the blood, act in various diseases, is in a general way too 
 little known for us to be able to estimate the influence each 
 exerts in every case. But this much we know, that in the 
 majority of diseased states the separate conditions mutually 
 influence each other, so that it is very difficult to discover in 
 every instance the really active condition, and altogether 
 impossible always to point out the only one that is so. The 
 conditions are proportionately simple in a few cases only, 
 and these have been described in their proper places in 
 foregoing pages ; we refer especially to the albuminuria in 
 venous congestion (page 71, ct seq.), in convulsive conditions 
 (page 51, et seq.), and at any rate in many forms of poison- 
 ing (pages 55 and 80). In all other cases the conditions are
 
 MORBID ALBÜMINÜEIA. 109 
 
 less simple and intelligible, so that altliougli it may be posi- 
 tively affirmed that the albuminuria has originated in some 
 one or other or in several of the ways above described, its exact 
 cause, and wherein consist the conditions for one or other mode 
 of origin cannot be so definitely stated. The best illustration 
 of the manner in which various conditions co-operate to pro- 
 duce albuminuria, and how these may alternate in one and the 
 same morbid process, is to be found in what Gerhardt was 
 the first to designate as "febrile albuminuria '' (96). And 
 in this instance we are in the position of being able to recog- 
 nise, with distinctness, at least a few individual conditions. 
 Even with regard to the conditions now occupying us, there 
 is still much that is wanting for the completion of our know- 
 ledge of the processes in fever, but the more recent investi- 
 gations with reference to the circulation, tissue-changes, and 
 nutrition, enable us to indicate the conditions, some with 
 certainty and others with more or less probability, which 
 will give rise to albuminuria in various febrile disorders 
 unaccompanied by any special lesion of the kidneys. In the 
 first place, as regards the circulation, and the blood-pressure 
 in particular, which, as previously explained in detail, has the 
 greatest influence in the production of albuminuria, it is 
 obvious that it does not remain the same, or invariably 
 undergo changes of the same character, in all febrile 
 diseases, or in any single disease throughout its whole course. 
 That it should remain unchanged is not to be expected, inas- 
 much as the heart's functional capacity, upon which the 
 blood-pressure mainly depends, varies according to the 
 nature and duration of the disease. As a general rule, in 
 those febrile conditions in which the cardiac activity has not 
 been previously impaired by the severity of the infection, the 
 action of poison and the like, the blood-pressure at the com- 
 mencement must of necessity be increased in consequence of 
 the numerical increase in the heart's pulsations which accom- 
 panies the rise of temperature, the force of the contraction 
 in each separate systole remaining the same, or possibly 
 augmented by the increase of temperature. This result has 
 been obtained in the few experiments recently performed by 
 Zadek and Basch with the object of measuring the pressure in 
 febrile conditions (97). In this respect, therefore, thecondi-
 
 110 CERTAIN PECULIAR FORMS OF 
 
 • 
 tion of a patient suffering from fever exactly resembles that 
 of an animal artificially lieatecl_, so long as the increase in the 
 bodily temperature does not exceed certain limits and does not 
 exercise a paralysing effect upon the nervous apparatus (see 
 page 47). The diminution also in the quantity of urine is as 
 common in fevers, and for reasons that are well known, as in 
 cases where the temperature is artificially raised, so that those 
 instances of febrile albuminuria which present themselves, 
 accompanied by a properly maintained action of the heart, 
 a strong pulse, &c., may, without any hesitation, be classed 
 together with that form which is induced by the artificial ap- 
 plication of heat. The elevation of the bodily temperature is 
 the essential, if not the only condition for the production 
 of the albuminuria, the immediate origin of which has been 
 explained in previous pages. The conditions may be entirely 
 different in the subsequent course of a fever, or in cases of 
 severe infection or poisoning, or even at the commencement 
 of a fever in a person already debilitated. In these cases, 
 no doubt, the blood-pressure Avill fall below the normal 
 degree. And therein, as we have seen when discussing the 
 influence of diminished pressure, may be discovered a condi- 
 tion for the production of albuminuria, but one which will 
 probably be insufficient 'per se for such a purpose, inasmuch 
 as the pressure is not usually reduced to a considerable 
 extent. But there are other factors of various kinds which 
 act in the same direction, and whose influence is greater in 
 severe febrile conditions accompanied by decreasing cardiac 
 activity than in others ; among these a prominent place may 
 be assigned to derangements of the nutrition of the renal 
 epithelium and possibly also of the walls of the vessels. We 
 know that such derangements occur, and that their intensity 
 varies with the disease which originates them, and we have 
 already discussed their possible influence in the causation of 
 albuminuria. As a further step we have to consider the 
 altered condition of the blood in fevers. We do not know 
 much about this, but we know enough to enable us to assort 
 that this factor also can play a certain part in the production 
 of febrile albuminuria. I here refer to what has been stated 
 in a previous page with regard to the influence which the 
 increased amount of urea contained in the blood exercises
 
 MOEBID ALBUMINüßlA. Ill 
 
 upon the filtration of albumen (see page 97, et seq.) The 
 above-mentioned factors are assuredly sufficient for the 
 explanation of every febrile albuminuria in the ordinary 
 sense of the words, involving as they do only the excretion 
 of coagulable albumen. But the possibility is by no means 
 excluded that tho febrile varieties of the metamorphosis of 
 tissue, the changes in the condition of the blood, unknown 
 it may be to us, but doubtless present, may serve as a 
 screen for a number of other factors favorable to the deve- 
 lopment of albuminuria. This supposition must almost 
 necessarily be accepted with regard to the instances 
 designated by Gerhardt as " latent albuminuria,' ' in which 
 albuminous substances, non-coagulable by heat, were excreted; 
 and consequently for cases of peptonuria or propeptonuria, as 
 those occur not merely in non-febrile but also in febrile 
 diseases, and, as it would appear, often under the influence of 
 the fever alone, and not of the particular disease which the 
 latter accompanies. The few statements that can be made 
 on this subject have already found a place in the fore- 
 going sections (see pp. 8 and 107). Unfortunately, under 
 the circumstances, the domain of facts has its narrow limits 
 while there is a wide field for hypothesis. 
 
 This wide field would have to be thoroughly traversed if 
 the attempt were to be made to explain every instance of 
 albuminuria occurring in the course of disordered states, but 
 without the kidneys being deeply involved. I do not assert 
 that the morbid processes are everywhere enveloped in 
 so much obscurity, that the causes which have led to the 
 albuminuria are always beyond our comprehension. This is 
 by no means the case, for in this or that disorder the par- 
 ticular circumstance to which the albuminuria is due can 
 often be definitely specified ; we know, for example, that the 
 albuminuria in cholera is due to the great inspissation of the 
 blood, whereby it is made to contain more albumen and, for 
 a short time, more saline constituents (see pp. 97 — 99) ; 
 secondly, to the intense venous congestion of the kidneys; and 
 lastly, to that degeneration of the epithelium and walls of the 
 vessels which necessarily results when the tissues are tra- 
 versed by abnormally constituted blood flowing in an abnor- 
 mally retarded current. Each of these factors may^^er se, as
 
 112 CERTAIN PECULIAR FORMS OF 
 
 already explained^ give rise to albuminuria ; two or three of 
 tliem combined will, as a matter of course,- be tbe more 
 certain to produce it. Witb regard to tbe temporary albumi- 
 nuria, not seldom to be observed in diarrhoeas of other kinds, 
 and which has recently attracted attention (98), we are to 
 some extent justified in attributing it to the diminution of the 
 water of the blood and the diminished blood-pressure which 
 usually co-exists ; but these exhaust the category of morbid 
 conditions, apart from kidney disorders proper, in which there 
 are at least a few facts as a basis of support for the ex- 
 planation of any existent albuminuria. 
 
 There are, as a matter of course, on the whole but few 
 difficulties in explaining the excretion of albumen in renal 
 disorders proper, i. e. nephritis in its various forms and 
 amyloid degeneration ; that is to say, in those processes in 
 which albuminuria is so constant and so marked a pheno- 
 menon that they were in former times simply identified with 
 it. And the acute inflammatory processes are the simplest 
 of all as regards the facility with which the albuminuria can 
 be explained. For the fact is that each vascular portion in a 
 state of inflammation is abnormally permeable, and permits 
 the escape of a fluid containing in particular a large amount 
 of albumen and of cells in addition. Albuminuria is con- 
 sequently a necessary symptom of all active inflammations in 
 the kidneys, that is, both of those forms which are acute from 
 their commencement and throughout their course, and of the 
 acute inflammatory exacerbations which occur in the chronic 
 forms. If it be not invariably observed in inflammations of 
 a purely circumscribed character, the reason for this may be 
 partly because the connection oE the inflamed portions with the 
 discharge-tubes is interrupted, and partly also because the 
 amount of albumen yielded by the area in question is too 
 small to be detected, especially if such circumscribed inflam- 
 mations do not affect the glomerular vessels. For there can 
 be no possible doubt but that the glomeruli are invariably 
 the principal and most prolific source of the albumen, and 
 hence it is that the urine containing the highest proportion 
 of albumen is always yielded in cases of acute (diffuse) 
 nephritis. In every acute inflammation of the kidney the 
 glomeruli are especially affected, or we may rather say that
 
 MOEBID ALBUMINURIA. 113 
 
 tlioy are the startiug-point for tlie inflammation ^ as has Leon 
 shown by the investigations of Klebs^ Salvioli, Cohnheim, 
 Friedländer, and Ribbert (gg) on the subject of glomerulo- 
 nephritis. In all cases the deposit of exudation in the 
 Bowman-Miiller's capsules can be easily demonstrated. The 
 possible participation of the interstitial vascular system in 
 the excretion of albumen must^ however, be assumed, 
 because the interstitial tissue and the epithelium of the 
 uriniferous tubules almost always become involved, and an 
 escape of albumen into the interior of the tubules may 
 doubtless take place in consequence. But fi'om the 
 anatomical appearances it is easy to form a conception of 
 the condition of the uriue in some other respects in every case 
 of acute nephritis, and it would appear especially that the 
 diminution in the quantity must necessarily be referred to 
 the co-operation of several conditions. In the first place the 
 glomerular vessels are compressed, on the one hand, by the 
 escape of the exudation into the capsules, and by the cell- 
 proliferatiou proceeding from the walls of the latter ; on the 
 other hand, their walls become infiltrated with fluid and 
 swollen, and their calibre greatly diminished. A second 
 factor is the retardation in the current, which, according to 
 Cohnheim, takes place in inflamed tissues ; and, lastly, the 
 uriniferous tubules situated in the inflamed interstitial areas 
 must become occluded by the pressure from without, and 
 by the infiltrated and detached epithelial cells. 
 
 It is, I think, a less easy and a less simple task, to arrive 
 at an explanation of the processes which take place in those 
 renal affections which are embraced under the term '■' chronic 
 nephritis " or '' chronic form of Bright's disease." This is 
 not the place to enter minutely into the question, so warmly 
 discussed of late, as to whether all those affections included 
 under that designation, are naturally connected aud invari- 
 ably depend on one and the same process, or whether and to 
 what extent they are to bo distinguished from each other. 
 It is the less necessary to discuss this question inasmuch as 
 no great difference of opinion prevails on those points in 
 which we are now interested, that is, with regard to the con- 
 dition of the urine, and to the anatomical appearances in tho 
 kidney — the differences in question mainly relating to the
 
 114 CERTAIN PECULIAR FORMS OF 
 
 development and succession of the processes, and to the 
 relation whicli the hypertrophy of the heart, and the vascular 
 changes in general, bear to the renal affection. It is thus 
 almost universally admitted that, from a clinical point of view, 
 there are two well-marked types of chronic kidney disease. 
 The first of these exhibits from the commencement the follow- 
 ing characteristics : more or less extensive anasarca, marked 
 ansemia, highly albuminous urine abounding in morphotic 
 constituents (casts, red and white blood-corpuscles, epithelial 
 cells), scanty in quantity when the disease is at its height, 
 or scarcely reaching the normal amount, and, lastly, no mani- 
 fest hypertrophy of the heart. The second variety commences 
 without anasarca, and generally without any remarkable dis- 
 turbance of the general health ; the urine is limpid, clear, poor 
 in albumen, but excessive in quantity, and these symptoms 
 are usually associated with hypertrophy of the left side of the 
 heart. Every physician who has had only a moderate 
 amount of experience is acquainted with cases of disease 
 which correspond to the one or other of these types — cases, 
 the symptoms of which, without any other disease or any 
 precursory stage, make their appearance exclusively in one 
 or other of these modes, and which run their course for many 
 years, it may be, with variations in intensity until death 
 ensues.^ In like manner, considered anatomically, two typi- 
 cal forms stand out sharply from the great variety of all 
 
 ^ In discussing the question of the development of cardiac hypertrophy in 
 renal diseases, several authorities attach considerable importance to the 
 influence of the prolonged duration of the latter, and the chronic character 
 of their course, and I therefore make the express remark that I have 
 repeatedly seen cases belonging to the former of the above-mentioned types 
 going on for many years without cardiac hypertrophy, hut Avith good general 
 nutrition, if death occurred before the above-described first type became 
 changed ; that is, before it passed into that named by myself and others, 
 secondary atrophy, a process the development of which may require many 
 years. It is true that in these cases the whole series of symptoms was not un- 
 intemiptedly present ; the dropsy altogether disappeared at intervals, whereas 
 the albviminuria, and, therefore, the renal lesion as well, were continuous. At 
 the present time there is in my division of the hospital a strong carpenter, 
 admitted for the third time, who a year and nine months ago first fell ill with 
 symptoms of the first type of nephritis, but apparently regained his 
 strength and went on with his work. After being under treatment for 
 several months the dropsical symptoms have now again abated, and the
 
 MORBID ALBUMINURIA. 115 
 
 chrouic renal affections ; the one described as the large white 
 or mottled kidney (chronic parenchymatous, diffuse nephritis. 
 Weigert's sub-chronic nephritis, &c.), and the other known 
 under the name of the '' red granular or contracted kidney '' 
 (genuine renal cirrhosis) ; the former is the more inflammatory 
 form, the chief microscopical characters of which are swelling 
 and fatty degeneration of the epithelium of the uriniferous 
 tubules and accumulation of round cells in the interstices 
 (and likewise in the Malpighian capsules) ; the latter is more 
 of an indurated character, in consequence of the development 
 of a firm connective tissue with but few cells and tending 
 towards atrophy, and of wasting of the glomerular vessels. I 
 repeat that there are these two forms, standing out clearly by 
 reason of their marked character, but I also lay stress upon the 
 fact that all chronically diseased kidneys by no means corres- 
 pond exactly to one or the other type, but that numerous cases 
 occupy an intermediate position between them, or approach 
 partly to the one and partly to the other type ; and that conse- 
 quently these two types may be regarded as the terminal 
 extremities of a series in which there are gradual transitions 
 from the one extremity to the other. And this further 
 remark must be made that the first form may even clinically 
 pass by degrees into the second, and inasmuch as we are 
 accustomed to regard the anatomical changes in both cases 
 as of an inflammatory nature, those of the first type being 
 of more recent origin, those of the second of an earlier date 
 and as resulting from the former, we may well suppose that the 
 second type represents, in its anatomy at least, a later stage 
 of the first type, or, at all events, a slower form of develop- 
 ment. But the question may well be asked, do all these 
 considerations constitute a sufiicient reason for adopting a 
 modern view, which regards all forms as mutually connected 
 in every respect, and promulgates the doctrine of the " unity 
 of chronic nephritis " or of '' Bright's disease of the kidney V 
 If this view be a reasonable one, then no distinction, clinical 
 
 patient appears to be in good Lealtla. Notwithstanding the long duration of 
 the disease there is not a single symptom of hypertrophy of the heart, and 
 there is no ground whatever for the suggestion of amyloid disease, in which 
 the hypertrophy is absent. On the other hand, it is well known that in the 
 second type the earliest syniptuni of renal disorder is usually accompauied by 
 cardiac hypertrophy, which can fur the most part be clinically clemonsUatedj
 
 116 CERTAIN PECULIAR FORMS OP 
 
 or anatomical, could be drawn between " chronic interstitial 
 pneumonia or cirrhosis of the lung " and other forms of 
 " chronic pneumonia/' for these conditions are precisely anala- 
 gous to those of the chronic affections of the kidney. Among 
 the vast number of forms of chronic pneumonia, there is one 
 which clinically stands out so sharply from all the others, 
 that everj experienced physician immediately recognises in 
 it the typical cirrhosis of the lung which, since Corrigan's 
 classical description, has been and still is, unhesitatingly 
 regarded as a peculiar form. And need I say that there are 
 other forms of " chi'onic pneumonia," whose symptoms differ 
 from this latter type, as widely as day does from night, so that 
 the two cannot be confounded together ? or need I say that 
 between these typical forms, placed as they are at each 
 extremity of the large series of chronic pneumonias, there 
 exist an innumerable number of cases representing very 
 gradual stages of transition from the one to the other, in 
 such a manner as to prevent any definition of an exact limit 
 to the series ? And is the case different in an anatomical point 
 of view ? No anatomist will have any hesitation in recog- 
 nising a typical " cirrhosis of the lung," set up perhaps as 
 a, result of pleuritis or of some disease due to inhalation of 
 irritating dust, and in distinguishing it from other chronic 
 forms of inflammation of the lung, notwithstanding the 
 numerous imperceptible transitions from the latter to the 
 former and vice versa, and in spite of the fact that a really 
 pure interstitial pneumonia as little exists as a pure, ex- 
 clusively interstitial nephritis. Neither in cirrhosis of 
 the lungs, of the kidneys, or of any other organ is the 
 morbid process confiued exclusively to the interstitial tissue, 
 nor in the other chronic inflammations is the so-called paren- 
 chyma alone involved and the connective-tissue framework 
 unaffected. It would be difficult to imagine that any such 
 exemptions exist in the living body, in which no system of 
 the elementary tissues is separated from its neighbour by an 
 impenetrable wall. We are scarcely able in all cases of chronic 
 pneumonia oven to determine which system forms the starting- 
 point of tho disease, and there is just the same difliculty in 
 many cases of chronic nephritis. The important point is to 
 determine the predominant factor in the morbid process, what
 
 MOltBID ALBUMINURIA. 117 
 
 it is that impresses special features upon the disease and 
 stamps the anatomical marks upon the affected organ. This, 
 in typical cases of cirrhosis, is represented by a development 
 of fibrillary connective tissue, which forces everything- else 
 into the background in consequence of its vast predominance 
 and its results ; on the other hand, in the cases which are 
 the farthest removed fi'om this type, the new formation of 
 connective tissue recedes into the background when contrasted 
 with the cellular infiltration and the parenchymatous degene- 
 ration of the epithelium. It is not the longer duration and the 
 more tedious progress of the disease which are the primary and 
 principal factors in the production of the cirrhotic type, for, 
 as I have already mentioned, years may pass by without this 
 type becoming developed, while in other cases it makes its 
 appearance after a brief interval. A better opportunity is 
 afforded us in the lungs than in any other organs, of watch- 
 ing the development within a few months of a perfect state 
 of cirrhosis, such as in other cases of chronic pneumonia is 
 not attained after an interval of several years. It is, there- 
 fore, not the peculiarity of every chronic inflammation to 
 induce cirrhosis ; for there are, for example, suppurations 
 running a very chronic course, but the production of cirrhosis 
 necessitates the antecedent occurrence of something or other 
 that is peculiar, or its supervention in the course of the 
 disease. The nature of this peculiarity does not fall within 
 the scope of our present investigation. 
 
 It would, moreover, appear that the diversity in the course 
 of the two types is not dependent upon the renal affection 
 alone. In addition to the fact that dropsy is as constant in 
 the one type as it is rare in the other, the way in which this 
 symptom makes its appearance is so peculiar that the idea 
 suggests itself that some disease of the skin is concerned in its 
 production. It is perfectly evident that the dropsical effusion 
 cannot be referred to suppression or diminution of the urinary 
 secretion, an explanation advanced by some observers. Even 
 the complete interruption of the discharge of urine, which 
 may oi'iginato from obstruction in the urinary passages, does 
 not, jper se, produce dropsy as a consequence. Cohnheim 
 (lOo) very particularly refers to the fact that neither hydraemia 
 nor hydraemic plethora can be the cause of the dropsy in
 
 118 CERTAIN PECULIAR FORMS OF 
 
 tliose diseases of the kidney. Its proportionately rapid 
 supervention, the great extent of the anasarca, and above 
 all its localisation, would rather seem to indicate the exist- 
 ence of special local abnormalities, which Cohnheim is inclined 
 to look for in some inflammatory change of the skin or its 
 vessels. It is in fact difficult, without some such assumption, 
 to explain how it comes to pass that, in the first form of 
 chronic nephritis (and also in acute nephritis), the eyelids or 
 the scrotum are the usual seats of the oedema, and often 
 those which are first affected ; for, as regards these parts, the 
 influence of gravity cannot be a sufficient cause for the 
 appearance of the symptom.^ How different are the 
 features presented by the genuine renal cirrhosis ! Even 
 in this affection a period of dropsy may set in, especially if 
 the heart's action becomes defective and the typical features 
 of the disorder become obliterated. The condition of such 
 patients obviously then resembles that of cases of heart- 
 disease in the stage of defective compensation, and especially 
 with regard to the dropsy, which in these latter depends 
 mainly upon venous congestion. Hence in these cases the 
 localities in wliich oedema first appears are the lower extremi- 
 ties, and the dependent parts in general ; and this oedema is 
 accompanied by more or less intense cyanosis, of which no 
 trace is exliibited by the dropsical patients included in the 
 first category, unless, perhaps, some special causes supervene 
 in addition. 
 
 All these diversities serve to explain the dissimilar con- 
 ditions of the urine in the two typical forms. In the one, 
 the large white (mottled) kidney, the condition which influ- 
 ences the result is the abnormal permeability of all the 
 elements of the tissue, duo to the swelling and fatty degen- 
 eration of the epithelium, and to the infiltration of the organ 
 by round cells ; a condition from which the glomeruli and 
 their capsules are not exempt. Under these circumstances, 
 the transudatory and secretory apparatus must necessarily 
 yield a highly albuminous fluid, in the production of which 
 
 * In two cases of scarlatinal dropsy without albuminuria I noticed oedema 
 of the face alone in one instance ; in the other only a'dema of the face and 
 scrotum, persisting for several weeks, in the latter case without the previous 
 appearance of any other trace of dropsy.
 
 MOEBID ALBUMINURIA. 119 
 
 the swelling and degeneration of the epithelium^ uamely^ 
 of the capsules, glomeruli, and uriniferous tubules, though 
 not unconcerned in the escape of the albumen (see page 78), 
 have not even been taken into account. It is evident 
 that there will be no lack of blood and pus-corpuscles, 
 epithelial cells and casts, whether these last are formed out 
 of coagulated albumen or epithelium. In like manner it is 
 obvious that the urine must be reduced in quantity in conse- 
 quence of the pressure which the infiltrated cells exercise 
 upon the capsules and glomeruli, and likewise upon the 
 uriniferous tubules, and in consequence of the more or less 
 decided occlusion which will take place in the last-named 
 structures as a result of the swelling, degeneration, and 
 detachment of the epithelial cells. In this respect the con- 
 ditions resemble those of acute nephritis, but in the latter 
 the progress of the symptoms is of a more violent character, 
 and corresponding with the acuteness of the inflammation, is 
 marked by intense hypercemia and considerable haemorrhage. 
 But even in the chronic form, to which we are now alluding, 
 such acute exacerbations are by no means rare ; on the other 
 hand, an improvement may set in, the morbid process coming 
 to an end in certain spots, though complete restoration does 
 not take place. That such changes occur is shown by the 
 varying condition of the urine, and especially by the diminu- 
 tion from time to time of the formed constituents. 
 
 We have already stated that it is more than probable that 
 simultaneously with this nephritis some peculiar disorder of 
 the skin sets in, causing it to become oedematous. When 
 this is the case, it is obvious that an improvement may occur, 
 -accompanied by absorption of the watery effusion, which is 
 more freely removed by the kidneys, if at the same time the 
 morbid process of which they are the seat undergoes an 
 improvement or its progress becomes arrested. But even in 
 the absence of any such improvement in the state of 
 the kidneys, the absorption of copious effusion would 
 •cause a strong current of fluid to set in towards these 
 organs, and any inflammatory products that might be 
 present would be thereby steadily removed. As a matter 
 of fact, we often notice that as oedema disappears, the 
 urine becomes more abundant, but without losing any of its
 
 120 CERTAIN PECULIAE FORMS OF 
 
 other characteristics ; that is to say, it remains cloudy, con- 
 tains more or less blood and much albumen, and deposits a 
 copious precipitate o£ formed elements. Possibly this is to be 
 explained by the fact that the inflammatory processes in the 
 kidney still continue, whereas the condition of the skin becomes 
 improved. The increase in the quantity of urine, which occurs 
 at a certain stage in this form of chronic nephritis, might con- 
 sequently bo regarded as due to the absorption of the dropsical 
 effusion ; but the converse could not be assumed, viz. that the 
 disappearance of the latter is due to increased diuresis. 
 This latter process takes place when the form of disease has 
 its starting point in {" secondary ") atrophy, which is induced 
 when the development of the fibrillary connective tissue pre- 
 ponderates. The conditions in that case more and more 
 approximate to those of the primary or genuine cirrhosis of 
 the kidney. 
 
 In this last-named condition it is not the abnormal permea- 
 bility .of the tissue and of the vessels in particular which is 
 the determining factor, but the increased arterial pressure. 
 We may not assume that the vessels embedded in the close 
 meshes of a fibrous connective tissue, and themselves for the 
 most part thickened and indurated, are to an abnormal extent 
 permeable by albumen ; and such a view is also decidedly 
 contravened by the state of cicatricial connective tissue in 
 other parts, c.(j. the skin, when dropsical effusion exists. 
 The small and the varying amount of albumen found in the 
 urine in cases of renal cirrhosis must, therefore, in my 
 opinion, be referred to the coexistence of small inflamma- 
 tory areas, the predominance of which is a feature of the 
 former type, but which are not altogether wanting in the 
 disease in question. In cases in which these are absent, or 
 no longer active, the albuminuria, that is, the manifest 
 excretion of albumen, will disappear, and the more so because 
 the quantity of urine will be simultaneously increased and its 
 percentage of albumen consequently still further reduced. 
 It is universally admitted that the increase in the quantity 
 of urine is the result of the enormous increase of pressure, 
 which must occur in the vessels which are still pervious, in 
 consequence of the wide-spread destruction of these parts 
 and the co-existent cardiac hypertrophy. I regard it also as
 
 MORBID ALßUMINürJA. 121 
 
 certain^ that iu this cirrhosis, in which the large majority of 
 the glomeruli are not seldom destroyed, the increase in the 
 quantity of tlie urine is in great measure due to the increased 
 activity of tlie secretory epithelium, a large portion of which 
 is usually in a normal condition. This view is further sup- 
 ported by the fact that the quantity of tlio specific urinary 
 constituents (at least of the urea), secreted by sucli kidneys, 
 corresponds absolutely with the conditions connected with 
 the nutrition, though the percentage is reduced. The epi- 
 thelium in this case acts similarly to all otlier glandular epithe- 
 lium when under increased arterial pressure {conf., p. 40). 
 
 Disorder of the skin with tendency to oedema, as occurs 
 in the first type, or in acute nephritis, is absent in the 
 typical cirrhosis, although the cutaneous arteries are not 
 seldom thickened just as those in the kidneys (loi). This 
 vascular disorder, however, is not such as to cause oedema. 
 It is only when the heart's action becomes feeble that 
 oedema and other eifusions set in, and are accompanied by 
 decreased secretion of urine. 
 
 I must repeat that the above descriptions correspond only 
 to the marked types of chronic nephritis, to those which 
 stand at the ends of the scale, and that there are numberless 
 cases in which the typical characters are more or less 
 obliterated. To arrive at a proper estimate of these con- 
 ditions it will always be useful to remember the analogy 
 they present with chronic inflammations of the lung, the 
 mutual relationships of which, however, are more distinct. 
 
 Finally, with reference to amyloid degeneration I can be 
 very brief iu my remarks, for I have little that is positive 
 to state with regard to the influence of this condition upon 
 the secretion of urine. I agree with others in supposing 
 that the vessels in a state of amyloid degeneration are 
 abnormally permeable, and therefore offer less than the 
 normal obstacle to the escape of the albuminous substances 
 dissolved in the blood. No strict proof can be adduced 
 for that hypothesis, which, however, is perhaps supported 
 by the fact that obstinate diarrhoea is such a common 
 symptom in cases of extensive amyloid degeneration 
 of the intestines. This may, however, be due rather to 
 defective absoi-ption and increased peristaltic action. It
 
 122 LITERAT CEE REFERRED TO. 
 
 appears to me to bo probable that not only tlie glomerular 
 vessels wlien in a state of amyloid degeneration^ but that 
 the epithelium and the interstitial vascular system as well, 
 when similarly affected^ are involved in the excretion of 
 albumen. When examining kidneys in a state of amyloid 
 degeneration I have repeatedly noticed a marked deposit of 
 albumen in the tubuli uriniferi, especially of the cortex, 
 with but very little excretion in the capsules. Posner also 
 incidentally alludes to the same appearances (102). It is, 
 moreover, a well-ascertained fact that pure amyloid degene- 
 ration rarely occurs alone, but is far more often associated 
 with interstitial nephritis ; the urinary secretion, in such 
 cases, exhibiting corresponding alterations. 
 
 Literature referred to in the Text. 
 
 (i) J. B. Stokvis, Reclievches experimentales sur les conditions patlio- 
 gcniques de rallniminurie. Bruxelles, 1867. 
 
 (2) Runeberg, Deutsches Archiv f. klin. Med., xxüi, 1879, S. 41. 
 
 (3) C. Posner, Virchow's Archiv, Ixxix, S. 335. 
 
 (4) Eibbert, Centralblatt f. d. med. Wiss., 1879, S. 836; Nephritis vxnd 
 
 Albuminurie. Bonn, 1881. 
 
 (5) Litten, Centralblatt f. d. med.' Wiss., 1880, S. 161. 
 
 (6) Litten, Frerichs' und Leyden's Zeitschrift f.ldin. Med., i, S. 177-178. 
 
 (7) Cohnheim, Virchow's Archiv, 1868, xli, S. 220. 
 
 (8) Cohnheim, Allgem. Pathol. Berlin, ii, 1880, S. 315. 
 
 (9) R. Iloidenhain, in Hermann's Handb. d. Physiologie. Leipzig, v, 1880, 
 
 S. 33ÖU.375. 
 
 (10) Charcot, Progrcs medical, 1881. 
 
 (11) Lepine, Revue mensuelle de med. et de chinirgie, Paris, 1880, Mars, 
 
 Avril. 
 
 (12) Estelle, Revue des sciences mdd., 1880, No. 9. 
 
 (13) Hamraarstcn, Pflüger 's Arch., xvii, 1878, S. 413. 
 
 (14) Hofmeister, Hoppe- Seyler's Zeitschr. f. phys. Chemie, 1880 u. 1881 ; 
 
 Maixner, Viertoljalirsschr. f. pract. Heilk., 1879, 3 ; R. Jaksch, Prager 
 med. Wochenschr., 1881, Nos. 7 — 9. 
 
 (15) Selmi, Mem. dell' Acad, di Bologna nach Virchow-Hirsch's Jahresb., 
 
 1881, S. 140. 
 
 (16) W. Kühne, Verhandlungen des Heidelberger naturhist. Vereins, N. F., 
 
 1876, i, S. 194; Schmidt-Mühlheim, du Bois-Reymond's Arch. f. 
 1880, S. 33 ; E. Salkowski, Virchow'.s Archiv, Ixxxi, 1880, S. 552. 
 (i 6a) Kulme, Phys. Chemie, S. 466, 
 
 (17) Virchow, dessen Arch., iv, 1852, S. 309; Fleischer das. Ixxx, S. 482 ; 
 
 Bence Jones, Philos. Transactions, 1848, i, p. 55; Langendoiif und 
 Mommsen, Virchow's Arch., Ixix, S. 452 ; Kühne, 1. c, ii, S. 6.
 
 LITERATURE REFEEEED TO. 123 
 
 (i8) Prout, s. bei Beneke, Grundlinien dei- Pathol, des StofEwechsels. Berlin, 
 
 1874, S. 232; Fürbringer, Berliner klin. Wocli., 1878, No. 15; 
 Gowers, Lancet, 1878, ii, No. i. 
 
 (19) Stokvis, Maandblaad der Sectie voov Naturwetensch, 1872, No. 6. 
 
 (20) Lassar, Virchow's Arcli., Ixxvii, S. 157. 
 
 (21) Hindenlang, Berliner klin. Wochenschr., 1881, No. 15. 
 
 (22) Harlej', Med. Times and Gaz., i865,Novbr. ; Bechamp, Comptes rend., 
 
 1865, i u. ii ; Foster, Journ. of Anat. and Physiol., 1866, i, p. 167 ; 
 Vintschgau u. Cobelli, Wiener akad. Stzgb., 1866, lix, S. 283. 
 
 (23) Seegen u. Ivratschmer, Pllüger's Arch., 1877, xiv, S. 593. 
 
 (24) Leube, Erlanger phys. med. Societätsber., 1878, März 4. 
 
 (25) Frerichs, Die Bright'sche Nierenkrankheit. Braunschweig, 1851, S. 180 ; 
 
 J. Vogel, in Virchow's Hdb. der Pathol., vi, 2, S. 522 ; Ultzmann, 
 Wiener med. Presse, 1870 ; Gucneau de Mussy, Clinique med., ii, 
 p. 230, citirt nach Runeberg, in Deutsch. Arch. f. klin. Med., xxvi, 
 S. 214 ; Leube, 1. c. ferner daselbst, 1877, Juli 9 ; u. Virchow's Arch., 
 Ixxii, S. 145; Gull, Lancet, 1873, i, p. 808; Moxon, Guy"s Hosp. 
 RexJ., vol. xxiii ; Kooke, Brit. Med. J., 1878, Octob. 19 ; Dukes, idem., 
 Novbr. 30; Saundby, idem., 1879, ^^^ ^° 5 Edlefsen, Mitth. des 
 Vereins Schleswig-Holstein'scher Aerzte, 1879, i. No. 2 ; Marcacci, 
 Gaz. Ilebdom., 1879, No. 16 ; Munn, New York Med. Record, 1879, 
 March 29 ; Bull, Nordiskt med. Arsk. xi, cit. nach Runeberg. Für- 
 bringer, Ztschr. f. klin. Med. v. Frerichs u. Leyden, i, S. 340 ; 
 Kleudgen, Arch, f . Psychiatrie und Nervenkrkh., xi, 2. 
 
 (26) Kiiss bei J. Picard, These de la presence de I'unee dans le sang. Strass- 
 
 bourg, 1 856 und : Lemons de physiologic. 
 
 (27) V. Wittich, Virchow's Arch., 1856, x, S. 325. 
 
 (28) Henle, Nachrichten von d. G. A. Univei-sität zu Göttingen, 1863, 
 
 S. 257- 
 
 (29) Ribbert, Nephritis u. Albuminurie, S. 5, 6, und 66. 
 
 (30) Frommann, Virchow's Arch., xvii, S. 141 ; Reimer, Arch. d. Heilk., xvi, 
 
 1875, S. 296 fE. 
 
 (31) Bartels, Nierenkrkh. in v. Ziemssen's Hdb. d. Pathol., ix, i, S. 39 u. 
 
 177- 
 
 (32) Nussbaum, Pfluger's Arch., xvi u. xvii. 
 
 {33) Henseu u. Dähnhardt, Arb. aus d. Kieler physiolog. Inst., 1868. Kiel, 
 S. 27. 
 
 (34) Cohnheim, 1. c, i, S. 409. 
 
 (35) Emminghaus, Berichte der sächs. Ges. d. Wissensch. (aus dem Leipziger 
 
 physiol. Inst.), 1873, S. 414, 415. 
 
 (36) D. Newman, Proceed, of the R. Soc. of Edinb., 1878, p. 648. 
 
 (37) Gottwalt, Hoppe-Seyler's Ztschr. f. physiol. Chemie, iv, S. 423. 
 
 (38) V, Bamberger, Wiener med. Wochenschr., 1881. 
 
 (39) F. Hoppe, Virchow's Arch., 1856, ix, S. 245. 
 
 (40) Ludwig und Zawarykin, Wiener ak. Stzsbg., xlviii, 1863, S. 16. 
 
 (41) Rindowsky, Centralbl. f. d. med. Wiss., 1869, S. 145. 
 
 (42) Bridges Adams, Hämoglobinausscheidung in d. Niere. Dissertat. Leip- 
 
 zig, 1880.
 
 124 LITERATURE REFERRED TO. 
 
 (43) Virchow, sein Arcli., xii, S. 310. 
 
 (44) Ludwig, Wiener ak, Stzgsb., 1863, xlviii, Novbr. 
 
 (45) Griitzncr, Pfliiger's Archiv, xi, 1875, S. 370. 
 
 (46) Litten, Verhandlungen d. Berl. med. Gesellsch., 1878, Mai 29 und 
 
 Centralblatt f. d. med. Wiss., 1880, S. 161 S. 
 
 (47) Nawalichin, Centralbl. f. d. med. Wiss., 1870, S. 483. 
 
 (48) G. H. Meyer, Zeitschr. f. physiol. Heilk., 1844, S. 149; Robinson, 
 
 Med.-Chir. Transact., xxvi, p. 51 ; Frerichs, 1. c, S. 278 ; Correnti, 
 Studi critici, &c. Firenze, 1868 ; Ph. Munk, Berliner klin. Woch- 
 enscbr., 1864, S. 133 ; H. Colin, Klinik der embol. Gefässkrankh., 
 i860, S. 628 ; Litten, 1. c. ; Stokvis, 1. c, S. 82. 
 
 (49) V. Wittich, Königsberger med. Jahrb., 1861, iii, S. 52 ; Vulpian, Gaz. 
 
 hebdomad de med., &c., 1873, p. 341 ; M. Herrmann, Wiener Akad. 
 Stzgsb., 1861, xlv, B. 317 ; Knoll, Eckard's Beitr. zur Anat. u. Pbys., 
 1870, vi, S. 39. 
 
 (50) Paschutin, Ber. der sächs. Ges. d. Wiss. (aus dem Leipziger phys. 
 
 Inst.), 1873, S. 229. 
 
 (51) Zadek, Zeitschrift f. kliu. Med. v. Frerichs u. Leyden, ii, S. 509. 
 
 (52) W. Schmidt, Poggendorff's Ann. der Physik, &c., 1856, xcix. 
 
 (53) Eckhard, Das, 1866, cxxviii, S. 61. 
 
 (54) J. Eanke, Die Blutvertheilung und der Thätigkeitswechsel der Organe, 
 
 Leipzig, 1871. 
 
 (55) Hafiz, Ber. d. säcbs. Ges. d. Wiss. (aus dem Leipziger physiol. Inst.), 
 
 1870, Aug. I. 
 
 (56) Heidenbain, 1. c, S. 262, 263. 
 
 (57) Euneberg, Deutsch, Arch. f. klin. Med., 1880, xxvi, S. 211. 
 
 (58) Vierordt u. Aberle, Die Messung des Arterienumfanges. Tübingen, 
 
 1856. _ 
 
 (59) Cohnbeim, I.e., ii, S. 310. 
 
 (60) Weissgerber u. Perls, Arch. f. exp. Pathol, u. Pharmacol., vi, S. 130 IT. 
 
 (61) M. Herrmann, Zeitscbr. f. rat. Med., 1863, xvii, S. i ; v. Overbeck, 
 
 Wiener ak. Stzgsb., xlii, 2, S. 189. 
 
 (62) Frerichs, 1. c. ; ßosenstoin, Virchow's Arch., liii, S. A. S. 14, 15. 
 
 (63) Gl. Bernard, Lemons sur les proprietes physiol., &c., Paris, 1859, ii, 
 
 P- 136. 
 
 (64) liuneberg, D. Arch. f. klin. Med., xxiii, S. 59. 
 
 (65) Stokvis, 1. c, S. 84 ; M. Herrmann, 1. c. 
 
 (66) Frerichs, Klinik der Leberkrkh, i, S. 373. 
 
 (67) Schwengers u. Leichtenstern, Berliner klin. Woch., iSSi, Nos.34 u. 35. 
 
 (68) Ludwig, Wiener ak. Stzgsb., 1863, xlviii, Novbr. ; Senator, Virchow's 
 
 Arch., Is, S. 496 ; Heidenhain, 1. c, S. 316. 
 {6g) Bartels, Deutsch. Arch. f. klin. Med., i, S. 13 ; Senator, Virchow's Arch., 
 xlii, S. I. 
 
 (70) Stokvis, 1. c, S. 106 ; Kohts, Deutsch. Arch. f. klin. Med., v, S. 19S. 
 
 (71) Pb. Munk u. Leyden, Die acute Phospborvergiftung, Berlin, 1S65. 
 
 (72) Scbultzen u. Riess, Ann. d. Oharitc-Krankh., xv, 1869, S. 102 Jf. 
 
 (73) Meischnei', Die acute Phosphorose, Diss. Leipzig, 1864 ; Hossler, 
 
 Eulenberg'a Vjluschr., 18S1, xxv, S. 256.
 
 LITERATURE REFERRED TO. 125 
 
 (74) Tlicnard bei Frericlis, Leberkrkli, i, S. 316 ; Lehmann, Physiol. Chemie, 
 
 i, S. 57. 
 
 (75) Kuneherg, 1. c., xxiii, S. 259. 
 
 (76) Cohnheim, I.e., ii, S. 78 und dagegen i, S. 543. 
 
 (77) Gergens, Arch, f . exp. Pathol., &c., 1876, vi, S. 149 ; Weigert, Vivchow's 
 
 Arch., Ixxii, S. 254 ; Kabierske, Dissert. Breslau, 1880 ; Lassar, Virch. 
 Arch., Ixxvii, S. 157 ; Posner, 1. c, S. 333 u. S. 348 ; Browicz, Cen- 
 tralblatt f. d. med. Wiss., 1879, S. 145 ; Voorlioeve, Virchow's Archiv, 
 Ixxx, S. 247. 
 {78) Ermann, Eulenberg's Vjschr. f. ger. Med., xxiii, 1880, S. 61. 
 
 (79) Senator, 1. c, Ix, S. 477. 
 
 (80) Bartels, 1. c, S. 36. 
 
 (81) P. Hoppe-Seyler, Physiol. Chemie, S. 75; Gottwalt, Ztschr. f. pliys. 
 
 Chemie, 1880, iv, S. 437. 
 
 (82) Jaccoud, Des conditions pathogeniques de I'alb. Paris, 1861 ; Sommola, 
 
 Arch. g^n. do m($d., &c., 1867, ii, p. 616 ff; Revue mensuelle de med., 
 &c., 1880, No. 3. 
 
 (83) Stokvis,l.c., S. 63fE. 
 
 (84) F. Hoppo-Seyler, Virchow's Arch., ix, 1856, S. 245, u. Physiol. Chemie, 
 
 S. 152 ff; v. Wittich, MüUer's Arch., 1856, S. 286; H. Nasse, Mar- 
 burger naturwiss. Sitzgsber, 1866, Nos. 5 ^' 7 > Newman, I.e. 
 
 (85) Parkes, Med. Times and Gaz., 1852 and 1854; Gublcr, Union med., 
 
 1857, No. 155. 
 
 (86) Brunton u. Power, St. Barthol. Hosp. Rep., xiii, p. 283. 
 
 (87) Chiistison, On Granular Degeneration of the Kidneys. Edinb., 1839, 
 
 P- 36. 
 
 (88) C. Schmidt, Zur Characteristik d. epid. Cholera, Mitauu. Leipzig, 1850. 
 
 (89) R. Gscheidlen, Studien über den Ui-sprung des Harnstoffs, Leipzig, 
 
 1871. 
 
 (90) A. Fränkel, Virchow's Arch., Ixvii, S. 273. 
 
 (91) T6gai-t, Tlifese. Paris, 1845; Brown-Sequard bei Tessier, These sur 
 
 l'urcmie. Paris, 1856; Becquerel u. Barreswil, Union med., 1857, 
 No. 144 ; Hammond, Journ. de physiol., &c., 1858, p. 416; Cl. Ber- 
 nard, I. c, ii, S. 136 ff ; J. C. Lehmann, Virchow's Arch., xxx, 1864, 
 S. 593 ; Stokvis, 1. c,, S. 40 ff". 
 
 (92) Creite, Ztschr. f. rat. Med., xxxvi, 1869, S. 90. 
 
 (93) Lehmann, 1. c, Runeberg, Arch. d.)Heilk., xviii, S. 44. 
 
 (94) Creite, 1. c, Landois, Central bl. f. d. med. Wiss., 1873, ^- 883 ; Ponfick, 
 
 Virchow's Arch., xlii, 1874, S. 273. 
 
 (95) Ponfick bei Heidenliain, 1. c, S. 351. 
 
 (96) Gerhardt, 1. c. 
 
 (97) Zadek, 1. c. ; v. Basch, Ztschr. f. klin. Med. von Frerichs u. Leyden, 
 
 iii, S. 502. 
 
 (98) J. Fischl, Prager Vjhrsschr, 1878, cxxxix, S. 27 ; B. Stiller, Wiener 
 
 med. Wochenschr., 1880, Nos. 18, 19. 
 
 (99) Klöbs, Path. Anat., ii, S. 644 ; Salvioli, Archivio per le sc. med., 1879, 
 
 iii; Cohnheim, 1. c, ii, S. 320 ff; Friedländer, Verhdlg. der pliysiol. 
 Ges. zu Berlin, 1880, Novbr. 19 ; Ribbert, Nephritis u. Albuminurie.
 
 126 LITEEATUßE EEFERRED TO. 
 
 (loo) Colinlielin, 1. c, ii, S. 434 ff- 
 
 (loi) Gull u. Sutton, Med. -Chir. Transact., Iv, i872,May.2S; Senator, Ver- 
 
 handl. der Berliner med. Ges., 1880, Mai 12. 
 (102) Posner, I.e., S. 323, Anm. 
 
 EXPLANATION OF THE ENGRAVING. 
 
 Section of rabbit's kidney hardened by boiling and alcohol, coloured by a 
 solution of picro-carmine. Tlie red colouration is not shown iuj the 
 drawing. 
 
 Fig. I. After a ligature had been kept on the vein for ten minutes. 
 a. Deposit of albumen in the uriniferous tubules of the 
 medulla. 
 Fig. 2. Ligature on one iireter, retained for thirteen minutes, a. Ex- 
 tensive lymph-spaces filled with albumen, between the much- 
 dilated tubuli urinif eri. h. (Edematous adventitia of an artery.
 
 iC'.acfi^c^ 'd/tt. 
 
 Syz^-CUi^ft' iiW-w. G'tt^'fc. 
 
 Qjd.Mi'
 
 A CONTRIBUTION 
 
 THEORY OF UllINARY SECllETION.^ 
 
 It is well known that there are, at tlio present time, twa 
 opposite theories on tlie subject o£ the secretion of urine ; 
 one of tliese may be described as tlie filtration theory, the 
 other the secretion theory. The former, originated, as we 
 all know, by Ludwig, transfers the entire process of secre- 
 tion to the Malpighian corpuscles, and assumes that the 
 filtered fluid is subsequently converted into urine in accord- 
 ance with purely physical laws. I may take it for granted 
 that this view is well known. 
 
 In like manner I need not enter upon a minute discussion 
 of the objections to this theory, and which, especially of 
 late, have assumed some prominence. Although these do 
 not all possess an equal amount of demonstrative force, and, 
 from the standpoint of Ludwig's theory, one or other of 
 them may be invalidated (as I shall by-and-bye have some 
 opportunity of showing), it must be admitted that certain 
 facts are irreconcilable with the theory in question. These 
 objections have been recently summed up by Ileidenhain,^ 
 and, so far as they refer to the secretion of the so-called 
 specific constituents of the urine, he has, I think, given a 
 very proper estimate of them. The result is that more 
 weight must again be attached to Bowman's view Avith regard 
 
 ^ A translation o£ a lecture delivered by Dr. Senator before the Phj'sio- 
 logical Society of Berlin, December 9tli, 1881, and appended to tlie fore- 
 going essay at tlie author's request. ' Archiv für Anatomie und Physiologie,' 
 1SS2. 
 
 ^ Hermann's ' Handbuch der Physiologie,' v. i.
 
 128 THE THEORY OP THE 
 
 to tlio secretory function of tlie epitlielium of the uriniforous 
 tubules, and since Heidenluiin and bis pupils- have experi- 
 mentally demonstrated tlie correctness of this view, there 
 can scarcely be any doubt as to this function, even apart 
 from the consideration, adduced also by Bowman, that the 
 nature of these cells places them in the category of the 
 glandular epithelia, I consider it, therefore, to be an 
 established fact that the epithelial cells of the convoluted 
 uriniferous tubules, and possibly also to some extent those 
 of Henle's loops, do secrete in a specific manner certain 
 constituents of the urine. 
 
 But Heidonhain has lately gone a step beyond this, inas- 
 much as he regards the excretion of the water (and of the 
 salts, its invariable accompaniment) from the vascular tufts, as 
 an instance, not merely of filtration, but of a real secretion 
 from the epithelium covering the glomeruli. And indeed 
 he believes that the activity of these epithelial cells depends 
 upon their supply of blood — its diminution when the current 
 is retarded being an especial feature — and that their normal 
 activity is also shown in preventing the escape of the serum- 
 albumen. The last remnants of Ludwig's theory would thus 
 bo demolished. It seems to me, however, that, on the one 
 band, this portion of Heidenbaiu's theory is destitute of a 
 sufficient basis, and is open to numerous objections ; and, on 
 the other, tbat there is no necessity for abandoning the 
 assumption that filtration takes place from the glomerular 
 vessels, whilst the epithelial cells of the tubuli uriuiferi are 
 the seat of secretion. 
 
 In the first place it appears to me that to regard those 
 epithelial colls as actively secreting agents, that is, as 
 glandular epithelium, involves a very bold assumption, since 
 they differ in their histological clniracters from all the really 
 glandular epithelium with which we are acquainted. For, 
 after birth these cells are quite flat, and resemble the endo- 
 thelium of serous membranes or possibly the connective - 
 tissue colls ; and wo should scareely be disposed to attribute to 
 these such secretory activity as belongs only to cells very dif- 
 ferently constituted, even if it were merely a question of the 
 secretion of water. We are the less inclined to do so, 
 inasmuch as we are acquainted with glands exercising such
 
 SECEETION OF URINE. 129 
 
 a function, but as a matter of fact, exhibiting very dif- 
 ferently constituted epitlielial cells. The glands in question, 
 which secrete only water and the salts which are its invari- 
 able accompaniment, are the lacrymal glands and the sweat- 
 glands. Their glandular epithelium is, however, not to bo 
 compared with the epithelium of the vascular tufts. And 
 also in other respects, the condition of these glands is very 
 different from that of the glomeruli. The former are to 
 a certain extent independent of the blood-supply ; on the 
 other hand, they are to a large extent influenced by specific 
 irritants and the condition of their innervation, as has 
 recently been demonstrated particularly with regard to the 
 secretion of the sweat-glands.^ It is a point of special 
 importance that the secretion of sweat continues even 
 when the flow of blood is diminished. With regard to the 
 influence of the blood-supply upon the lacrymal secretion, 
 there are no experimental observations possessing an equal 
 amount of demonstrative force, but all experience supports 
 the view that similar conditions obtain. We know at least 
 that lacrymation is not checked in spite of the greatest 
 reduction in the arterial pressure and notwithstanding the 
 most profound anaemia ; the flow, indeed, is rather more 
 copious in these conditions under the influence of the ordinary 
 stimuli. And it may here be mentioned that CI. Bernard in 
 his experiments upon horses, fully under the toxic influence 
 of curara, noticed that the lacrymal secretion was increased 
 before death — when the blood-supply was assuredly dimi- 
 nished. 
 
 The circumstances of the case with regard to the glomeruli 
 are of an entirely different character. Their excretion is 
 dependent exclusively upon the supply of blood, and no 
 stimulus can re-establish it when it has been arrested by 
 reducing the supply. In this respect this excretion differs 
 essentially from that which takes places in the uriniferous 
 tubules. For our knowledge on this point we are indebted 
 to Heidenhain's investigations, and also to those of Nuss- 
 baum, Grützner, and others. In animals in which the 
 spinal cord has been divided, and the blood-pressure is conse- 
 quently so much reduced that no mnne is secreted, the secretion 
 ' S. Luclisinger in Hermann's ' Handbuch der Physiologie,' v. i. 
 
 9
 
 130 THE THEORY OP THE 
 
 may be re-established, and even without increasing the blood- 
 pressure, by the employment of various forms of stimuli, but 
 especially by injecting the so-called " specific potential con- 
 stituents of urine" {harnfähige Stoffe). This excretion, how- 
 ever, is solely the result of specific glandular secretion in the 
 uriniferous tubules, as is shown by the fact that it continues 
 after the vascular tufts have been excluded, either by (as in 
 frogs) applying a ligature to their vessels, or by cauterisation.^ 
 The epithelial cells of the tubuli uriniferi behave like other 
 glands, the activity of which is called forth or increased by 
 adequate stimuli ; the vascular tufts, on the other hand, 
 notwithstanding their epithelial covering, do not exhibit a 
 similar capacity. Heidenhain is therefore compelled to assume 
 further that the quantity of water in the blood is the factor 
 which alone determines the activity of these epithelial cells, 
 and is at the same time their adequate stimulus; although he 
 does not overlook the necessity which consequently arises of 
 assigning an exceptional position among all glandular cells 
 to these epithelial structures." 
 
 If, then, the assumption of a specific secretion of water 
 by those epithelial cells appears to be open to serious 
 objections, there are also many pathological facts which 
 flatly contradict it, and are evidences against the existence 
 of those peculiar properties which Heidonhain is compelled 
 to ascribe to the cells in question. We know that in renal 
 atrophy a large proportion of the vascular tufts, with their 
 epithelial investment and their capsules, are completely de- 
 stroyed, and yet the quantity of urine is not diminished, but, 
 on the contrary, very considerably increased. If the filtration 
 theory be accepted, the explanation of all this is very simple, 
 viz. that the pressure is very considerably increased in the 
 vessels which have escaped destruction and in those of the 
 interstitial vascular system ; in the first place because a large 
 number of small vessels of the kidney have been destroyed, 
 and in the second, because of the cardiac hypertrophy which 
 is not simply the mechanical consequence of the destruction 
 of the vessels. In this case the attempt might be made to 
 explain the increased secretion, if Heidenhain's view be 
 
 1 See Heidenhain, ibid., pp. 338 — 340, p. 3^0, et seq^. 
 » Ibid., pp. 337-338-
 
 SECRETION OP UKINE. 131 
 
 adopted, by supposing that the epithelial cells o£ the non- 
 affected glomeruli secrete more freely than usual, in con- 
 sequence of the inci'eased arterial pressure and the increased 
 blood-supply associated therewith. But anyone who has 
 ever seen a kidney of this kind, in which only a few 
 remnants of parenchyma are discoverable, will assuredly 
 come round to the opinion that it is scarcely possible 
 to attribute such an increase of secretion to the few 
 unaffected glomeruli. Nevertheless I admit that this is 
 no cogent objection against Heidenhain' s view, and that 
 the explanation referred to, although a highly improbable 
 one, might be admitted in its favour. There is, however, 
 more difficulty in the case of amyloid degeneration of the 
 kidney. In this affection the degenerative process usually 
 involves first and foremost the Malpighian tufts ; it is 
 frequently confined to these and to their epithelium, of which 
 nothing is eventually recognisable. At the same time the 
 quantity of urine is not only not diminished, but as a general 
 rule, is increased beyond the normal amount. This fact can 
 scarcely be reconciled with Heidenhain's assumption, but 
 it is a necessary result if we adopt the theory that the 
 Malpighian tufts are the seat of filtration. For in amyloid 
 degeneration, hydra)mia, that is to say, an abnormally slight 
 concentration of blood, is always present ; and it is well 
 known that cseteris paribus, a diluted solution passes more 
 readily through a filter than a concentrated one. In order 
 to explain only the increased quantity of urine excreted, it is 
 not necessary to assume that the vessels in a state of amyloid 
 degeneration are abnormally pervious, an assumption that 
 may do well for the explanation of the albuminuria, and 
 which, moreover, has no connection with Heidenhain's view. 
 In addition to this, amyloid degeneration of the kidneys some- 
 times occurs without albuminuria. Lastly, we are indebted to 
 Bartels^ for a clinical observation which completely contradicts 
 that view of Heidenhain's. In the case of a man suffcriug from 
 thrombosis of the inferior vena cava, but with normal action 
 of the heart, the urine passed was copious in quantity and 
 contained much blood and albumen. In consequence of the 
 thrombosis, there existed a marked congestion in all the 
 ^ See V. Ziemssen's ' Handbucli der Pathologie,' is, i, pp. 39, 177.
 
 132 THE THEORY OF THE 
 
 rootlets of tlie inferior vena cava (as evidenced by the 
 intense oedema of tlie lower half of the body), and conse- 
 quently a retardation of the blood-current in the kidneys, 
 which, according to Heidcnhain, would necessarily impair 
 the function of the epithelium in question, and cause a 
 decrease in the quantity of urine. In this manner indeed, he 
 explains the albuminuria, associated with a diminution in 
 the quantity of urine, which occurs in other kinds of venous 
 congestion in the kidneys.^ Now, in this case of Bartels', either 
 the nutrition and function of the epithelium were impaired in 
 consequence of the retardation of the blood-current, in which 
 case the excretion of urine must have decreased and not 
 increased; or else they were not injured in spite of the 
 retardation of blood, a supposition, however, which is not 
 compatible with Heidenhain's view. And moreover, they 
 would, if intact, allow no albumen or blood to pass. And if 
 it be supposed that in this case the albumen and blood 
 could be derived not from the vascular tufts, but from the 
 interstitial vascular system, an assumption which Heidenhaio 
 himself decidedly opposes, we do not get out of the difficulty ; 
 whereas if the filtration theory be accepted, the condition as 
 a consequence of the highly increased pressure, admits of a 
 very simple explanation. 
 
 There are, besides, experimental facts which controvert 
 the assumption that the epithelium is capable of secretory 
 activity in the manner suggested ; or at least negative the 
 idea that the cells permit albumen to transude only when 
 the blood-supply is diminished or the blood-current is 
 retarded, but not when the supply of blood is increased. 
 As these matters belong to that division of albuminuria 
 which is to some extent pathological, and have already been 
 discussed very briefly in another place,^ I shall not enter 
 into them here, and will only express the opinion that they 
 can easily be explained if we accept the theory of filtration, 
 and not that of secretion in the tufts. 
 
 All alleged objections, some of which have a greater and 
 others a lesser weight, appear to nie sufficient as a whole 
 to upset the assumption of a secretory action of the epithe- 
 
 1 Ibid., p. 371. 
 
 * See pp. 39 — 77 of the foregoing translation.
 
 SECRETION OP URINE. 133 
 
 Hal cells wliicli cover the tufts. Nevertheless there is some 
 justification for the reasons which have caused Heidonhain 
 to give up so completely the filtration theory. So far as 
 they relate to the excretion of the so-called specific con- 
 stituents of urine, and these latter are regarded as a product 
 of secretion by the epithelium of the uriniferous tubules, and 
 not the result of filtration, there can, as I said before, be 
 no question as to their correctness. It is, in some measure, 
 these same reasons which have induced Heidenhain to allow 
 that the process which takes place in the kidneys in general 
 is one of secretion, and not of filtration, and have, therefore, 
 caused him to place these organs on the same footing with 
 all other glands in which indubitably no mere process of 
 filtration takes place. For, as he very justly says, " as 
 regards all other glands, without exception, we know defi- 
 nitely that the passage of water out of the blood into the 
 secretion-spaces does not depend upon simple filtration.^' ^ 
 But, according to my judgment, this very comparison with 
 all other glands would necessarily prevent us from expecting 
 that the processes in the kidneys would take the same 
 course. For the kidneys differ in their construction very 
 essentially from all other glands ; it is not only by leaving 
 out of consideration the whole system of the Malpighian 
 bodies, with their afferent and efferent vessels, that any 
 general comparison can be instituted between the kidneys 
 and other glands. But as they most assuredly possess that 
 system, we are the more justified in expecting differences in 
 the processes of excretion rather than a conformity with 
 those of other glands. From this point of view, therefore, 
 we have certainly no grounds for refusing to admit that 
 filtration takes place in the vascular tufts. Heidenhain thinks 
 that his view is further supported by the fact that the quantity 
 of urine by no means invariably coincides, that is to say, rises 
 and falls, with the increase and diminution of pressure, as 
 would necessarily be the case if the excretion depended upon 
 filtration. This objection can easily be refuted by the state- 
 ment that, in point of fact, the kidney is no mere filtration 
 apparatus, but is in some degree a true gland, and that 
 therefore we must not expect that its action will be entirely 
 
 1 Ibid., p 331.
 
 134 THE THEOEY OF THE 
 
 dependent upon pressure. The reason, however, why 
 Heidenhain maintains this plea is that he considers the water 
 of the urine to be derived as a rule only from the Mal- 
 pighian tufts, and not from the capillaries surrounding the 
 uriniferous tubules, in accordance with the opinion hitherto 
 held with regard to the former structures. However, this 
 assumption also seems to be contrary to all analogy and 
 probability, for no true gland yields a secretion free from 
 water.^ And that the uriniferous tubules, after removal of 
 the glomerular system, can supply a true fluid urine has been 
 proved by Nussbaum in his experiments on frogs. The 
 potential constituents of urine, which are constantly present in 
 the blood, form, as I have already mentioned, the stimulus to 
 the secretory activity. When the force of the circulation 
 has been diminished after experimental division of the spinal 
 cord, a proportionately greater quantity of only one of 
 these potential urinary constituents is required in order to 
 excite to secretion the epithelium whose function the retarded 
 supply has impaired. The case must obviously be different 
 under normal conditions of circulation. In the first place, 
 the epithelium of the uriniferous tubules, when in a state of 
 normal nutrition, will react to slighter stimuli ; for the blood 
 which circulates around these tubules is, as Ludwig urged 
 some years ago, concentrated by the escape of water, and 
 therefore conveys proportionately more urinary materials to 
 the epithelium. There is also this other fact to be con- 
 sidered, viz. that in the present case several urinary con- 
 stituents (urea, uric-acid-salts, chloride of sodium, &c.) co- 
 operate, and may, under normal conditions, produce an 
 effect identical with that which under abnormal conditions 
 (after division of the spinal cord, &c.) is evoked by a larger 
 quantity of a single constituent. It must, therefore, be con- 
 sidered as proved that a portion of the water of the urine, 
 and doubtless the smaller portion, is supplied by the epithe- 
 lium of the uriniferous tubules, and is a product of true 
 glandular activity. If, therefore, the watery constituent of 
 the urine is not always excreted in such quantity as Lud- 
 wig's theory of filtration would lead us to anticipate, the 
 
 ' In the sebaceous glands there is no real secretion, but only proliferatioa 
 and fatty metamorphosis of the epithelium.
 
 SECRETION OP UKINE. 135 
 
 explanation is to be found in the fact that the kidney is a 
 filtrating apparatus only to a partial extent, and that the 
 anomalies are due not to the filtered, but to the secreted 
 elements of the urine. 
 
 But even if we admit, just for a moment, that all the 
 water in the urine is derived only from the tufts, yet the 
 facts adduced by Heidenhain with reference to the secretion 
 of water are by no means inconsistent with the filtration 
 theory. These facts are : — i. That after constriction or 
 closure of the renal veins the urine is immediately dimi- 
 nished in quantity (and at the same time becomes albu- 
 minous), whereas the pressure in the glomeruli is increased. 
 The usual explanation of this, according to Ludwig, is that 
 when a ligature is applied to a renal vein, the efferent 
 uriniferous tubules are compressed by the turgid veins in 
 the pyramidal portions, and thus the escape of urine is pre- 
 vented in a purely mechanical manner. Heidenhain does 
 not agree with this explanation, because such a dilatation of 
 the veins requires a certain time for its development, 
 whereas immediately after ligature of the veins the flow of 
 urine almost entirely ceases and is very soon completely 
 arrested, indications which point to the conclusion that the 
 process of excretion is rapidly suspended.^ Much import- 
 ance cannot certainly be attached to this objection, for it 
 appears to me very probable that when the escape of blood 
 is prevented, the mechanical obstacle is immediately produced, 
 and in the direction from the pyramidal portions backwards 
 towards the glomeruli, and that a few seconds only are 
 required for this to take place. But even if, in this case, 
 the flow of urine ceases with such remarkable rapidity, the 
 fact appears to me to be inconsistent rather than otherwise 
 with the assumption that the excretion has come to a stand- 
 still. For in true glands, as, e.g. the liver and the salivary 
 glands, the excretion does not cease at the very instant that 
 the blood-current is interrupted, but only in a gradual 
 manner ^ — a fact which is perfectly intelligible. 
 
 2. The other point relates to the condition of the urine as 
 regards its quantity when a liquid is conveyed into the blood. 
 On the one hand, for instance, according to Ponfick, a con- 
 ^ Ibid,, p. 325. ^ Heidenhain, loc. cit., i^p. 264, 46.
 
 136 THE THEORY OF THE 
 
 siderable quantity of serum or dog's blood can be injected 
 without any perceptible increase in tbe excretion of urine ; 
 on the other hand, according to Pawlow, the absorption of 
 large quantities of fluids from the stomach produces an aug- 
 mentation of the urinary excretion without any rise in the 
 blood-pressure.^ I cannot conceive that these facts consti- 
 tute any obstacles to the theory of filtration. For, as 
 Heidenhain] himself insists, if, in the first case, when 
 fluid is injected into the blood, the pressure does not rise in 
 the manner previously supposed, it follows that there is, 
 ceteris ijarihus, no reason why increased filtration shoald 
 take place : but as regards the diuretic effect of the introduc- 
 tion of fluids into the stomach, in this case the question of 
 the dilution of the blood has to be taken into consideration, 
 for, as we all know, the filtration is very considerably pro- 
 moted by the dilution (see above). As a matter of course 
 the dilution produces the same effect, even when it is not the 
 result of absorption from the stomach. Thus, if instead of 
 serum or blood a dilute solution of chloride of sodium be 
 injected into the blood, a considerable increase in the quan- 
 tity of the urinary excretion would be noticed just as before, 
 and this increase would be unattended by any increase of 
 pressure. 
 
 If all these considerations do not directly establish the 
 truth of the filtration theory, at all events they do not con- 
 tradict it. 
 
 But finally, and this is a fundamental point of great im- 
 portance, Heidenhain thinks that, generally speaking, the 
 capillaries are not endowed with any universal capacity for 
 allowing larger quantities of fluid to pass through their coats 
 when the arterial blood-supply is increased, and that the 
 capillaries of the renal glomeruli, on account of their epi- 
 thelial covering, must offer more than usual resistance to 
 the filtration pressure. The latter point, i.e. the greater 
 resistance of a wall covered with epithelium need not be 
 contested, but surely the statement that transudation from 
 the cajjillaries is independent of pressure and especially of 
 arterial pressure, is contrary to the laws of filtration. In 
 proof of his assumption, Hcidenhain appeals to experiments 
 
 1 Ibid., p. 333.
 
 SECRETION OF URINE. 137 
 
 made in Ludwig's laboratory, with regard to tlie condition 
 of the lymphatic current under increased arterial pressure. 
 I do not consider this comparison between the flow from an 
 opened lymphatic and transudation from the capillaries 
 to be admissible, for reasons given in the monograph 
 already alluded to,^ and which, to avoid prolixity, I will 
 not again discuss. It is quite sufficient for me to point 
 out that morphologically as well as chemically, the contents 
 of the lymphatic trunks differ from transudations ; that 
 those contents cease to flow under circumstances which 
 undoubtedly have no similar effect upon transudations ; and 
 that all the lymph-channels in one portion of the body may 
 be cut off without inducing oedema. The invariable and only 
 cause of oedema is the insufficiency of the veins, or of the 
 veins and lymphatics together, to carry away the transuded 
 fluid. Therefore what is true of the contents of the lymphatic 
 trunks does not apply as a matter of course to transuda- 
 tion from the capillaries. In order to discover how transu- 
 dations are affected, they themselves must be studied, and so 
 far as this has been done, the result has always proved that 
 augmented pressure is invariably followed by increased 
 transudation from the capillaries. Chabbas, acting under 
 Grünhagen's direction, has found this to be correct with 
 regard to the aqueous humour ^ which most certainly is to be 
 considered as a transudation, and our manifold clinical ex- 
 perience confirms the statement that real transudations (not 
 exudations) rise and fall with corresponding variations of 
 pressure. This statement, however, as a matter of course, 
 does not exclude the possibility that other conditions may 
 co-operate. 
 
 And now to recapitulate my observations, I consider myself 
 justified in concluding that there are no reasons whatever 
 for relinquishing the theory that a transudation alone escapes 
 from the glomerular vessels of the kidneys, in accordance 
 with the laws of filtration. Secondly, that a secretion of 
 the specific constituents of urine in a watery (concentrated) 
 solution takes place in the convoluted uriniferous tubules, 
 
 ' ' Die Albuminurie,' &c., pp. 28 — 30, and the foregoing translation, 29 — 3 1 . 
 ' Dogiel and Jesner's later investigations on this subject refer to the 
 alterations in the quantity of albumen.
 
 138 THE THEORY OF THE 
 
 and it tlierefore follows that perfect urine represents a mix- 
 ture of a transuded with a secreted solution. 
 
 Now if the fluid which escapes from the Malpighian tufts 
 be a transudation^ it must necessarily contain the constituents 
 common to all transudations — that is to say, besides water 
 there are the materials held in solution in the blood-plasma, 
 in proportion of course to their capacity for filtration, and, 
 therefore, not merely salts, traces of urea, &c., but also 
 albuminous substances (serum-albumin and globulin) . For 
 there is no transudation without albumen, and if a fluid con- 
 taining albuminous matters in solution filters at all through, 
 an animal membrane, the albuminous substances will like- 
 wise pass through in a quantity corresponding to their 
 capacity for filtration, such capacity being usually slight, the 
 quantity also being subject to variations under different 
 conditions. These conditions are : the quality of the mem- 
 brane, especially its thickness, the concentration of the solu- 
 tion, the salts it contains, its temperature and the pressure 
 under which filtration goes on. As these conditions 
 undoubtedly vary in different parts of the body, there need 
 be no surprise at the differences as regards quantity of 
 albumen in the transudations. Those normal transudations 
 in particular which are separated from the capillaries by 
 epithelium, such as the aqueous humour, the cerebro-spinal 
 fluid and the endo-lymph, contain so little albumen that 
 they are often set down as " almost non-albuminous.'^ For 
 the same reason the transudation from the glomeruli must 
 likewise be considered as only very slightly albuminous, but 
 certainly not as absolutely free from albumen. 
 
 It is well known that the older theories of Küss, v. Wittig 
 and Henle assumed that the glomerular transudation contains 
 albumen. In order to explain the non-appearance of this 
 substance in normal urine, the idea was suggested that the 
 epithelium of the uriniferous tubules withdraws the albumen 
 from the passing fluid. The correctness of this last view 
 has never been thoroughly demonstrated, but just as little 
 has it been effectually controverted. It used to be asserted 
 that degeneration of the epithelium is not followed by albu-
 
 SECEETION OF URINE. 139 
 
 minuria, but this statement is not correct.^ All that can be 
 maintained against the view in question is, that it scarcely 
 coincides with our ideas as to the function of glandular 
 epithelium to assume that these structures absorb anything 
 from the secretions whose escape is unimpeded, and it is still 
 more extraordinary that albumen alone should be absorbed. 
 
 In contrast with this theory, Ludwig, as we know, imagines 
 that the filtrate which escapes from the tufts is free from 
 albumen, but he does not explain why this should be the case, 
 and regards the question of the absence of albumen as un- 
 solved, and one which requires elucidation." It would appear, 
 however, that the sole object of his assumption is to explain 
 the absence of albumen in normal urine. In the mean- 
 time, however, the state of the question has become changed. 
 Many recent investigations have shown that small quantities 
 of albumen are to be found in the urine of healthy persons, 
 and that this is not a rare occurrence, but one whose fre- 
 quency is remarkable, considering the views hitherto received.^ 
 Physiologists have taken no cognisance of this fact, or have 
 devoted no space to it in their discussions ; but treating it 
 with neglect they go on searching for an explanation of the 
 absence of albumen from normal urine, and especially 
 from the fluid which escapes from the Malpighian tufts. 
 The majority of physiologists adduce as an explanation that 
 the normal albuminous substances of the blood-plasma are 
 unable to escape from the vascular tufts, being prevented by 
 the epithelial investment, or the peculiar structure of the 
 walls of the vessels. This assumption is destitute of all 
 analogy ; and if it be true that all other capillaries, whether 
 with or without an epithelial covering, are permeable for 
 albumen, it is clearly the less admissible, inasmuch as certain 
 albuminous substances which pass readily through a filter 
 (egg-albumen, peptone, &c.) do undoubtedly pass through 
 the glomeruli. We may, therefore, reply that the assumption 
 is only made ad hoc, that is to say, only for a desired pur- 
 pose — in order to explain the absence of albumen in urine. 
 
 ' See Senator, ' Die Albuminurie,' &c., p. 73 (p. 78 o£ foregoing trans- 
 lation). 
 
 2 ' Lehi-bucli der Physiologie,' ii Auö., ii, 1861, pp. 428, 429. 
 * See Senator, 1. c, p. 15.
 
 140 THE THEORY OF THE 
 
 But tliis purpose is defeated^ for as a matter of fact, albumen 
 can he found even in normal urine. How is tlii"s fact to be 
 explained by the aid of that assumption ?^ 
 
 The opinions hitherto maintained with regard to the con- 
 stituent parts of the glomerular transudation are therefore 
 unfounded. It must be admitted that this transudation does 
 contain albumen^ but, as I have already mentioned, the 
 epithelial investment prevents the quantity of albumen from 
 being otherwise than extremely minute. And there is 
 another important circumstance which must cause the 
 quantity of albumen in this transudation to be still less than, 
 for instance, in the so-called " nearly non-albuminous " 
 transudations (the aqueous humour, the cerebro-spinal fluid, 
 the endolymph) ; the fact in question being that this filtrate 
 escapes under much, higher pressure. We know that the 
 highest capillary pressure in the body (not excluding that in 
 the intestinal capillaries) prevails in the glomerular vessels. 
 If the filtration pressure rises, then more fluid will pass out 
 from an albuminous solution, but this fluid will bo relatively 
 poorer in albumen though the absolute quantity may be 
 increased. Consequently, the transudation from the glome- 
 ruli will be still poorer in albumen than those above alluded 
 to as containing the smallest proportion of that constituent. 
 But, finally, and in the third place, it must be mentioned that 
 when this transudation reaches the uriniferous tubules, the 
 specific secretion of the latter, which is undoubtedly free from 
 albumen, is added to it ; so that in proportion as this addition 
 is made, perfect urine will finally contain a less percentage of 
 albumen than is to be found in the glomerular transudation. 
 
 So far as I can see, this explanation rests upon no 
 ai'bitrary assumption^ but upon recognised physical laws, and 
 it offers us a means of explaining the occasional appearance 
 of albumen in normal urine. For, doubtless, even in the 
 normal condition of things, the pressure in the glomeruli, as 
 well as the quantity of the secretion escaping from the urini- 
 ferous tubules, is liable to variations ; and in proportion as the 
 influence of these two factors is increased or lessened, will 
 the urine contain either more or less albumen, the pre- 
 
 ' For additional details see Senator, " Albuminurie," pp. 32 — 24 (the same 
 pages in the translation).
 
 SECRETION OF URINE. 141 
 
 sence of which will be more or less easily detected. The- 
 circumstances, therefore, with regard to albumen are com- 
 pletely analogous to those of many other normal constituents 
 of urine (sugar, oxalic acid, pyrocatechin, &c.), which are 
 found, under physiological conditions, sometimes in infini- 
 tesimally small quantities, and sometimes in larger proportion 
 and therefore more easily detected. I refrain from entering 
 into further particulars, inasmuch as in the monograph 
 already alluded to I have discussed at some length other 
 circumstances which, even in the normal state, may conduce 
 to the appearance of large and easily detectible quantities 
 of albumen in the urine, that is to say, may set up a physio- 
 logical albuminuria. I have also in that treatise explained 
 the influence of changes in the renal circulation and of other- 
 pathological conditions.
 
 THE 
 
 HYGIENIC TREATMENT OE ALBUMINUEIA/ 
 
 In the treatment of various disorders of the kidneys, and 
 especially of those usually classed together as acute or 
 chronic forms of Bright's disease, albuminuria is the sym- 
 ptom which deserves the closest attention ; but not, as is still 
 generally asserted, because a long-continued excretion of 
 albumen impairs the nutrition of the system. This, in my 
 opinion, is a mistaken notion, founded as it is on a highly 
 exaggerated estimate of the loss of albumen such as 
 occurs in most cases even of very serious affections of the 
 kidneys. In a very marked case of albuminuria, the 
 albumen rarely amounts to more than a few tenths per cent., 
 and we know that the percentage generally increases with 
 the diminution in the quantity of urine and diminishes when 
 the latter is increased. If, therefore, the proportion of 
 albumen in the urine be very considerable, say '5 or '8, 
 this being an extraordinarily high percentage, the daily 
 amount passed will weigh only a few grammes, perhaps six 
 or eight, or possibly ten as a maximum. A loss of 
 albumen exceeding this amount is altogether exceptional, 
 and, when it occurs, is of very short duration and never lasts 
 for many days or weeks. Losses of albumen to this extent 
 do not appreciably injure an adult, unless his system has 
 been extremely reduced in other ways. Six to eight 
 grammes of albumen represent the quantity contained in 
 forty grammes of beef ; and it is evident that if that is all, 
 half-a-pound of meat would almost suffice to cover the 
 
 J A lecture delivered before the Berlin Medical Society, October nth, 
 
 1882.
 
 HYGIENIC TREATMENT OF ALBUMINURIA. 143 
 
 weekly loss of albumen, even wlien very considerable in 
 amount. 
 
 The importance of albuminuria, as a symptom, is due 
 rather to the fact that it furnishes us, so to say, with a means 
 whereby the existence and gravity of renal disorders may be 
 determined and estimated. If this symptom were absent, it 
 would not be easy to diagnosticate with certainty a renal 
 affection, and it would be still more difficult to decide that 
 the case was one of Bright' s disease (though in this latter 
 albumen may sometimes be absent from the urine) ; moreover 
 in estimating the gravity, the progress, or the retrogression 
 of the disease, we depend, as a general rule, upon the 
 quantity of albumen contained in the urine. Another 
 reason for the importance of albuminuria as a symptom may 
 also be adduced, viz. the possibility that in some cases the 
 excretion of albumen may act as a stimulus to the kidney. 
 We do not, indeed, know that this effect can be produced by 
 those forms of albumen which are found in the urine in cases 
 of ordinary albuminuria, but we do know that egg-albumen 
 acts in this way. When this substance finds its way into 
 the blood, it is excreted by the kidneys, but frequently this 
 is not all that happens, for, as J. C. Lehmann and Stokvis 
 have observed, more albumen is excreted than is introduced ; 
 as a matter of course not more egg-albumen, but a form 
 which possesses the properties of the ordinary albuminous 
 substances of the serum (serum-albumin and globulin). It 
 is not improbable that peptone likewise, and perhaps also 
 hemi-albumose (propeptone) may act in a similar way, i.e. 
 excite albuminuria. Moreover, the idea has been repeatedly 
 entertained, both in ancient and modern times, that the 
 albumen in ordinary albuminuria, in the various forms of 
 Bright' s disease, is not altogether the same with the normal 
 albumen of the serum, and if this view bo correct, though 
 its truth has never been demonstrated, it may well be 
 supposed that this albumen also has an irritative action on 
 the kidney, like that of a foreign body or possibly of a 
 poison. 
 
 As regards the therapeutics of albuminuria, every un- 
 prejudiced physician will confess that up to the present 
 time we have not on the whole been very successful
 
 144 HYGTENIO TREATMENT OP ALBUMINURIA. 
 
 witli our purely medicinal treatment. This is the reason 
 why new remedies are continually being "recommended. 
 They are, however, as little efficacious as the old ones. 
 Neither the astringents, tannin in particular, nor fuchsin, 
 nor Pilocarpin, nor the acids, produce the effects with which 
 they have been credited, and the same remark applies to 
 nitric acid, lately recommended in accordance with Hansen's 
 prescription forty years ago, bat which Frerichs ^ has already 
 found to be useless. There is, at most, one drug, viz. iodide 
 of potassium, which must be allowed to possess a certain 
 amount of efficacy in some forms of chronic nephritis. It 
 must be understood that I am referring now to the albumi- 
 nuria, and not to other symptoms such as the dropsy and 
 the asthmatic attacks, for which we possess really efficacious 
 remedies. 
 
 It is easy to be deceived with regard to the usefulness of 
 a remedy employed in cases of acute renal affection, for these 
 very often terminate favorably without any medicinal treat- 
 ment, and the albuminuria in particular, which not unfre- 
 quently continues for some time as the last remaining sym- 
 ptom, eventually disappears, unless the circumstances are 
 altogether unfavorable. And in dealing with chronic renal 
 affections it is easy to over-estimate the value of a remedy 
 if we forget that their course is usually fluctuating, and that 
 whether medicines are given or not the quantity of albumen 
 in the urine may go on diminishing for days and weeks. 
 Such fluctuations are due to the fact that the inflammatory 
 process in the kidney is not uniform but irregular in its 
 course, and to the occurrence of complications which increase 
 the albumen ; while against these may be set the avoidance 
 of injurious influences and the adoption of suitable hygienic 
 arrangements. 
 
 Since we can do so little with medicines in the treatment 
 of albuminuria, the greatest importance must be attached to 
 hygienic measures, and experience teaches us that the 
 results to be anticipated, if not remarkably brilliant, are 
 far better than those attained by any medicinal treatment 
 whatever in the absence of such measures. That such is 
 the case is proved by the fact that in chronic renal affections 
 ^ 'Die Bright'sche Nierenkraiikheit,' 1851, s. 237.
 
 HYGIENIC! TREATMENT OF ALBUMINURIA. 145 
 
 better results are often obtained in hospitals tlian outside 
 these institutions. For ordinary hospital patients are under 
 much more favorable hygienic conditions than are found 
 outside, and I have not unfrequently seen patients improve 
 in hospital either without medicine, or under the same treat- 
 ment to which they had for a long time been subjected, and 
 without benefit, as out-patients. 
 
 The most important question is that which refers to the 
 diet. Some amount of attention has been given to this 
 subject, but it appears to me that the indications have nob 
 been sufficiently considered, nor the full purport of the 
 question properly appreciated. In discussing questions as 
 to the dieting of patients suffering from nephritis, there are 
 two points to be considered: — (i) The influence which the 
 ^process of digestion fer se has upon the albuminuria, and (2) 
 the influence which the kind of food has upon the symptom 
 in question. With regard to the first, recent observations 
 have shown that during digestion the excretion of albumen 
 is augmented in patients suffering from albuminuria, or that 
 the symptom recurs when temporarily in abeyance ; and a 
 transient condition of albuminuria has indeed been noticed 
 in healthy persons during the digestion of a full meal. 
 Hence the rule t\iQ,t in alhmninuria the demands of the system 
 for food are to he satisfied by small quantities frequently 
 repeated, and not by abundant supplies. 
 
 The choice of the food, however, is a still more important 
 •consideration. Physicians long ago noticed that the albumen 
 was increased after the ingestion of certain articles of food 
 and drink ; but it is only recently that these observations 
 have been tolerably well understood and added to by others. 
 The fact has been demonstrated by the experiments, already 
 alluded to, of -J. C. Lehmann and Stokvis, and it must bo 
 further observed that the injurious effect of egg-albumen 
 was witnessed not only when this was injected into the blood, 
 but when introduced in large quantities into the stomach — a 
 fact noticed by other observers besides those above men- 
 tioned. 
 
 It would therefore appear that egg-albumen acts injuriously 
 not only when it is introduced as such into the blood, but 
 also after it has undergone alterations in the stomach and 
 
 10
 
 146 HYGIENIC TEEATMENT OF ALBUMINÜßlA. 
 
 bowels. At any rate it is advisahle strictly to forbid the use 
 of eggs wlienever albuminuria exists. 
 
 With regard also to other albuminous articles of food, and 
 especially meat, if we wish to get rid of the albuminuria, we 
 must limit the supply within much narrower bounds than 
 physicians now prescribe, guided as they are by what I have 
 already alluded to as an exaggerated estimate of the loss of 
 albumen. I have repeatedly noticed the occurrence of albu- 
 minuria in apparently healthy men after eating heartily of 
 meat, and still more frequently observed increased amount 
 of albumen in cases of albuminuria. Similar observations 
 with regard to cheese have been recorded by Christison. 
 
 It is unnecessary now for me to enter into an explanation 
 with regard to the injurious effects of highly albuminous food, 
 for a year ago I had the honour to address you on the sub- 
 ject of the pathogenesis of albuminuria, and I then discussed 
 this question.^ I will just add that Lichtheim^ has recently 
 pointed out another danger attendant upon a full albuminous 
 diet, viz. the possibility of an accumulation of urea in the 
 blood and its accompanying results (urcemia), as a conse- 
 quence of the abundant formation of urea with co-existent 
 disease of the kidneys ; and this warning holds good not only 
 of urea but of other final products of the disintegration of 
 albumen, especially of phosphoric acid, the excretion of which, 
 according to Fleischer's investigations, is likewise impeded in 
 renal affections. 
 
 We must therefore adopt the rule of limiting the amount 
 of meat, and if it cannot be altogether withheld, we must 
 recommend those kinds which contain less albumen, such as 
 veal and young fowls, i.e. the so-called " white meat.'' For 
 the same reason fish, which also contains less albumen than 
 beef, for example, may be more safely recommended for such 
 patients. 
 
 After what has been already said, I need not further 
 G?:plain why the use of vegetable food may be freely per- 
 i:)ifcted. Green vegetables, salads, cabbages, and the like, 
 
 ^ Vide ' Verliandlungen der Berliner med. Ges.,' xiii, 1881-82, and 
 Stnator's forcgoinf^ treatise 'Albuminuria in Health and Disease,' Berlin, 
 
 j'<S2, pp.19, 54' 94' 6^ ^^7- 
 
 Con-esp.-Bl. der Schweitzer Aerzte,' 1S82, No. 7.
 
 HYGIBNIC TREATMENT OF ALBUMINURIA. 147 
 
 whicli are poor in albumen, are preferable to those whicb 
 contain more of this constituent, and especially to the legu- 
 minous kinds. 
 
 As a matter of course, the choice of the several articles 
 of diet will depend upon the state of the digestion and other 
 individual conditions. And especially with reference to the 
 question as to whether/ai in large quantities is to be allowed 
 or not — a very important point as regards nutrition when, 
 the supply of albumen is limited — the answer to this will 
 depend simply upon the condition of the organs of digestion. 
 
 With regard to liquids, alcoholic drinks have been 
 hitherto forbidden for purely empirical reasons, based, how- 
 ever, upon clinical experience to the effect that renal 
 diseases are caused by the misuse of alcohol, and especially 
 by the immoderate consumption of brandy. Quite recently 
 it has been proved by Pentzoldt's ^ experiments that inflam- 
 matory renal affections can be produced in dogs by adminis- 
 tering ethyl- and amyl-alcohol. The patients must there- 
 fore be confined to water, effervescing drinks, and the 
 various alkaline acidulous waters ; but it will be difficult 
 altogether to forbid alcohol, especially to patients accus- 
 tomed to its use. Spirits, Cognac, &c., must be forbidden 
 under all conditions unless their employment be necessitated 
 by special indications, e.cj. collapse, &c. The prohibition 
 need not be so strict with regard to wine. I have hitherto 
 adopted the rule of allowing claret, more from habit than 
 for any special reasons. Some importance has been, 
 attached to the amount of tannin contained in claret, but 
 the quantity is too small to be of any consequence, and, as. 
 before observed, I am unable to attribute any great efficacy 
 to tannin as a remedy. Beer is generally considered to be 
 more injurious than wine, although the strongest kinds of 
 beer contain less alcohol than the majority of wines. But 
 beer appears to me to act more injuriously than wine in 
 cases of albuminuria. Only in one case of so-called albu- 
 minuria with healthy kidneys, occurring in a colleague, the 
 patient stated that wine invariably caused a reappearance or 
 increase of albumen, whereas no such effect was observed 
 after drinking beer. 
 
 ^ 'Sitzgsb. d. pliys. med. Soc. zu Erlangen,' 18S2, Juni 19.
 
 148 HYGIENIC TREATMENT OF ALBUMINURIA. 
 
 In tlie last place experience teaclies that hot spices and 
 highly cured meats are hurtful ; errors of diet of every kind 
 always do mischief. I have had repeated opportunities of 
 observing cases in which the albuminuria was undoubtedly 
 increased after grave errors in diet. 
 
 It is a fact of the greatest interest that the dietetic treat- 
 ment of albuminuria, the so-called '^ milk-cure " which was 
 long ago adopted and still maintains its deserved reputation, 
 is in perfect harmony with the principles laid down in the 
 foregoing remarks. It is true that a diet consisting 
 exclusively of milk, though very often talked about, can but 
 rarely be persevered with for a lengthened period, and the 
 expression, therefore, is not to be taken quite literally. If, 
 for example, a patient takes two litres of milk per diem, a very 
 considerable quantity, he does not obtain even the minimum 
 amount of albumen which an adult requires to support life. 
 Voit^ states that an adult prisoner, doing nothing and 
 receiving only the so-called " sustentation-diet,^' requires a 
 daily supply of 85 grammes of albumen, 30 grammes of fat 
 and 300 grammes of hydrocarbons, and that even for old 
 women, the objects of charity and living under very miser- 
 able conditions, the amount of albumen must not be reduced 
 below 76 — 80 grammes. If, however, we take the average 
 percentage in milk as 3*41, two litres will contain only 68 to 
 70 grammes, or considerably less than the quantity required 
 to support life. The fat contained will amount to 74 
 grammes or more than twice the necessary quantity ; the 
 hydrocarbons again, not quite 100 grammes, will be much 
 below the standard. This latter deficiency will, however, be 
 partly made good by the excess of fat which can supply the 
 place of the hydrocarbons. A further supply of the latter is 
 required to cover the deficiency. I have already said that 
 according to my experience, milk alone is scarcely ever taken 
 or tolerated, at least for more than a few days, but patients 
 can and will take it if hydrocarbons, especially in the form 
 of a few hundred grammes of Avhite bread, be added, and if, 
 instead of pure milk, we give them milk-gruel made with 
 flour, oatmeal, &c. A "milk diet" of this kind can easily 
 be continued for many weeks with very good results, as 
 ' " Physiol, des Stoffwechsels," &c., in Hermann's ' Hdb.,' vi, i, i88i.
 
 HYGIENIC TREATMENT OP ALBUMINURIA. 149 
 
 it appears to me, corresponding as it does to tlie recommenda- 
 tions I have made with regard to the diet for cases of 
 albuminuria. 
 
 I append a few remarks with regard to the employmenl; 
 of mineral toaters, though these belong as much to the 
 medicinal as to hygienic treatment. Some good results are 
 often obtained from the external and internal use of these 
 waters, but we are not always able to explain the manner 
 in which the effects are produced. Experience teaches us 
 that for drinking purposes, the saline, or the aJTi aline -saline 
 tvaters produce the most favorable results, and for certain 
 special peculiarities connected with each case, which I cannot 
 now discuss, either a cold or a warm spring may be selected. 
 In accordance with ordinary notions, we should expect that 
 these waters would act injuriously rather than otherwise, 
 inasmuch as saline substances are considered to be renal 
 irritants, and the general rule is sedulously to avoid all 
 irritants when dealing with inflamed organs. It therefore 
 appears to me that the effect must be explained in another 
 manner. It may be that these waters have a beneficial 
 effect upon the digestion, and subsequently upon the blood, 
 either by producing quantitative changes in the composi- 
 tion of the latter, or by altering its quality, especially in 
 regai'd to its albuminous constituents. On these latter 
 points we have, however, no certain knowledge. In 
 England the opinion has for a long time prevailed that a 
 faulty assimilation and condition of the albumen are the cause 
 of albuminuria, and that the latter is to be treated by 
 improving the digestion and assimilation. But as this idea 
 is based rather upon speculation than upon positive 
 proofs, it has, generally speaking, gained no acceptance 
 among us. We must not, however, in my opinion thus 
 absolutely refuse to entertain the idea of a faulty condition 
 of the blood as a cause of albuminuria, and from this point 
 of view the internal use of certain waters is the more intel- 
 ligible. With regard to treatment by a course of haths, 
 the effect of these in promoting tissue-changes is unquestion- 
 able, and they may possibly so far have a good effect upon 
 the albuminuria, but their purely local action upon the skin 
 is a matter of still greater importance.
 
 150 HYGIENIC TREATMENT OF ALBUMINURIA. 
 
 And tliis brings me to tlie second portion of tjie liygienic 
 treatment, viz. to the attention to the functions of the slcin. 
 In the treatment of renal affections this point has always 
 been regarded as more important even than the diet, doubtless 
 from a consideration of the fact that these disorders may result 
 from taking cold and from other injurious influences acting 
 upon the skin, e.g. burns and certain irritating applications 
 which produce inflammation. Moreover, the fact that, in 
 some respects, the skin and kidneys act vicariously for each 
 •other, has led to the practice of exciting the activity of the 
 cutaneous functions in treating renal disorders, with the 
 object, as we say, of relieving the kidneys. We can only 
 suppose that with increased activity of the skin, the kidneys 
 have to excrete less water and a smaller quantity of solid 
 constituents, since their blood-supply is reduced. I will not 
 attempt to decide whether these causes alone are sufficient 
 to produce such results. The fact is that, when a consider- 
 able quantity of water passes off through the skin, and the 
 urine in consequence is very much diminished in quantity, 
 the albumen is absolutely reduced, but perhaps relatively 
 increased. It may be that a portion of the albumen passes 
 off through the skin, for this substance is found in the cuta- 
 neous perspiration (Leube) though in very minute quantity ; 
 or perhaps some proportion of the albumen, which otherwise 
 would have escaped with the urine, remains in the system. 
 
 It is, therefore, advisable that the skin should be con- 
 stantly kept in a more or less active state of perspiration, 
 and thus we find a reason for the good effects of a course of 
 bathing, not that any good results while the bath is being 
 taken, for much less water is then being excreted by the skin, 
 but because repeated warm baths, even when the water is 
 pure, increase the turgescence of the cutaneous vessels. But 
 a prolonged use of saline baths causes this turgescence to be 
 still more protracted, because the tissue of the skin becomes 
 impregnated with the saline constituents, and these, which 
 are only gradually removed and remain for some time after 
 the course of bathing is ended, have an irritating action 
 upon the skin and keep up a certain amount of congestion. 
 
 It follows from what has been said, that the patients ought 
 to take the greatest care to avoid chills, and that they should
 
 HTÜIENIC TREATMENT OF ALBUMINURIA. 151 
 
 wear woollen under-clotliing. Our object is best attained by 
 keeping the patients in bed for as long a period as is possible, 
 for weeks, and if necessary for months ; the adoption of this 
 plan keeps the skin under the most favourable conditions for 
 promoting its function. It involves also another point, which 
 is an important one as regards treatment, viz. it i^revenis as 
 far as 2^ossihle muscular onovement. 
 
 Observations have repeatedly proved, as I stated in vaj essay 
 of last yeai', that active muscular exertion increases the albu- 
 minuria. The obvious cause of this increase I then explained, 
 and I need not now recur to it. The patients must, therefore, 
 be prevented from taking excessive exercise, and even when 
 we wish to give them the benefit of fresh air, which is highly 
 desirable owing to the ansemia characteristic of renal affec- 
 tions, all active exercise must as far as possible be avoided, 
 and the patients must not walk or run or ascend heights, 
 &c., but confine themselves to driving about, under proper 
 precautions against chills. But otherwise it will be best to 
 confine the patients to their beds, where so many favorable 
 conditions exist in combination. 
 
 In addition to the three above-mentioned points with 
 regard to the diet, the cutaneous function and muscular repose, 
 there are a few other conditions which influence the course 
 of albuminuria, and which are, therefore, deserving of consid- 
 ei'ation ; among these are i^sychical influences. It is probable 
 that some of you have noticed that sudden affections of the 
 mind, such as anger, fear, &c., increase the albumen in the 
 urine. Several very striking instances of this kind have 
 come under my own observation. The rule must, therefore, 
 be adopted of guarding the patients as much as possible from 
 .such influences, and the best way to do this is to enforce a 
 prolonged withdrawal from business and other avocations. 
 
 In the last place I have observed that the albumen is 
 regularly increased in female patients during menstruation. 
 I need scarcely say that this observation refers to perfectly 
 pure urine, and not to such as contains any admixture of 
 menstrual blood. It may be that the pelvic congestion which 
 occurs in menstruation, causes an increase in any inflamma- 
 tory processes which exist in the kidneys, and thus augments 
 the albumen ; or perhaps the various systemic processes.
 
 152 HYGIENIC TREATMENT OF ALBUMINURIA. 
 
 the changes in the metamorphoses of the tissues, which cer- 
 tainly take place in menstruation, affect the symptom in 
 question. It is a well-established rule that the patients, at 
 these periods, must be even more carefully and strictly 
 watched than at other times, and kept absolutely to their 
 beds, in cases in which some relaxation of this rule has been 
 allowed for a greater or less portion of the day. 
 
 In taking as far as possible a full and complete survey of 
 all the points which seem to be of importance in the treatment 
 of albuminuria, you will easily have gathered from what I 
 have said that a suitable climate is preeminently indicated. 
 For this includes a combination of all possible and desirable 
 conditions for producing a favorable effect. The improvement 
 or cure which may result from baths and changes of climate is 
 due, not to any single factor, not merely to the water and the 
 air, but to a variety of other conditions which have been 
 already indicated. 
 
 Southern and dry localities, such as Gries and Meran, are 
 to be recommended for our purpose, and better than these 
 are vainous spots on the Riviera, especially Bordighera, 
 Cannes, &c., but the best of all is Cairo and Egypt generally, 
 which, however, owing to political circumstances, is not very 
 inviting just at present. A lengthened sojourn in such 
 places is decidedly advantageous in consequence of the effects 
 produced upon the cutaneous functions and the removal of 
 the patient from all unfavorable mental impressions. Active 
 exercise also becomes unnecessary, and, lastly, the diet, which 
 in southern latitudes contains more vegetables and less animal 
 and albuminous substances, fulfils the indications above 
 detailed. 
 
 In the case of poor patients, admission into a hospital, 
 though not to be compared with a suitable climate, has in 
 some respects a similar effect, as I mentioned in my introduc- 
 tion, and it is for these patients a kind of substitute for 
 change of climate. In the wards of a hospital they are at 
 any rate quieter and more sheltered than they could other- 
 wise be, and the greater part of the day or even the whole 
 day can be spent in bed. 
 
 I cannot conclude this address without uttering an impres- 
 sive warning against too sanguine expectations with regard
 
 HYGIENIC TREATMENT OF ALBUMINURIA. 153- 
 
 to the results of the above methods in dealing with chronic 
 albuminuria. Astonishing and brilliant cures are just as 
 little to be obtained by these as by any other plans. With 
 a certain amount of perseverance we can sometimes succeed 
 in considerably reducing the amount of albumen, and even 
 in causing the symptom to disappear for a longer or shorter 
 interval — a change which some may proclaim as a cure. We 
 must for the present be content with these modest results in 
 a domain which presents so many difficulties to therapeutics. 
 
 Note. — The proof-sheets of this translation of Dr. Senator's 
 essays have been re\'ised by the author, Avhose kindness and 
 courtesy the translator desires gratefully to acknowledge.
 
 INDEX. 
 
 TAOE 
 
 Albumen, forms in which excreted 3 
 
 15, 138 
 
 24, 140 
 
 19,44 
 
 . 20 
 
 . 141 
 
 — • iu normal urine 
 
 — in transudations . 
 
 — in urine after digestiou 
 — of animals 
 
 — losses of, in albuiiiinuria 
 
 — modifications of, in urine 
 
 — morbid conditions of, as a 
 
 cause of albuminuria 
 
 — urinary, source of . 
 tests for . 
 
 Albuminuria, after division of the 
 renal nerves 
 
 — after ingestion of egg-alburaen 100 
 
 — after ligature of the renal 
 
 artery 
 
 of the renal vein 
 
 of the ureter . 
 
 — alcoholic beverages and 
 
 — as a result of increased tem 
 
 perature ... 
 
 — as a result of muscular exer- 
 
 cise .... 51, 151 
 
 — as a result of the condition of 
 
 the blood ... 
 
 — as depending on altered blood 
 
 pressure . 
 
 — diet most suitable for . 
 
 — drugs used in treatment of 
 
 — factors of . 
 
 — from degeneration of the 
 
 renal eijithelium 
 
 — hygienic treatment of 
 
 — in amyloid degeneration of 
 
 the kidneys 
 
 — in animals as an effect of 
 
 heat .... 
 
 — in fevers 
 
 — iu petroleum poisoning . 
 
 — iu phosphorus poisoning 
 
 — iu progressive anaemia . 
 
 — in renal diseases jiroper 
 
 — in venous congestion of the 
 
 kidneys . . . .56 
 
 — meaning of the term . . 5 
 
 46 
 
 61 
 
 57 
 
 63 
 
 147 
 
 47 
 
 94 
 
 39 
 145 
 144 
 
 1 
 
 78 
 141 
 
 121 
 
 36,48 
 89, 109 
 . 89 
 36,80 
 . 86 
 . 112 
 
 PAGE 
 
 Albuminuria, meat as diet for, its 
 
 drawbacks . . . 146- 
 
 — milk diet for ... 148 
 
 — mixed . . ... 12 
 
 — normal . . . . .15 
 
 — true and false ... 5 
 
 — without lesion of kidneys . 96 
 Alcoholic beverages and albumin- 
 uria 147 
 
 Alterations in the blood pressure 
 as a cause of albuminuria . 39 
 
 Amyloid degeneration of the kid- 
 neys, albuminuria in . . 121 
 
 Auffimia, progressive pernicious, 
 albuminuria in ... 86 
 
 Aorta, effects of ligature of . 44 
 
 Arteries, increase of blood-pres- 
 sure in, and albuminuria . . 41 
 
 Baths, in the treatment of albu- 
 minuria ..... 149 
 
 Blood, condition of, as a cause of 
 albuminuria . . . .94 
 
 Blood-pressure, alterations of, in 
 
 kidneys and albuminuria . 39 
 
 — diminished, results of . .65 
 
 — methods of increasing . . 42 
 
 Cardiac hypertrophy in renal dis- 
 ease ..... 114 
 
 Changes, qualitative, in blood as a 
 cause of albuminuria . . 100 
 
 Chloride of sodium as a test for 
 albumen . . . . .14 
 
 Cholera, albuminuria in . 100, 111 
 
 Climates, suitable, for cases of 
 albuminuria .... 152 
 
 Coagulative necrosis of the renal 
 epithelium and albuminuria . 89 
 
 Congestion of kidneys, various 
 forms of . . . . .65 
 
 Convulsions, albuminuria in . 51 
 
 Cutaneous oedema iu certain renal 
 diseases, cause of . . .117
 
 156 
 
 INDEX. 
 
 PAGE 
 Digestion, albuminuria of 19, 44, 98 
 Diminished blood-pressure and 
 albuminuria . . . .31 
 
 Egg-albumen, results of ingestion 
 
 of . . . .100, 142, 145 
 Epithelium, renal, degeneration 
 of, as a cause of albumin- 
 uria . . . . .78 
 
 degeneration of, in phos- 
 
 phorus poisoning . . 80 
 — of glomeruli, function of 78, 130 
 
 Eebrile albuminuria , . 89, 109 
 Ferrocyanide of potassium and 
 
 acetic acid as tests for albumen 14 
 Filtration in the kidneys . 25, 51 
 
 Glandular secretion in the kidneys 32 
 Globulin in the urine ... 6 
 Grape sugar in normal urine . 21 
 
 Hasmatogenous albuminuria . 97 
 
 Hemi-albumose (propeptone) . 10 
 
 Increase of temperature as causing 
 albuminuria . . . 3(1, 40 
 
 Lymph, formation and flow of, as 
 compared with urino . 29, 137 
 
 Malpighian tufts, epithelium of 
 the, in relation to albuminuria . 24 
 
 Meat diet, drawbacks of, in albu- 
 minuria ..... 146 
 
 Menstruation as influencing albu- 
 minuria ..... 151 
 
 Metaphosphoric acid as a test for 
 albumen and peptone . . 14 
 
 Milk diet in cases of albuminuria 148 
 
 Mineral waters in the treatment of 
 albuminuria .... 149 
 
 Muscular action as producing 
 albuminuria . . . 51, 151 
 
 Nephritis, chronic, types of . . 114 
 Nitric acid, as a test for albumen 14 
 
 Phosphorus-poisoning and albu- 
 minuria . 
 
 Oxalic acid in normal urine 
 
 . 21 
 
 Peptone and peptonuria . 8, 102 
 Petroleum-poisoning aud albumin- 
 uria 89 
 
 Pro-peptone, tests for . 
 Pro-peptonuria 
 
 — cases of 
 Psychical affections, as influe 
 albuminuria 
 
 80 
 
 12,13 
 9,102 
 10, 11 
 
 icing 
 
 . 151 
 
 Rabbits, experiments on, with 
 
 phosphorus . . . .82 
 Renal artery, effects of compres- 
 sing and tying . . .61 
 
 — cirrhosis .... 115 
 
 — diseases proper, albuminuria 
 
 in 112 
 
 — nerves, effects of division of . 46 
 
 — vein, effects of tying . . 57 
 Rest, bodily and mental, in the 
 
 treatment of albuminuria . . 151 
 Retardation of the blood-current, 
 as a cause of albuminuria . . 26 
 
 Serum-albumin in the urine . 6 
 Skin, attention to functions of 
 the, in the treatment of albu- 
 minuria 150 
 
 Sweat and tears, secretion of, com- 
 pared with that of urine . .129 
 
 Temperature, increased, effects 
 
 of . . . . . 36, 46 
 Theories of urinary secretion 27, 127 
 
 Urea, increase of, in blood, in 
 fevers, phosphorus - poisoning, 
 
 &c 99 
 
 Ureter, effects of tying . 63, 67 
 
 Urinary secretion, theories of 27, 127 
 Urine, a product of filtration aud 
 
 of secretion . . 33, 128 
 
 — condition of, in venous con- 
 
 gestion of the kidney . 71 
 
 Venous congestion of the kidneys 
 
 and albuminuria . 56, 68 
 
 — eff"ect of, on glomeruli and 
 
 secretory apparatus . , 70 
 
 — resulting from ligature of 
 
 vein (57), of artery (61), of 
 ureter . . . .63 
 
 Waters, mineral, and baths for 
 albuminuria .... 149
 
 SOME CONSIDERATIONS OX THE NATURE AND 
 PATHOLOGY 
 
 TYPHUS AND TYPHOID FEVER, 
 
 APPLIED TO 
 
 THE SOLUTION OP THE QUESTION OF THE IDENTITY OR 
 NON-IDENTITY OF THE TWO DISEASES. 
 
 BY 
 
 THE LATE 
 
 ALEXANDER P. STEWART, M.D. 
 
 {Bead before the Parisian Medical Society on the 16th and 23rd 
 April, 1840.) 
 
 EDITED BY 
 
 W. CAYLEY, M.D., 
 
 PHYSICIAN AND LIXTUEER ON MEDICINE TO THE MIDDLESEX HJSrlTAL; 
 PHYSICIAN TO THE LONDON I'EVEE HOSPITAL.
 
 ON THE NATURE AND PATHOLOGY 
 
 TYPHUS AND TYPHOID PEVEE.^ 
 
 It is my object, in the following- pages, to attempt, by a 
 reference to facts, the elucidation of a question, wliicli is 
 confessedly surrounded with difficulties, and has called into 
 the field of controversy some of the most gifted men of the 
 present day, — some of them espousing one opinion, some 
 another, while others still suspend their judgment, till the 
 production of new facts and reasonings shall have dissipated, 
 in part at least, the dai-kness in which the subject is 
 involved. It is, indeed, not a little remarkable that, in a 
 country like Great Britain, where typhus sacrifices yearly its 
 thousands of victims, — where it is all but universally ad- 
 mitted that the local lesion of the intestinal follicles is not a 
 characteristic sign of the disease, — and where, on that very 
 ground, the doctrines of Broussais have never been able to 
 establish themselves, there should still bo wanting any 
 standard work upon the nature, symptoms, and uecroscopic 
 appearances of typhus, such as those of Chomel, Louis, and 
 others, who, on this side the Channel, have achieved the 
 triumph of pathological science in a class of diseases of which 
 the anatomical lesions were so long unknown. Hence the un- 
 certainty that prevails in France in regard to the question I 
 
 ' This paper is reprinted from a copy in the library of tlie Royal Melical 
 and Chirargieal Society, which contains many marginal corrections iu the 
 handwriting of the author.
 
 160 ON THE NATURE AND PATHOLOGY OF 
 
 liave clioseii for consideration — a question which, beyond a 
 doubt, has been for a dozen years, and is st'ill, exciting an 
 interest here, to which British medical men are compara- 
 tively strangers. Hence the tours of inspection undertaken 
 from time to time by distinguished continental physicians, with 
 a view either to weaken the conclusions that may be drawn 
 from facts already published, or to dispel a scepticism which 
 these facts, so limited in number, have not been able to 
 overcome. Hence also the objections naturally enough 
 raised to the information collected by them, on the ground 
 of defective opportunities, hurried observation, and imper- 
 fect knowledge. Hence, in short, such reflections on the 
 doubtful character of the information received from English 
 authors, as are made by Chomel in his ' Lectures on Typhoid 
 Fever,' those of MM. Gauthier de Claubry and Montault, in 
 their prize essays on the ' Analogies and Differences between 
 Typhus and Typhoid Fevers,' and the following words of 
 Valleix,^ in apology for citing American instead of English 
 authors, in reference to fevers prevalent in Great Britain. 
 " We admit that it would have been better to have presented 
 a series of observations on typhus made in England itself; 
 but where can we find them ?" 
 
 These observations will derive great additional weight 
 from a brief consideration of the work of Dr. Tweedie, 
 entitled ' Clinical Illustrations of Fever,' which is referred to 
 by most of the French writers on the subject, and whence a 
 great part of their ideas on English typhus is drawn. I 
 confess I have been puzzled, in perusing the above-named 
 treatise, to find out what definite meaning the distinguished 
 author attaches to the word " fever ;" whether he under- 
 stands by it a symptom produced by a local affection, or a 
 distinct disease arising from a specific cause. His valuable 
 remarks upon contagion, and his strictures upon the doc- 
 trines of Broussais, would lead to the latter, while the cases 
 detailed give countenance to the former supposition. I 
 cannot better or more shortly give an idea of the cause of 
 my difficulty, than by giving an analysis of the cases 
 referred to. 
 
 Of 73 patients who died, 54 were inspected. Of the latter 
 * ' Arch, de Mcdccine,' 3rd scries, vol. iv, p. 216.
 
 TYPHUS AND TYPHOID FEVER. IGl 
 
 Dumber, lo secm referable to typhus, and 17 to typboiS 
 fever. Of the remaining- 27, I find that 4 died of well- 
 niai'ked and extensive meningitis, i of pbreuitis, 2 of erysi- 
 pebxs of the bead and neck, 5 of phthisis, 4 of pleuro-pneu- 
 monia, 3 of pneumonia, 2 of pleuro-pericarditis, i of pleuritis, 
 I of pulmonary apoplexy, i of abscess of lung, 4 of 
 peritonitis. Two of the above cases were sequela3 of scarla^ 
 tiua and smallpox. Of those cases which were not 
 inspected, there are, as far as can be gathered from the brief 
 account of symptoms, 5 of typhus, 3 of typhoid fever, 3 of 
 meningitis, 2 of pneumonia, and i of phthisis. Of several, 
 it is stated that they were evidently cases of purely head, 
 chest, or abdominal affections, and in one, which was proved 
 by dissection to depend on intussusception and gangrene of 
 a considerable portion of gut, it is remarked, that " the 
 symptoms were referable to some obstruction in the intes- 
 tines, rather than to any form of fever." In the above 
 summary, I have been careful to exclude those that were 
 evidently, or appeared to be sequeLv. of continued fevers, 
 and to include those only in which the feverish symptoms 
 clearly depended, throughout their course, on local affec- 
 tions. Deducting, howevei', those I have alluded to, and 
 Avhich form ratlier more than the half of the cases detailed, 
 there still remain 35, more or less clearly marked out as 
 belonging to two kinds of specific fevers, the one differing 
 from the other in the extrnordinarj- gravity of its sym- 
 ptoms, the rapidity of its course, and the absence of local 
 lesions. 
 
 This leads me to remark, in concluding these pi-eliminary 
 observations, that when I began, in 1836, the practical study 
 of fever, I was much struck with the simultaneous occur- 
 rence, in tbe wards of the Glasgow Fever Hosjjital, of two 
 sets of cases, in which the symptoms (however little most of 
 them might seem to differ, when viewed individually) pre- 
 sented, when taken collectively, characters so mai-ked as to 
 defy misconception, and to enable the observer to form, with 
 the utmost precision, the diagnosis of the nature of the 
 disease, and the lesions to be revealed by dissection. More 
 particularly, it was remarkable to observe that while, in the 
 one disease, the affection^ in those who presented no erup- 
 
 11
 
 162 ON THE NATURE AND PATHOLOGY OP 
 
 tiorij was so slight and of so short duration, as to make it 
 very questionable whether it deserved the ualiie of typhus, 
 and while the fatal cases presented an abundant and gene- 
 rally a profuse eruption ; those labouring under the other, 
 which equally, and even in a much higher proportion, went 
 on to a fatal termination, rarely presented any, and then 
 only a very scanty eruption. It was further remarkable, 
 that while in the one several successive patients had either 
 been restored to health, or fallen victims to the severity of 
 the affection, the disease, under whicli those laboured, who 
 lay side by side with them, though characterised by much 
 less urgent symptoms, pursued its gradual course through 
 weeks and months consecutively, and in the majority of 
 cases to a fatal issue. And finally, it was more remarkable 
 still, that, to complete the contrast already so striking, dis- 
 section proved the existence, in the one diseg,se, of most 
 extensive local lesions, in the other, the absence of all pro- 
 minent local lesion whatsoever. 
 
 Another circumstance, I must not forget to mention, viz. 
 that though, during the sumn^er and autumn of 1836, the 
 cases of typhoid fever were numerous ; from the month of 
 November in that year (at which time both the type and 
 the amount of typhus became much more formidable), till 
 June, 1838, the period that my connection with the hospital 
 ceased, not more than a dozen cases — if there were even so 
 many, and these at long intervals, were admitted for treat- 
 ment. In speaking of the two varieties of fever as totally 
 different diseases, before going into the proof of the asser- 
 tion which is the point in dispute, I have merely employed 
 a phraseology in common use, of which even those who 
 maintain the complete identity of the affections have not 
 been able to rid themselves, and whereon, if I were disposed 
 to insist upon words, I might found a strong argument in 
 support of my position ; and have expressed a conviction 
 forced upon me by the consideration of facts and reasonings, 
 whicli I now proceed to unfold. 
 
 It is far from my intention, in this paper, to take up in 
 all its bearings the vast subject of the " analogies and 
 differences between typhus and typhoid fever." That task 
 I hope to be able, along with my friend and fellow-worker.
 
 TYPHUS AND TYPHOID FEVEE. 163 
 
 Dr. Anderson, to undertake hereafter. My present object 
 is to develop, as shortly and as clearly as I can, some of 
 their leading- features of difference, in support of the position 
 I have taken up. I jDi'opose, then, to consider: — i. The 
 probable origin of the two affections. 2. Their proximate 
 causes. 3. Their course. 4. Some of their symptoms. 5. 
 Some of their anatomical lesions. 6, Their treatment. 
 
 I. Without entering- upon the abstruse question of infec- 
 tious germs, or discussing theoretically the probability of 
 the opinion that ascribes the origin of continued fever to 
 animal, as intermittents are known to proceed from vegetable 
 miasmata, I proceed at once to examine the question in a 
 practical point of view. Dr. Copland, in his able article 
 upon infection, places exanthematic typhus under the third 
 class, viz. that of " specific infections,^' characterised as 
 '^immediately or mediately disseminating and perpetuating 
 their kinds," &c., and directly refers that form of typhus to 
 " emanations from the secretions, exci-etious, and surfaces of 
 persons already affected." Under the second class, viz. of 
 " conditionally ^perpetuating or contaminating- infections," he 
 places "animal effluvia," or more particularly, "emanations 
 from living- bodies in close and unventilated situations." 
 Among the " diseases resulting therefrom," stand " adynamic, 
 putro-adynamic, and malignant fevers. '' Now, in this 
 classification, it is plain that while we are informed of the 
 origin of the latter, we are only told the mode of propaga- 
 tion of the former. Exanthematic typhus is said to be the 
 result of " emanations from persons already affected ;" but 
 whence the original disease ? In reference to this question, 
 I observe, that Dr. Eoupell^ had given the weight of his 
 name to the opinion that exanthematic typhus does not 
 originate from vitiated air, extreme filth, closeness, &c. I 
 cannot but express my surprise at this opinion, as the amount 
 of .evidence against it seems quite overwhelming. 
 
 On no two points (and so far I must anticipate my 
 remarks on the eruption in typhus) are the distinguished 
 authors who describe the frightful epidemics of army typhus 
 during the last six centuries more completely agreed, than 
 
 ^ ' Roupell's Treatise, &c.,' p. 64, quoted at p. 107, "vol. xxxi of ' Med.- 
 Cliiruro-, Eeview.'
 
 164 ON THE NATURE AND TATHOLOGY OF 
 
 on the influence of impure air in tlie production of tho 
 disease, and tlie very frequent presence of "the rubeoloid 
 exanthema in those affected with it. Dr. Tweedie, in his 
 interestiug observations on the ' Influence of Impure Air on 
 the Generation of Typhus/ refers to the opinion of Sir John 
 Pringle, who states, "^that he has observed the hospitals of 
 an army, not only when crowded with sick, but at any time 
 when the air is confined, and especially in hot weather, pro- 
 duce fever of a peculiar kind, which is often mortal ; and he 
 remarked, that the same thing arose in full and crowded 
 barracks, and in transport ships, when filled beyond a due 
 number, and detained long by contrary winds, or when the 
 men had been long kept at sea under close hatches in stormy 
 weather." He also refers to the experience of Mr. Pearson, 
 who, he says, ''told me, that when he was surgeon of the 
 Lock Hospital, he uniformly observed, when more than a 
 certain number of patients were placed in any of the wards, 
 fever became prevalent in the establishment ; and that, from 
 repeated observation of this fact, he was induced to restrict 
 the number of beds in each ward, and never afterwards wit- 
 nessed the recurrence of fever in the house. ^' It appears to 
 me that the instance cited by Dr. Roupell (at p. 54 of his 
 work) of fever coming on, in the Refuge, open in 1830-31, 
 on the north side of the Thames, at a time when the wards 
 were crowded to excess, might alone suflSce to cast strong 
 doubts on the correctness of his opinion. 
 
 If we consult the details given from p. 7 to p. 42 of Gau- 
 thier de Claubry^s elaborate treatise, of various epidemics of 
 typhus, described by such men as Pringle, Roux, Hufeland, 
 Ducastaing, Reveille Parise, Tresat, Tort, Gilles de la Tourette,- 
 Laurent, Ardy, Magnin, &c., and his summary from p. 100 
 to p. 114, we find the unanimous voice referring the gene- 
 ration of the disease to vitiated air, arising from the crowded 
 state of the hospitals, the carnage among troops and inhabi- 
 tants, and the want of burial ; the scarcity of provisions, 
 depressing passions, exposure to cold and fatigue are like- 
 wise more or less frequently mentioned ; but we are entitled 
 to regard these as merely accessary ; for we have already 
 seen the development of typhus where these conditions were 
 wanting. Montault, from an extensive induction of facts,.
 
 TYPHUS AND TYPHOID FEVER. 165 
 
 likewise comes to the same conclusions ; Copland/ ex- 
 pressly points out the influence of the circumstance in 
 question^ in producing " \äg\\\j infectious and typhoid forms 
 of fever/' 
 
 How, indeed, is it possible, except on this supposition, to 
 explain the appearance of typhus in a country, and in the 
 midst of armies, perfectly healthy, till the development of the 
 conditions in question, but which, under their influence, 
 were desolated by a pestilence, whose ravages, more fright- 
 ful than those of war, consigned many, whom the sword had 
 spared, to " an ever-yawning- and never-satisfied grave ?" 
 We cannot, in order to account for this, admit the idea, that, 
 by some strange and inexplicable principle of election, 
 infectious miasmata direct their course from distant shores 
 to the seat of war, especially when we see in their invariable 
 antecedence and sequence, the relation of cause and effect so 
 clearly made out between the conditions referred to, and the 
 appearance of the disease. What reasonable cause can be 
 assigned for the murderous epidemic that arose, in the spring 
 of 1810, on board the Plymouth prison-ships, and cannot be 
 referred to contagion or infection, as the disease first 
 declared itself among the prisoners confined in what have 
 been well termed '' these floating tombs,'' if not the very 
 natural one of the long-continued confinement of hundreds of 
 persons, in a situation uniting all the conditions most adverse 
 to health ? These considerations ai-e borne out by the un- 
 disputed fact, that the type of fever becomes much more 
 malignant in hospitals crowded to excess, and by Gauthier 
 de Claubry's curious statements at p. 148 of his work, where, 
 speaking of the treatment of typhus, he mentions that, 
 during " the wars of the empire," patients previously 
 despaired of, notwithstanding the assiduous use of thera- 
 peutic agents, were quickly restored to health, on the eva- 
 cuation of the hospitals, with fresh aii", barley-water, and 
 lemonade. How completely does this agree with the 
 experience of Pringle, as quoted above. Let me further 
 refer to a paper by Dr. Peebles, in the forty-fourth volume 
 (No. 125) of the ' Edin. Med. and Surg. Journal,' as detail- 
 ing the results of his own experience in Italy, and giving a 
 ' Art. " I'jfectiun," p. 352.
 
 166 ON THE NATURE AND PATHOLOGY OF 
 
 remarkably clear, succiuct, and cümprelicnsive digest of the 
 mass of evidence bearing on this interesting subject. Dr. 
 Alison's statements in bis recent pamphlet on the Scottish 
 Poor Laws fully confirm the general opinion. I have only 
 to add, in again partly anticipating details, to which I shall 
 presently advert, that 22 of 30 patients who positively 
 declared to me that they had not in any way been exposed 
 to infection, replied as follows to my inquiries respecting the 
 number who lived together. In throe oases there were 4 ; 
 in seven 5 ; in two 6 ; in three 7 ; in two 8 ; in one g ; in 
 one 10; in one 12 ; in one 13. Many of those, who traced 
 their affection clearly to contagion, stated the number o£ 
 those who lived together as 12 and 13, and in one or two 
 instances, as "16 at least." This, be it recollected, in one, 
 or at most two small rooms, in the most miserable, darkest, 
 and worst aired purlieus of a large manufacturing city. 
 After the facts I have adduced, I think wo may safely con- 
 clude, that " animal effluvia,'^ to use the term of Dr. 
 Copland, or " emanations from living bodies in close and 
 unventilated situations,'' possess the pi'operty of generating 
 the specific poison, whatever be its nature, that gives rise to 
 exanthematic typhus. 
 
 With regard to the producing cause of typhoid fever, all 
 is vague and uncertain. Chomel, after his analysis of the 
 causes assigned by patients, remarks (p. 306), " Thus, 
 scarcely, out of a number of patients so considerable (i i-^), 
 is there one in four who attributes his state to some slightly 
 energetic cause." But what chielly concerns us to know is, 
 whether the conditions we have seen to be so powerful in 
 the production of typhus are the same, or anything like the 
 same, in regard to typhoid fever. Exactly on this i)oint, 
 Louis remarks,^ " No more can the dwelling in places, low, 
 and inhabited during night by too great a number of indi- 
 viduals, figure among the causes in question, one eighteenth 
 only of the patients being in that condition ;" and he con- 
 cludes, from a comparison of all the commonly assigned 
 causes with the facts ascertained by himself, in these remark- 
 able words : " The deepest darkness then prevails regarding 
 the causes of the affection under consideration." Chomel 
 
 1 Vol. ii, p. 457.
 
 TYPHUS AND TYPHOID FEVER. 167 
 
 likewise (p. 300) uses almost the same words in beginning 
 his third article, " The causes of typhoid fever are wrapt in 
 the greatest obscurity/' It were difficult to find a more 
 striking instance of the little effect of the circumstances we 
 have mentioned, in producing typhoid fever, than the 
 epidemic at Bischofsheim, in the department of the Lower 
 Rhine, in August, September, and October, 1832, described 
 by Ruef in the ' Gazette Medicale ' for 1834, and referred to 
 by Gauthier de Claubry, who maintains the identity of that 
 disease and typhus. (P. 133, et seq. of his essay.) The 
 disease first showed itself, without suspicion of being trans- 
 mitted, in the upper, best aired, and, as is expressly said, 
 " the most healthy part of the village,"' which is situated 
 partly on and partly at the foot of a rising ground, and 
 spread successively to the middle and lower quarters. 
 Again, the result of Lombard's researches, conducted at 
 Geneva throughout several successive years, is, that the 
 cases of typhoid fever are numerous during the autumn, and 
 comparatively few during the winter months ; whereas the 
 ravages of typhus, as everyone knows, are most formidable 
 during" winter. 
 
 IL I come now to consider the proximate causes of the 
 two diseases. To avoid all ambiguity in the use of the terms, 
 infection and " contagion, which have caused, perhaps, a 
 greater war of words than any two terms in any science, I 
 shall merely state that, with Dr. Copland, I take infection 
 in its classical sense, and understand by it the imparting of 
 any taint, pollution, or contamination whatsoever, to a 
 person previously in health. By contagion, I understand a 
 mode of infection, viz. infection by contact. As applied to 
 the subject of fevers, it will at once be seen that infection 
 has not merely a reference to disease, but to miasmata, or 
 specific poisons, independent of disease, to the contaminating 
 agent, as well as the individual contaminated, and communi- 
 cating disease. In this point of view, the question is set at 
 rest by the remarks offered under the first head. Hence, we 
 consider typhus as a truly and eminently infectious disease. 
 The same, we have seen, cannot be said of typhoid fever. 
 The question, then, we have now to consider, nai*rows itself 
 into one of transmission or propagation fi'om a diseased to a
 
 168 ox THE NATUinO AND TATHOLOGi: OF 
 
 Wealthy person. The difTereiice, in this point of view, 
 between infection and contagion is one of degi*ee, and not of 
 kind ; and there are cases of morbid impression, which it 
 would be very difficult, if not impossible, to refer either to 
 the one or to the other, so imperceptibly do they glide into 
 each other. It is natural, however, to conclude that, as the 
 genus includes the species, so a disease that is first produced 
 by the action of a specific infectious agent on the animal 
 economy, must be directly transmissible from a^ persoa 
 diseased to a person in health. To argue at any length in 
 favour of the transmission of typhus, whether through the 
 medium of the atmosphere, or Ijy the direct inhalation of the 
 morbific matter from a persom labouring under its effects, 
 would be a waste of time. It is admitted all but univer- 
 sally. The fearful rapidity with which it extends its 
 ravages ; the great number of cases in Avhich patients refer 
 their complaint to living with, or attending" others affected 
 with it j the all but universal occurrence of the disease in 
 nurses and resident medical attendants, put beyond a doubt 
 the communication of the disease. Lassis, shortly after pub- 
 lishing his ingenious work, ' Eecherches sur les Veritables 
 Causes de Typhus, ou de la Non-contagion des Maladies 
 Typhoides,' fell a victim to the contagion, the existence of 
 which he denied. Need I further refer for the proof of this 
 position to the names of Sydenham, Morton, Pringle, Hux- 
 ham, Hildenbrand, Chomel, Twecdie, Houpell, Gauthier de 
 Glaubry, Montault, Lombard, indeed to almost all the 
 •writers on the subject ? The facts stated by Tweedie, from 
 p. 85 to p. 99 of his treatise, by Gauthier de Claubry (p. 
 100 to 114), and by Dr. West in his able paper on " Exan- 
 thematic Typhus,'' in the fiftieth volume of the ' Edinburgh 
 Medical and Surgical Journal/ are conclusive as to the com- 
 munication of typhus to medical attendants, nurses, and 
 patients labouring under other complaints, and they arc com- 
 pletely borne out by my own experience. It is well known, 
 that, for many years past, every resident clerk in the Glas- 
 gow Infirmary, with very rare exceptions, many students 
 who frequented the fever wards, several of the acting physi- 
 eians, and almost all the nurses, have, at one time or other, 
 been attacked with typhus, and that not a few have fallen
 
 TYPHUS AND TYPHOID FISVEE. 161) 
 
 victims ; and Dr. Cowan, under wliom I liad for a long 
 period the honour of serving, in his pamphlet, entitled 
 * Statistics of Fever and Smallpox in Glasgow,^ says (p. 
 lo) of the district surgeons, " Few of those gentlemen 
 escape an attack of fever/' Dr. West's statements us to the 
 spread of the disease amoug patients admitted for other com- 
 plaints to St. Bartholomew's, but placed in the same wards 
 with others affected with typhus, and the necessity of at 
 length closing the ward, show the groundlessness of the 
 objection that contagion arises merely from concentration. 
 During the winter of 1837-38, an isolated case of typhus in 
 one of the medical wards of Glasgow Infirmary, communi- 
 cated the disease to most of those in the same ward, aud 
 several died. The following ai-e the results I obtained from 
 the statements of 139 patients, whose cases I investigated with 
 particular care in the years 1837-38. Much more extensive 
 researches subsequently made by Dr. Anderson and myself, 
 the details of which, unfortunately, I have not with me, will, 
 I doubt not, bear out this statement. 
 
 Doubtful or 
 
 From in- 
 
 
 r 
 
 1 
 
 Typlius in 
 
 III same 
 
 Coiitii- 
 
 cause unkuow 11. 
 
 lection. 
 
 
 fiinii ly . 
 
 house. 
 
 giou. 
 
 Males .21 
 
 39 
 
 of 
 
 1 
 
 27 
 
 8 
 
 4 
 
 Females . iS 
 
 61 
 
 whom 
 
 42 
 
 12 
 
 7 
 
 39^ 100 I 69 20 II 
 
 I have already spoken of the conditions in Avliich 22 of 
 the patients Avere placed who denied the influence of infec- 
 tion in the production of their complaint. Gauthier de 
 Claubry remarks (p. 113) that it requires ''some degree of 
 medical courage " to uphold the propagation and perpe- 
 tuation of typhus by specific infectious germs, according to 
 Hildenbraud. On the supposition of its identity with typhoid 
 fevei', this may be so ; the difficulty vanishes on supposing 
 them different. 
 
 What is the state of the case in typhoid fever ? It is well 
 known, and stated both by Chomel and Gauthier de Claubry, 
 that the all but universal opinion in France is against its 
 being infectious, Louis does not even mention it ; Andral 
 
 ' Of these 39, there were 30 who positively denied contagion, 6 are not 
 marked, and 3 were doubtful.
 
 170 ON THE NATURE AND PATHOLOGY OF 
 
 (p. 728, English edition) gives his verdict against it ; 
 Montault (pp. 12 and 186) recapitulates the arguments 
 against it. On the other hand, MM. Bretonneau, Gendron, 
 Chomelj Lombard, and Gauthier de Claubry maintain, more 
 or less decidedly, the contagious nature of the disease. It is 
 rather amusing that the last-named author, while arguing 
 for the contagion of typhoid fever, in order to prove its 
 identity with typhus, adduces the contagion of the latter in 
 the English hospitals, in support of his position, while 
 Montault, holding the difference of the two affections, feels 
 constrained, in order to get over an imaginary difficulty, to 
 express a doubt (p. 12) as to the cleanness and salubrity of 
 the British, as compared with the French hospitals, aud to 
 assert that " the English physicians are not perfectly 
 acquainted with the anatomical alteration of typhoid fever ;" 
 while Gauthier de Claubry, in order to get over the real 
 difficulty arising fi'om the absence of anatomical lesions in 
 the Glasgow and Edinburgh typhus, speaks of the '' serious 
 circumstances of misery and exhaustion of strength, which 
 have so deplorably modified the constitution of the inhabi- 
 tants of these wretched countries, Scotland and Ireland.'^ 
 Those who know the admirable cleanness aud ventilation of 
 our fever hospitals, and the acquaintance of our medical men 
 with the lesions referred to, will readily dispense with any 
 serious refutation of such gratuitous suppositious ; aud the 
 too sweeping assertion of Gauthier do Claubry, as we shall 
 afterwards see (though partially borne out by the recent 
 statements of Dr. Alison, regarding the condition of the lower 
 classes in the large cities of Scotland), even wore it 
 admitted in its fullest extent, proves nothiug in his favour. 
 Chomel's third conclusion (p. 339) is, that, if the identity 
 of the anatomical lesions in the two diseases were proved, 
 the question of contagion would be set at rest. We shall 
 see hereafter what is the testimony of facts in regard to the 
 lesions in typhus. Meantime, let us consider the facts in 
 reference to contagion. 
 
 Louis, I have mentioned, docs not allude to the subject. 
 From this we might conclude, that he had found no facts in 
 support of the theory of contagion, for we can scarcely sup- 
 pose that an observer so scrupidously accurate Avould neglect
 
 TYPHUS AND TYPHOID FEVER. 171 
 
 SO important a branch of his subject; but we prefer an 
 appeal to positive facts. Chomel^ we have already seen, 
 states how very few patients ascribed their illness to any 
 energetic cause. Five only out of 115 were placed 'Mn cir- 
 cumstances favorable to contagion/^ 79 could " assign no 
 appreciable cause " (p. 306). In accordance with this I may 
 state that, in no case, though questioned with the greatest 
 care, cither in Scotland or in the hospitals of Paris, have I 
 ever found the disease referred to contagion. On the other 
 hand, it appears from the statements regarding the epi- 
 demics of Nancy by Leuret, of Chateau de Loire by Gendron, 
 of Andlau and Stolzheim by Mistier, of Bischofsheim by 
 Keuf, and those contained in Bretonneau's memoirs (com- 
 mented on by Gauthier do Claubry, from p. 118 to 135), and 
 from the clear statements, borne out by dissections, of 
 Lombard (in his valuable paper upon the Geneva epidemic 
 of 1835, inserted in the 'Gazette Medicale '), seem to prove 
 the possible transmission of typhoid fever, when epidemic. 
 Without hazarding any decided conclusion on a point still so 
 keenly debated, I would simply direct attention to the differ- 
 ences as regards the probable origin and propagation of the 
 two diseases, which the foregoing facts appear to establish ; 
 and also to the interesting question, whether, if typhoid fever 
 really depends on, and is propagated by a specific poison, 
 that poison is, or is not generated in the same circumstances 
 as the infection of typhus ? 
 
 III. There are circumstances connected with the course of 
 the two diseases well worthy of attention. The fact, as un- 
 doubted as it is remarkable, that the mean duration of 
 typhus is about one half that of typhoid fever, is one 
 that perplexes considerably the advocates of their identity. 
 Chomcl argues (p. 337) that it only shows a difference of 
 intensity. Gauthier de Claubry, who very judiciously does 
 not venture to face the statistical details on the subject, and 
 treats of it only under the head of the relative intensity of 
 the two diseases, meets the objections on the same ground 
 as Chomel. I have already remarked the extraordinary 
 diiference of the duration in the Glasgow epidemic of 1836. 
 Hildenbrand states the mean duration of typhus at about 
 twenty-two days, and that of the Glasgow typhus, from the
 
 172 ox THE NATURE AND i'ATHOLOGY OF 
 
 results of mauy tliousanci cases, duriug- successive years, 
 approaclies very nearly to this result, being about twenty- 
 one days. An analysis o£ my own cases gives me a mean 
 duration of 20*82 days, or, deducting tlireo cases, one of 
 wbicli terminated fatally from phthisis on the 42 ud, 
 «,uother not convalescent from consecutive paralysis on the 
 ■6otli, and a third restored to health about the looth day, 
 :after severe attacks of glossitis, pleuro-pncuinonia, and a 
 variety of other complaints, ig*6 days. Valleix, in his third 
 memoir on ' Typhus and Typhoid Fever,'^ states the mean 
 duration of six cases of the former, and seven of the latter 
 {observed in London by Dr. Shattuck, of Boston), as 
 respectively 24^ and 22^ days. To account for this discre- 
 pancy with the unanimous voice of other authors, it is enough 
 to refer to the small number of cases, and to state that the 
 cases of typhus Avere of great severity (five out of six having 
 died), while those of typhoid fever were very mild, and only 
 one in seven terminated fatally. It appears, on the other 
 hand, from Chomel (p. 44), that tliree fourths of the cases 
 cured began to show signs of amendment, only between the 
 15th and 30th, and eigliteen of the whole number only 
 between the 31st and 40th days. Louis again (vol. i, p. 9, 
 13) mentions the duration in cases of death to be from 
 eight to boyouLl forty days ; in serious cases which were 
 cured, from fifteen to beyond fifty; or on an average thirty- 
 two days ; while that of the light cases was twenty-eight or 
 twenty-nine days. Montault (p. 22) states, that of sixty- 
 three cases observed by him, the mean duration was thii'ty- 
 six days. The mean duration of nine cases of all different 
 shades of intensity, very carefully watched by myself, chiefly 
 in the wards of M. Chomel in the Hotel Dieu, is 38*7 days. 
 One of these, admitted on the 13th of last December, has 
 not yet terminated. I take the duration of the fever from 
 his first convalescence (on the 75th day), after which he had 
 a relapse without any mai'ked local affection, and his 
 recovery is very doubtful. M. Chomel in his summary on 
 the 22nd of last March, of all the fever cases (twenty-five in 
 number) that had occurred during the previous six months, 
 stated 
 
 ' ' Arch, do Mcdecuio,' 31110 si'rle, 1. vi, p. I35-I3'^-
 
 T\THUS AND TYPHOID FEVER. 17^ 
 
 The mcnn duration of the very serious cases as -31 cla3's. 
 those of moderate intensity^ as 18 
 the h'ghtest cases, as - - 10 
 
 giving an average for the whole number of ig'6 days. He, 
 however, called particular attention to the fact, that the cases 
 were much less numerous, and the affection greatly milder, 
 and much less fatal than usual, the mortality, commonly i 
 in 3 or 4, being only i in i2'6. 
 
 Being firmly persuaded that the remarkable length of 
 typhoid fever often depends upon conditions not commonly 
 adverted to, I beg the reader's indulgence while I go into 
 some details on the subject. What I wish to establish is, 
 that typhus, when uncomplicated with any secondary affec- 
 tion, terminates in convalescence or death in the course of a 
 single attack; in other words, that a second attack of 
 typhus does not occur in the course of one and the same ill- 
 ness. On the other hand, it shall be my object to prove 
 that such is not the case with typhoid fever. 
 
 With respect to typhus, I allege generally, notwithstanding 
 the high authority of Dr. Copland, who maintains directly 
 the contrary,^ that (apart from secondary complications, 
 which often completely change the course and termination of 
 the disease) however long may be the period of excitement,, 
 — however long the adynamic stage, — however tedious the 
 period of convalescence, I have never, among thousands of 
 cases, seen a single case of relapse, in the proper sense of 
 tlic term, after the symptoms had begun to decline. Is this 
 objected to as vague ? I appeal to the following facts. Of 
 139 cases, examined during the course of the disease with 
 great minuteness, I find that iig presented no secondary 
 complications. Of these 20 died at the height of the fever, 
 the symptoms having presented a constantly increasing inten- 
 sity till the fatal termination. The remaining gg offered, 
 without a single exception, a steady aggravation of all the 
 symptoms till a certain period (more or less distant, 
 according to circumstances, from the beginning of the 
 disease), after which they exhibited as steady a decline. 
 The remaining ig were complicated in varying pi'oportions 
 
 ' ' Dictionary,' p. 1012, ai-t. " Typhus Fever."
 
 174 ON THE NATUL'E AND PATHOLOGY OF 
 
 with plitliisiS;, pneiiniouia, chronic bronchitis^ lieiniplegia, 
 •erysipelas, bedsores, diarrhoea, &c., to one or other of which 
 diseases four fell victims, the secondary affection generally 
 declaring itself after a temporary amendment. 
 
 Let us now inquire into the state of the case in typhoid 
 .fever. I find Montault (p. iS), when treating of con- 
 valescence, remarking, that '^ relapses are easy '^ in that 
 period. Louis,^ speaking of the same period, uses these 
 words : " Yet several of them (the healthy functions) were 
 re-established very slowly in several individuals, and con- 
 valescence was thereby retarded. The heat was more or less 
 great ; the pulse continued more or less quick ; the diarrhoea 
 persisted, though it could not always bo referred to impru- 
 dences in diet.^^ This is all I have been able to find in the 
 various authors I have consulted. I shall now cite several 
 cases in point. 
 
 On the 26tli of February, 1838, a young man, seventeen 
 years of age, was admitted to the wards of the Glasgow Fever 
 Hospital. He had been ten days ill with most of the symptoms 
 of follicular enteritis. On admission he had a few rosy 
 spots on the belly, very red and papillated tongue and 
 fauces, circumscribed flushing of cheeks, disturbed sleep, 
 tickling cough, extensive bronchitis, dull pain, tumefaction, 
 and gurgling in the belly, with moderate diarrhoea. He had 
 expistaxis on the 12th, i8th, 19th, and 23rd days of the 
 disease, and on one occasion to the extent of one or two 
 pounds. The eruption became pretty copious, then declined, 
 and on the 30th day disappeared. At that time the pulse, 
 which had ranged between 104 and 90, fell to 80 and 76; 
 the bronchitis all but disappeared ; the tongue, which had 
 been excessively red, chapped, and aphthous, became smooth 
 and less florid ; the gurgling less ; and the appetite good. 
 On the 20th March (the 32nd day), he had rigors, continued 
 on the 2 ist with rise of pulse to 104, and followed on 
 the 23rd by pretty copious eruption on breast and back, by 
 return of thirst, clamminess of tongue, loss of appetite, sibi- 
 lant wheeze in chest, renewed tenderness of belly, frequent 
 bilious vomiting, continued for five days, and opistaxis for 
 
 ' Vol. ii, p. II.
 
 TYPHUS AND TYPHOID FEVER. 175 
 
 six days running. Tlic symptoms followed tlioir regular 
 course^ and the eruption liad nearly disappeared, when, on 
 the 4th of April (47th day), a fresh, elevated, lenticular 
 eruption appeared on the chest and epigastrium. The only 
 altered indication after the appearance of this eruption was a 
 temporary rise of pulse from 92 to 104. On the iith of 
 April (54th day) he was dismissed by his own desire ; and 
 I heard some time afterwards that he had rapidly convalesced 
 after his removal. 
 
 The phenomena observed in this case scarcely require any 
 comment ; and I therefore proceed to detail others that have 
 fallen under my notice. 
 
 On the 9th of last December, a young woman, set. 22, 
 entered M. ChomeFs female ward, the Salle St. Augustin, 
 with symptoms of typhoid fever of ten days' standing. The 
 affection was mild, the eruption abundant, the intelligence 
 good. Amendment soon took place. The countenance, 
 previously very languid, became more lively, the pulse sunk 
 to 92, and she seemed rapidly convalescing, when, on the 
 24th of December (25th day) — as I learn from the reports 
 furnished me by my friend JM. Gueneau de Mussy, to whose 
 experience and kindness I am much indebted — the pulse rose 
 to 108. There were marked and sudden prostration, pain, 
 and crepitant rale in the right subscapular region ; deafness, 
 which had been considerable, became complete ; stupor and 
 involuntary discharges came on after some days, and death 
 followed on the 28th of December. Inspection disclosed the 
 followed appearances. Incomplete splenisation of lower 
 part of right lung ; diseased aggregate glands at the lower 
 part of the ileum, some ulcerated, some going on towards 
 cicatrization, others not ulcerated, and in the state in which 
 they arc described about the sixth day of the disease. Who 
 can ascribe the supervention of such serious symptoms as 
 those I have sketched to the inflammation of a small portion 
 of the lower lobe of the right lung ? Is it not much more 
 rational to refer them, and to ascribe the morbid appear- 
 ances, as M. Chomel did in his lecture on this case, to a 
 fresh intestinal eruption of a few days' standing ? 
 
 Again, on the 27th of last February, a young man, set. 
 21, entered tbe Salle St. Louis in the Hotel Dieu, on the
 
 176 ON THE NATÜliE AND PATHOLOGY" Oi<^ • 
 
 8tli day of typlioid fever. The eruption appeared next day, 
 became pretty copious, and on tlie 13th of March (the 
 23rd day of the fever) it is reported as all but gone. All 
 the symptoms had diminished greatly in intensity. The 
 pulse had fallen to 76. Convalescence took place. He was 
 eating and relished the half-diet of the hospital, when, on the 
 afternoon of the 31st, the pulse, in the morning go, rose to 
 136. Violent diarrhoea came on. The pain of belly, 
 formerly slight, became considerable, and a pretty copious 
 eruption of well-marked " typhoid spots " appeared. The 
 chest, minutely examined, presented nothing unusual. On 
 low diet the symptoms declined; and I find him marked in 
 my notes convalescent on the 4th of April. He is about to 
 leave the Hotel Dieu. 
 
 I refer further to a case detailed at p. 30 of the first 
 volume of Louis's wox'k. The patient had been three weeks 
 ill. During the first fortnight the ordinary symptoms, it 
 seems, were observed ; more particularly headache, relieved 
 by expistaxis, during the first week ; then gradually 
 increasing diarrhoea and pain of belly. In the third week 
 renewal of rigors and heat of skin. Appearance of the 
 eruption and recurrence of epistaxis on the 23rd day. 
 These phenomena were followed by violent delirium, termi- 
 nating in partial stupor, and death on the 26th day. On 
 dissection solitary glands, not ulcerated, in the upper ; both 
 solitary and aggregate glands ulcerated in the lower part of 
 the small intestine ; " a great number of small tumours 
 flattened, not ulcerated," in the large intestines. Do not the 
 symptoms fully bear out the opinion, that the formation of 
 the tumours described by Louis was coincident with the 
 aggravation of symptoms in the third week, and that the 
 extensive ulceration at the foot of the ileum was the result 
 o£ disease of much longer standing ? The invaluable 
 researches made of late years into the pathological anatomy 
 of this affection by Bretonncau, Petit, and Serres, Andral, 
 Louis, and Cliomel, Avould necessarily lead to this conclusion. 
 And, in point of fact, Louis says (p. 37) that they were 
 ''most probably developed at the same time as those in the 
 lirst half of the small intestines, being, like them, not ulce- 
 rated." Now, according to the generally received theory, the
 
 TFPHÜS AND TYPHOID FEVER. 177 
 
 glands in tlie upper liulf of the small intestine are developed 
 at an advanced period of tlie disease. 
 
 I conclude my remarks on this head with a reference to 
 Chomel's work. At p. 361 is the case of a patient, admitted 
 on the eighth day of the disease. Prostration, nausea, some 
 epigastric pain, slight diarrhoea, " a few rosy spots,-" were 
 the leading symptoms. They quickly yielded ; the diarrhoea 
 had almost ceased, and a great amelioration had taken 
 place, when, on the 23rd day, all the symptoms returned, 
 in a much graver form, accompanied by stupor, violent 
 diai'rhooa, '' inclination to vomit (it is expressly said), like 
 that at the beginning of the disease ;" — '^slightly marked^' 
 improvement on the 27th and 28th days ; recurrence of 
 same symptoms, with delirium and erysipelas, on the 
 30th day ; extension of erysipelas to whole right side of face, 
 and. neck, and also to scalp. Almost every trace of it had 
 disappeared on the 34th day, when epistaxis and stupor, 
 approaching to coma, were observed. Death ensued on the 
 35th day. Dissection disclosed a lohule of grey hepatisation 
 in one of the lungs. In the upper part of the ileum, 
 " patches partially ulcerated ; in the last fifteen inches, 
 numerous ulcerations of very small extent, and which appear 
 to depend on the alteration of the isolated follicles ; besides, 
 that a great number of the last-named glands present an ab- 
 normal volume, without ulceration " (p. 364) . 
 
 The symptoms mentioned as recurring on the 23rd day. 
 after the almost complete cessation of the diarrhoea and other 
 unfavorable signs, cannot certainly be accounted for by the 
 "lobule of grey hepatization," found after death, nor by the 
 erysipelas, which did not come on for seven days afterwards, 
 and was then ushered in by a new exacerbation, after a 
 second decline of all the symptoms. In fact, we have 
 there all the phenomena of a fresh attack on the 23rd 
 day, followed on the 30th by erysipelas as a 6'cqitela. 
 Am I not warranted, then, in concluding, that the exacer- 
 bation observed at the former date was accompanied by a 
 fresh eruption of isolated follicles ? This is strongly sup- 
 ported by another post-mortem appearance observed, viz. the 
 uniform rosy tint of the whole of that portion of the small 
 gut that lay in the lower pelvis. 
 
 12
 
 178 ON THE NATÜEE AND PATHOLOGY OP 
 
 After tlie facta that have been adduced, I feel almost 
 entitled to expect assent to the likelihood of. the opinion, 
 which, I am convinced, future observation will confirm, that 
 in typhus, when uncomplicated with any secondary affection, 
 a second attack does not take place, while in typlioid fever 
 the contrary is the case. 
 
 I have a few more remarks to offer upon the duration of 
 typhus. There are cases which are said to run their course 
 in a few days. I do not speak of the typhus siderans of 
 Saragossa, Torgau, and Mayence — a disease that was often 
 mortal in a few hours. It is not to those cases of frightful 
 intensity that I allude, though I may remark with Montault, 
 that the earliest death recorded in typhoid fever is, I believe, 
 that of a patient of M. Bretonneau, on the 5tli day. The 
 cases I refer to are those in which a cure is said to take 
 place on the yth or 8th day, or even earlier. Many 
 authors of distinguished eminence detail cases wherein certain 
 modes of treatment, early applied, have cut short, as the 
 phrase is, attacks of continued fever. In short, it has been 
 often laid down, that an early bleeding, an emetic, a strong 
 purgative, can crush the hydra in the birth, and restore the 
 patient to health. Dr. Henderson in his part of the Report 
 on the Epidemic Fever of Edinburgh,^ states expressly, 
 " If the presence of maculae, red spots, or typhoid eruption, 
 be considered as conclusive of the nature of the disease, 
 though not necessarily a symptom in all cases of continued 
 fever, then I can have no hesitation in deciding that this 
 fever may run its course in a few days ; for instances of 
 convalescence have occurred to me on the yth and 8th 
 days, in which the eruption had existed, without which the 
 diagnosis would have been jDcrplexed, as in other cases. ^' 
 
 Without denying the possibility of the above, I remark, 
 that it would have been desirable to know, whether, in the 
 cases spoken of, very minute inquiries were instituted re- 
 specting the exact days on which the pq,tients were first 
 attacked ; for every one knows that the premonitory period 
 of languor and uneasiness, extending often over a week, or 
 even more, is seldom taken into account by patients in 
 describing their complaints. But I object to the general 
 ^ 'Edinburgh Medical and Suririi;al Journal,' No. 141,
 
 TYPHUS AND TYPHOID FEVER. 179 
 
 position on otlier grounds. It is matter of notoriety tliat 
 very many cases of catarrh at all seasons, of influenza when 
 it is epiclemic_, and of bilious affections during- the heat of 
 summer, are sent to the fever hospitals, because they simulate, 
 in a most remarkable degree, the symptoms of commencing 
 typhus. So it was in Glasgow Fever Hospital. These cases 
 yielded in a few days to the exhibition of one or other of the 
 above-mentioned remedies, while the same means were used, 
 apparently without any effect, either as regarded their dura- 
 tion or intensity, in very many cases of genuine typhus. 
 So firm is the belief in Glasgow that those which terminate 
 in a few days are not cases of continued fever, that they are 
 not permitted to go into the convalescent wards, where sad 
 experience has shown the much greater contagiousness of 
 the disease. In fact (and this militates strongly against 
 Hildenbrand's opinion, that typhus is most contagious during 
 the " nervous stage,'' beginning to be so when the eruption 
 appears), scarcely one of the hundreds dismissed from the 
 acute wards ever returned labouring under typhus, though 
 they had remained for a week or ten days in wards some- 
 times crowded to excess ; while, of the few who, by mistake, 
 went into the convalescent wards, scarcely one escaped the 
 disease, and several died. No patient who presented the 
 eruption was ever known to contract the disease anew, even 
 among the convalescent patients. 
 
 I cannot omit to notice another circumstance connected 
 with the course of the two diseases, which appears to me 
 one of considerable interest ; I mean the occurrence of 
 crises. I do not refer, by this expression, to the dark and 
 debated question of critical evacuations, nor will I institute 
 any inquiry as to whether certain discharges, on certain 
 days, axe or are not attended with an improvement in the 
 general symptoms. All that I insist upon is the frequent, 
 I may say, the common occurrence of a perceptible crisis, 
 or what is vulgarly termed a turn in typhus. I think I may 
 appeal to the experience of every physician, and more espe- 
 cially of every resident clerk in a fever hospital (for they 
 have more constant opportunities of observation), whether 
 they have not often been struck at seeing, during their 
 morning visit, the glassy eye, the haggard features, the low
 
 180 ON THE NATÜUE AND PATHOLOGY OP 
 
 muttering delirium, tlie stupor approaching to coma^ tlie 
 tremor, the subsultus, the carpholog-y, the rapid, thready, 
 trem.ulous, and intermittent pulse, of the previous evening, 
 the formidable array of symptoms, in short, which seemed 
 to indicate a speedy and fatal termination, exchanged for 
 the clear eye, the intelligent countenance, the steady hand, 
 the comparatively slow and firm pulse, and the returning 
 appetite of approaching convalescence. To such cases as 
 these we might almost apply the Scripture phrase, '^At such 
 an hour, the fever left him ; " and if the crisis is not very 
 frequently so marked, we can, in the great majority of cases, 
 point with precision at least, to the day on which amendment 
 began to take place. In reply to the question whether this 
 iß the case in typhoid fever, I can only adduce my own 
 experience, when I state, that neither in the numerous cases 
 I saw in Scotland, nor in those I have watched in Paris 
 (about a dozen of them very carefully), have I ever seen 
 anything appix)aching, in the remotest degree, to what I have 
 noticed so frequently in typhus. 
 
 IV. I proceed to a fourth and very important branch 
 of my subject, viz. the consideration of symptoms. I shall 
 mot be tempted, by the highly ingenious and visionary con- 
 clusions drawn by Valleix, from his six cases of typhus,^ to 
 make any lengthened digression. That author actually 
 considers the absence of headache and affections of the 
 organs of sense as important diagnostic marks of typhus. 
 Instead of wearying the reader with the laboured refutation 
 I had prepared of this strange fancy, I shall merely state, 
 regarding my own cases, that, excluding those in whom the 
 headache ceased before the 5th day, it was present after 
 that period in 98. In between one sixth and one seventh 
 of this number it ceased before the loth day; in the remain- 
 ing five-sixths it continued throughout the advanced stages 
 of the disease, being present in many till the 20th and 25th 
 days ; and in 1 1 throughout the whole course of the affection. 
 Hearing, again, was either mure acute, or perverted, or 
 impaired in 6g patients. -And finally, while I refer to the 
 almost unanimous testimony of the multitude of distinguished 
 yuthors cited by Gauthier de Claubry in pp. 5 and 39 of his 
 ' ' Arcli. de Med.,' 3me seric, t. vi.
 
 TYPHUS AND TYPHOID FEVER. 181 
 
 work, I find recorded in my notes^ as among the most 
 constant symptoms, excessive intolerance of light (of which. 
 I can add my own experience) ; suffusion of the eyes to an 
 extent rarely if ever witnessed in typhoid fever; and minute 
 injection of the conjunctival vessels. In not a few cases 
 Chemosis, corneitis producing ulceration and onyx, iritis, and 
 in two or three cases Egyptian ophthalmia, occurred in the 
 course of the disease. What, again, are more common in 
 typhus than the glassy eye (considered by Kochoux peculiar 
 to it, from its very rare occurrence in typhoid fever), the 
 immensely dilated and extremely contracted pupil, and even 
 total blindness ? If reminded that, in adducing those facts, 
 I am proving the identity of the two diseases, I reply, that 
 if to prove the existence of analogies is to prove identity, 
 there is an end to all conclusive reasoning and accurate 
 knowledge. In order to establish from analogy the identity 
 of any two diseases, the resemblances must be so numerous, 
 so striking, and, above all, so important, and the differences 
 so few, so trifling, and so easily accounted for, as to warrant 
 the overlooking of the latter conditions, which have certainly 
 not as yet been answered in the case before us. 
 
 I. I have now to consider symptoms that have a material 
 bearing on the decision of this important question. The 
 state of the abdomen and bowels during life is naturally 
 regarded as worthy of particular attention. The common 
 use of purgatives in Great Britain throughout the course of 
 typhus, and their well-known beneficial effects, while they 
 render the declaration of Montairit (p. 93), that Hamilton's 
 method " still counts some partisans in England," not a 
 little amusing, and '^ passing strange," the sweeping con- 
 demnation pronounced against their repeated administration 
 by Gauthier de Claubry (p. 156—172), prove at the same 
 time the existence of certain symptoms to be combated. 
 Though not called upon here to undertake a defence of the 
 English mode of practice as applicable in all cases of typhus, 
 I refer to it as furnishing some very remarkable facts bearing 
 on the question at issue. Dr. West, in bis able paper on 
 Exanthematic Typhus (in the fiftieth volume of the ' Edin. 
 Med. and Surg. Journal') , makes the following observations : — 
 " The action of the bowels was not disturbed in the great-
 
 182 ON THE NATURE AND TATHOLOGY OP 
 
 majority of cases; in fact, tlie administration of. mild laxatives 
 was necessary, in most instances, in order to obtain an 
 evacuation, once in forty-eiglit hours ; and in some of the 
 most severe cases the bowels were very constipated. Diar- 
 rhoea occurred only in lo of these 60 cases; in three of 
 which the patients died, and it was only four times that it 
 lasted for longer than forty-eight or sixty hours. 
 In 13 cases the bowels were constipated." The following is 
 an abstract of the statements of Dr. Henderson in regard 
 to the state of the bowels in 154 cases of typhus. 
 
 
 Males. 
 
 I'einales. 
 
 Total. 
 
 Bowels easy in 
 
 26 
 
 73 
 
 99 
 
 loose in . 
 
 — 
 
 5 
 
 5 
 
 costive in 
 
 19 
 
 31 
 
 50 
 
 45 109 154 
 
 In reference to the following results obtained by myself, 
 I have only to remark, that in many of those cases in which 
 diarrhoea is described as spontaneous, the requisite informa- 
 tion was unfortunately not got as to the previous adminis- 
 tration of purgatives. 
 
 M;il.!S. Females. Total. 
 
 (T Spontaneous in . . 13 . 10 . . 23 
 
 Diarrhoea -^ From medicine in . . 26 . 27 . 53 
 
 ^ From medic 
 C Doubtful in 
 
 40 37 77 
 
 Costiveness nolwithstandin,^ the exhi- 
 bition of purgatives ... 20 . 42 . 62 
 
 60 79 139 
 
 Thus, according to Dr. West's observations, the bowels 
 were constipated in " nearly one fourth ; in Dr. Henderson's 
 in about one third; in my own in between one half and one 
 third of the cases. Again, spontaneous diarrhoea occurred 
 in one sixth of Dr. West's ; in only one thirtieth of Dr. 
 Henderson's, or, adding three, in which it came ' on very 
 late in the disease, and might be referred to secondary 
 affections, in one nineteenth ; and in nearly one sixth of my 
 own cases. 
 
 How different is the state of matters in regard to typhoid 
 fever? Chomel (pp. 6, 10) mentions diarrhoea as a symptom
 
 TYPHUS AND TYPHOID FEVER. 183 
 
 scarcely ever wanting, and states it as occurring (p. 230) in 
 40 out of the 42 fatal cases recorded by him. In the still 
 more precise observations of Louis^ we find it wanting in 
 only 3 of 128 cases, and in 58 of these it was contempo- 
 raneous with the commencement of the affection. Spon- 
 taneous diarrhoea was present in every one of the 9 cases 
 observed by myself; in 3, it was one of the first symptoms, 
 having declared itself on the first day, along with the general 
 premonitory symptoms. In one, it began on the 4th ; in 
 another, on the 6th; in two more, on the loth; in an eiglith, 
 on the nth ; in the ninth, it was observed after a few days' 
 illness, the precise day not being specified. This symptom 
 was present, in one case, from the ist till the 22nd day, 
 recurred on the 36th, and continued, during a second attack, 
 till the 46th day. Its shortest and longest durations were 
 respectively ten and forty-three days ; and its mean duration 
 above twenty-two days. 
 
 As to its characters, in two it was very violent, and opium 
 had little effect in checking it. In two, it occurred in severe 
 attacks, which assumed a periodic character ; and in the rest 
 it was moderate but always or nearly always present. With- 
 out insisting further on the comparative duration of th.e 
 diarrhoea in the two diseases, though it would, if minutely 
 investigated, bring out still more clearly the extraordinary 
 contrast already presented, — I proceed to the consideration 
 of the state of the abdomen in the two complaints. This 
 I propose to do under two heads, relating, first, to the 
 feelings of the patient, and second, to the sensations of the 
 medical attendant. 
 
 2. In 30 out of the 60 cases observed by Dr. West 
 there was pain in the abdomen, but in only 9 ^as it severe. 
 Dr. Henderson remarked it in 46 out of 198, and never in 
 the right iliac fossa. The following are the results of my 
 own observation : 
 
 Abdomen painful in 109 out of 139 patients. 
 
 
 Males. 
 
 Females. 
 
 Total. 
 
 .in intense, or at least severe, in . 
 
 17 
 
 27 
 
 44 
 
 slight 
 
 24 
 
 41 
 
 65 
 
 41 68 109
 
 184 ON THE NATURE AND TATROLOGY OF 
 
 The duration of the abdominal pain was as follows : 
 
 Males. Fomalcs. Total. 
 
 Througliout the disease, in . . . i8 . 27 . 45, 
 
 a considerable part of it, in . 6 . 9 .* 15, 
 
 From two to six days, in ... 12 . 24 . 36 
 
 One day only 5 • 8 . 13 
 
 41 68 109 
 
 Deducting tlio 13, in "wliom this symptom was present 
 only one day, and in whom it may fairly bo attributed to 
 some accidental cause, we have 96 cases out of 13g, in whom 
 abdominal pain was somewhat permanent, and in 60 only 
 did it continue throughout the greater part of the illness. 
 In the great majority, the pain was general, — in 32, it was 
 chiefly or entirely confined to the region of the liver, a cir- 
 cum. stance noted by Dr. West ; — 3 of those in whom this 
 was observed had long laboured under chronic hepatitis. 
 In 17 of the 32 alluded to (between one half and one third 
 of those in whom the pain was severe) the liver was exceed- 
 ingly tender to pressure ; and it was the seat of pain, more 
 or less acute, in 20 out of the 60 patients in whom the 
 abdomen was tender during the greater part of the disease. 
 Dr. West mentions the usual duration of the abdominal pain 
 as " about four days, though once it continued for fifteen 
 days, and in three other instances from six to eight days." 
 In 1 1 only of my own cases was pain observed in the right 
 iliac region, 8 of these presenting it during one day, 2 during 
 two days, and only one for three days consecutively. Valleix 
 notices the presence of diffuse pain on pressure, for three or 
 four days, in two of six typhus patients; and of pain on 
 pressure and constant uneasiness in four, and of colic in a 
 fifth of the six labouring under typhoid fever. 
 
 According to Louis, abdominal pain was present in 112 
 cases only of 128, was rarely general, occupied in the vast 
 majority either the iliac fossa) or the hypogastric region, 
 continued generally throughout the greater part of the disease, 
 its duration being commonly from ten to twenty-five days.. 
 In six cases it lasted a whole month. The results of mj 
 own observation are, that abdominal pain was present in 
 every case examined by me ; and that in six, in whom pain
 
 TYPHUS *AND TYPHOID FEVER. 185 
 
 was observed during their residence in tlie hospital, it was 
 either confined to the ileo-cfBcal fossa, or more severe there- 
 than elsewhere, having been diffused over the belly in three 
 of them during" a part of their disease. It began in four 
 on the ist, in one on the 6th, in one on the loth, in one on 
 the i4tli day of the fever. In the remaining two, it was 
 present, in a decided degree, on their admission to the 
 hospital, on the nth and ißtli days, and had most likely 
 been present for some time before, though not felt by the 
 patient. 
 
 This leads me to observe that the leading diagnostic 
 symptoms in the Glasgow epidemic of 1836 were the red, 
 chapped, and papillär tongue, the dull, circumscribed abdo- 
 minal pain existing for weeks together, along with constant 
 diarrhoea, harsh skin, and obstinate bronchitis. But what 
 chiefly merits attention is, that while in typhoid fever the 
 pain accompanies diarrhoea, in typhus the pain is often most 
 severe when the bowels are costive, and is relieved on the 
 exhibition of a purgative, proving its frequent connection 
 with and dependence on a loaded state of the intestinal 
 canal. In typhoid fever, on the other hand, it exists in- 
 dependently of any such condition ; a circumstance which, 
 along with its fixed seat, demonstrates its dependence upon 
 local lesion. This is particularly pointed out both by Dr. 
 West and Dr. Henderson, and it is fully confirmed by my 
 own experience. 
 
 To sum up what I have stated on this head ; abdominal 
 pain occurred in 186 of 403 cases of typhus, or, deducting 
 those in whom it was altogether transitory, in 1 73, i.e. between 
 one half and one third of the whole; while in the 128 cases 
 of Louis, it occurred 112 times (about five sixths), or, adding 
 those detailed by Valleix and myself, in 126 out of 143 cases, 
 i. e. in about ten elevenths of the whole. 
 
 3. The next subject that demands attention is the feel 
 of the abdomen. Dr. West mentions 1 1 cases out of 60, 
 as presenting "some fulness and t^'mpanitic distension;^' 
 Dr. Henderson, only 8 out of 198. In those observed by 
 myself, I find that the abdomen was
 
 186 OiNT THE NATURE AND PATHOLOGY OP 
 
 Highly tumid and tympanitic in 
 Slightly so ... . 
 
 Of natural feel 
 
 This symptom lasted throughout the disease in 
 During a considerable part of it, in 
 From two to six days ..... 
 One day 
 
 Males. 
 
 Females. 
 
 Total. 
 
 12 
 
 3 
 
 15 
 
 12 
 
 27 
 
 39 
 
 24 
 
 3° 
 
 .^4 
 
 35 
 
 .50 
 
 85 
 
 59 
 
 80 
 
 139 
 
 9 
 
 3 
 
 12 
 
 3 
 
 2 
 
 5 
 
 7 
 
 16 
 
 23 
 
 5 
 
 9 
 
 14 
 
 24 30 54 
 
 Deducting, ag-ain, as I am fairly entitled to do, tliose 
 cases in wliicli tlic symptom was very transitory, there 
 remain only 40 in wliom it was at all permanent, and in 17 
 only out of 139 did it continue during the greater part of 
 tlie affection. 
 
 In typlioid fever, on tlie otlior hand, Chomel (p. 12) 
 remarks its almost constant occurrence, and Louis discovered 
 it in 89 of 134 cases, in tlie great majority of wliicli it lasted 
 during tlie greater jiart of the disease. In one only did 
 it disappear in twenty-four hours. Valleix^ remarks its 
 transient existence in one out of six or seven cases of typhus 
 observed in London by Dr. Shattuck, whereas it was present 
 at an earlier stage, in a much higher degree, and for a much 
 longer period (its mean duration being about nine days) in 
 five out of six patients labouring under typhoid fever. It 
 was remarked in eight of the nine cases examined by myself, 
 and was present from four to thirty-four days, or on an 
 average a little more than nineteen days. In the remaining 
 case it was so very slight as to render it doubtful. 
 
 Adding together all the cases of typhus al)ove referred to, 
 we find the symptom in question occurring in 74 out of 403 
 cases, or between one fifth and one sixth of the whole. 
 Deducting those in which it was transitory, it occurred in 
 59 only, or in less than one seventh of the whole number; 
 whereas it was observed in 102 out of 149, or in rather more 
 than two thirds of all the cases of typhoid fever — no small 
 difference assuredly. 
 
 ' ' Arch, de Mcdecino,' ßme sdrie, t. vi, p. 142.
 
 lales. 
 
 Females. 
 
 Total, 
 
 8 
 
 9 
 
 17 
 
 15 
 
 18 
 
 33 
 
 23 
 
 27 
 
 50 
 
 16 
 
 41 
 
 57 
 
 TYPHUS AND TYPHOID FEVER. 187 
 
 4. Yet the statements I have made are very far from 
 exhausting the evidence on the subject. I, therefore, proceed 
 to inquire into the relation subsisting between the symptoms 
 spoken of ; and first, in regard to the coexistence of pain 
 of belly and looseness of bowels in typhus. Of 50 patients 
 in whom pain and diarrhoea existed at one period or other 
 of the fever : 
 
 T^• 1 C s])ontaiieous in 
 
 Diarrhoea was \ ^ . . 
 
 C. consecutive ui 
 
 Pain and constipation were observed in 
 
 The numbers in whicli diarrhoea and constipation were 
 observed were respectively 77 and 62. Therefore, had 
 abdominal pain occurred in the same proportion in those 
 wlio had diarrhoea, as it did in those who had constipation, 
 instead of having 50 only, we should have met with it in 70* 8. 
 In other terms, the occurrence in the same cases of pain and 
 diarrhoea is as i : 1*54, while that of pain and constipation 
 is as I : i"o8. 
 
 Remarkable as this difference is, it is in reality mucli 
 greater. I find from a further and very careful analysis 
 of the cases before me that abdominal pain and diarrhoea 
 were 
 
 Males. Females. Total. 
 
 Coincident in 14 16 30 
 
 Not coincident in ...... 3 4 7 
 
 Pain was relieved bj .supervention of diarrhoea in 4 8 12 
 
 21 28 49 
 
 Again, abdominal pain and constipation were 
 
 
 Males. 
 
 Females. 
 
 Total, 
 
 Coincident in 
 
 16 
 
 35 
 
 5r 
 
 Not coincident in 
 
 
 
 6 
 
 6 
 
 16 41 57 
 
 Thus, in only 30 out of 77 cases in which diarrhoea, either 
 spontaneous or consecutive, was noticed, did abdominal pain 
 and diarrhoea exist simultaneously; whereas, out of 62 cases 
 in whicli the bowels were confined, pain in the belly and
 
 188 ON THE NATURE AND TATHOLOGY OF 
 
 constipation coexisted in no less than 51. Had tlie latter 
 proportion been kept up, we should have had 63*3 instead 
 of 30, so that, according to our present data, the coincidence 
 of abdominal pain with constipation in typhus is to its occur- 
 rence along with diarrhcEa as three is to one. I might still 
 further heighten the contrast, by deducting one who died 
 of phthisis, in Avhom the abdominal pain did not supervene 
 till after the fever had run its course, and in whom it was 
 found on dissection to depend on very extensive tubercular 
 suppuration and ulceration of the intestines; another in whom 
 it supervened about the 20th day, along with a profuse dis- 
 charge from a very large bedsore ; and a third, in whom the 
 evacuations, though frequent, were mixed throughout with 
 scybala; but the difference is striking enough without any 
 such refinement. 
 
 I have marked a considerable number of the above as 
 relieved by diarrhoea, a circumstance which naturally pro- 
 vokes inquiry into the previous state of the bowels. I find, 
 then, that of the 30 in whom pain and diarrhoea were con- 
 temporaneous, 10 may be called cases of spontaneous diar- 
 rhoea, i. e. the purging was not, so far as I know, brought 
 on by medicine ; while in the remainder it may be ascribed 
 to that cause. • In 28 of those in whom diarrhoea, whether 
 spontaneous or consecutive, was observed, the bowels were 
 more or less obstinately constipated during the first stage 
 of the fever ; and in that number are included almost all 
 those in whom diarrhoea gave relief to pain. And finally, 
 of the 5 1 in whom constipation lasting throughout the disease 
 was accompanied by pain (in many cases exceedingly acute) 
 the operation of purgative medicine, — of castor-oil, turpentine, 
 jalap, calomel, or the neutral salts, given according to the 
 strength of the patients, and the indications presented in the 
 course of the disease, was followed by decided and immediate 
 relief in 20 cases. Dr. West mentions, that of 30 who had 
 pain, 8 only had diarrhoea, while 15 were constipated; a 
 result that fully bears out my statements. 
 
 Abdominal pain and spontaneous diarrhoea were coincident 
 in all of the nine patients labouring under typhoid fever to 
 whom I have alluded. The shortest period of coexistence 
 was four, the longest thirty-two, and the average is a little
 
 TYPHUS AND TYPHOID FEVEE. 180 
 
 -more tlian fifteen days. So constant did Louis find the co- 
 existence of these two symptoms, that (vol. ii, p. 34, 38) ho 
 considers abdominal pain, both in typhoid fever and other 
 'diseases, as pathognomonic of an inflamed state of the 
 mucous membrane. In opposition to this I may quote Dr. 
 Henderson, who remarks in his report, ^' In eight, a degree 
 of general tenderness of the abdomen coexisted with tumidity 
 and tension, in only one of which was there diarrhoea." 
 
 These statements form the best possible apology for the 
 judicious administration of purgatives in typhus, while the 
 spontaneous supervention of diarrhoea in many whose bowels 
 were confined demonstrates its propriety beyond the shadow 
 of a doubt, and fully warrants, as it appears to me, a most 
 important conclusion, in proof of which I have adduced the 
 above rather dry and tiresome details, namely, that whereas 
 in typhoid fever there is an early and almost uniform ten- 
 dency towards looseness of the bowels, there is as constant 
 a tendency in typhus to constipation; that while in the former 
 diarrhoea is a symptom, and a natural, I might almost say a 
 necessary, result of a constant local lesion, it arises in the 
 latter from the presence of an irritating substance, which 
 it is the object of the vis medicatrix to eliminate from the 
 system. 
 
 5. I shall offer only a few remarks on the connection 
 between the state of the bowels and the feel of the belly. 
 Of 54 patients in whom, as has been seen, more or less 
 swelling and tympanites {meteorismus) were observed, 25 had 
 diaiu'hoca, and 29 were constipated. The following tables 
 will show much more concisely and clearly than I could 
 express it iu words the duration and extent of the tympanites 
 in these two groups of cases : 
 
 Bowels loose. Bowels boiiiid. 
 
 Males, lemales. Total. Males. Females. Total, 
 Tympanites continued tlivougli- 
 
 out the disease in ...617 3 25 
 Throughout the greater part of 
 
 it in I o I I 2 3 
 
 From two to six days in . . 5 4 9 2 12 14 
 
 During one day in ... 4 4 8 2 5 7 
 
 16 
 
 29
 
 190 ON THE NATURE AND PATHOLOGY OE 
 
 On this table I have only* to remark, that 7 of the 25 had 
 spontaneous diarrhoea, but of these 7 only 2 had tension of 
 the belly for more than one day. But, by a careful analysis 
 of the cases, we arrive at still more remarkable conclusions. 
 The following are the results of my investigations : 
 
 Tympanites and diarrlicea coexisted in 
 Did not coexist in ... . 
 Tympanites was relieved by diarrhoea in 
 
 Tympanites and constipation coexisted in 
 Did not coexist in ... . 
 
 [iilcs. 
 
 Females. 
 
 Total 
 
 12 
 
 5 
 
 17 
 
 3 
 
 2 
 
 5 
 
 1 
 
 2 
 
 <-> 
 
 .3 
 
 16 
 
 9 
 
 25 
 
 8 
 
 18 
 
 26 
 
 
 
 3 
 
 3 
 
 29 
 
 Of the 29, the distension was relieved in 3 by the exhibition 
 of purgatives. The 5 in whom diarrhosa and tympanites 
 did not coexist were constipated at the time the tumefaction 
 was noticed, so that in point of fact distension of the belly 
 was coexistent with diarrhoea in 17, whereas it existed along 
 with constipation in 31. Finally, of the 7 mentioned above 
 as having meteorismus and spontaneous diarrhoea, the two 
 symptoms existed simultaneously only in 4.. Dr. West, 
 I observe, states,^ that of 1 1 cases in which *' there was 
 some fulness and tympanitic distension of the abdomen," 
 diarrhoea was coexistent with it in 7, '' while in 3 the bowels 
 were constipated." As to the extent of the tympanites, 
 I find that 
 
 Bowel« loose. Bowels boiiiul. 
 
 Mnles. IVniales. Total. Males. J'cniales. Total. 
 
 The abdomen was highly tympanitic in '808437 
 Moderately or slightly so in . .8 9 17 4 18 22 
 
 16 9 25 8 21 29 
 
 6. In 46 (17 males and 29 females) out of 54, in whom 
 meteorismus was observed, abdominal pain was also present 
 at one period or other of the complaint, but the two sym- 
 ptoms were coexistent only in 37 patients, in several of whom 
 the pain was so very transient and so slight, in comparison 
 to the duration and extent of the distension, as scarcely to 
 
 ^ ' Edinburgh Medical and Surgical Journal,' vol. i, p. 134.
 
 TYPHUS AND TYPHOID PEVEE. 191 
 
 merit notice. To show still further tliat there is no pro- 
 portion between tlie extent of abdominal tension and the 
 pain experienced, I would merely state that, of 15 patients 
 in whom the belly was highly tumid, 6 only felt severe pain; 
 in 5 there was slight tenderness; in 4 none whatever. Of 44, 
 on the other hand, in whom the belly was acutely painful, 
 we have seen that only six presented any remarkable tension; 
 in 18 it was slight; in 20 there was none at all. Dr. West's 
 statements are widely different. He states (loc. cit.) that 
 pain was present in all, except one, of those in whom the 
 belly was tympanitic. 
 
 I shall conclude my remarks on this head with a few 
 statements regarding the simultaneous occurrence of the 
 above symptoms in my own cases of typhoid fever. Tume- 
 faction of the belly and diarrhoea coexisted in eight. patients, 
 from 4 to 30, giving an average of fifteen days and three- 
 quarters. Tumefaction was unaccompanied by pain in one 
 patient, and lasted from the 12th to the 33rd day. In another, 
 abdominal pain was present on admission, but disappeared 
 next day, though the distension persisted throughout. In a 
 third, the abdomen was swollen, but not painful, from the 9th 
 to the 24th, both swollen and painful from the 25th to the 
 31st day. In the remaining 5, the symptoms coexisted from 
 four to thirty-four days, or on an average about twenty days 
 and a half. 
 
 I go on to speak of the eruptions observed in the two 
 diseases. This subject has lately begun to excite much 
 interest, more, perhaps, in Great. Britain than in France. 
 The proposal which has been made to overturn long-received 
 opinions, and to blot out a long and elaborate section from 
 the nosological dictionary, by placing typhus among the 
 exanthemata, could not fail to awaken a most interesting 
 controversy, and to bring under review the whole history, 
 and much of the symptomatology of typhus. Hildenbrand 
 was the first to propose this innovation. But it was started 
 in England and Scotland by two physicians, who had neither 
 had any communication with that distinguished author nor 
 with each other, viz. by Dr. Eoupell, who, it apj)ears from 
 his work, brought the subject under the notice of the London 
 College of Physicians in 1831 ; and by my friend Dr. Peebles,
 
 192 ON THE NATURE AND TATIIOLOGY. OF 
 
 who, on liis return to Scotland in 1832, after a long" residence 
 in Italy (where he had been struck with the öonstant occur- 
 rence of an eruption in the epidemics of contagious fever), 
 drew the attention of the profession in Edinburgh to its 
 presence, previously unnoticed, in the typhus of that capital ; 
 and after two years of attentive inquiry, published the result 
 of his researches, accompanied with a comprehensive sketch 
 of the history of eruptions in contagious fever, in the forty- 
 fourth volume of the ' Edinburgh Medical and Surgical 
 Journal ' — being the first, as I believe, to submit his senti- 
 ments to the medical world. I observe that Dr. West, in an 
 able and learned paper in the last number of the same 
 periodical, maintains the opposite opinion. For several 
 reasons I shall not enter upon this controversy. Besides 
 that the proof of the positions I mean to take up does not 
 require it, it appears to me that wo are not yet in possession 
 of data sufficient to demonstrate the truth of the doctrine. 
 That must be the work of many years of patient and very 
 extensive inquiry. I may remark, however, that there is 
 everywhere a growing conviction in its favour, and that, 
 if the claim of typhus to rank among the exanthemata has 
 not yet been fairly made out, its remarkable analogies with 
 that class of diseases are attested, alike by the uniform. 
 experience of the past, and the observation of present times. 
 Nor can I consent, without reserve, to conclusions drawn 
 from the alleged absence of eruption ; for the fact I have 
 already referred to (viz. that the eruption in the Edinburgh 
 typhus was unheeded before 1832), shows how appearances 
 may escape the eye of the most distinguished and practised 
 physicians when their attention is not particularly drawn to 
 them. It is also well known to many that, previous to a 
 visit which Dr. Peebles made to the Glasgow Fever Hospital 
 in the spring of 1835, the exanthema of typhus, then found 
 to be of general occurrence, had neither been looked for nor 
 registered in that institution, and was actually hailed as a 
 new discovery. And finally, I must express my conviction, 
 founded on observation, that a very large proportion of those 
 cases mentioned in fever reports, as having no eruption, 
 consists of patients (such as I have already referred to) in 
 whom the disease is only of a few days' duration, and does .
 
 TYPHUS AND TYPHOID FEVER. 193 
 
 not, for tlie reasons stated above, seem to merit tlie name 
 of typlms fever. These considerations, it appears to me, 
 have an important bearing on the decision of this debated 
 question. 
 
 While, however, I decline making any further remai^ks on 
 this branch of inquiry, I must refer shortly, for the practical 
 elucidation of my subject, to the history of the typhous 
 eruption. Much confusion prevails on this point. The 
 meaning of the term petecJdiB has, in the course of time, 
 undergone a great change. That it was used by the old 
 authors (loosely enough, doubtless) to denote what would 
 have been much better called an eruption, is evident from 
 their writings, and has been very clearly shown by Dr. 
 Peebles, five years ago, and by Dr. West in the April number 
 of the ' Edinburgh Journal.' Dr. Peebles accordingly pro- 
 posed to retain the old term in its altered but now generally 
 received acceptation, and to consider the rosy eruption as an 
 exanthema. Yet many, from the use of the term petechial 
 by the older writers, persist in denying their acquaintance 
 with the eruption ; some, on the other hand (Rasori, Pinel, 
 Tweedie), having used the same word in reference to the 
 eruption, are blamed for want of ^'precision and exactness 
 in the use of terms ; " Chomel (p. 336) considers " the true 
 petechige or purple spots " to be very much more frequent 
 in typhus than in typhoid fever; Yalleix^ maintains the 
 eruption to be always dark and persistent, and takes it as 
 synonymous with vibices ; while Copland" and Montault 
 (p. 154) describe '^ ecchymoses and petechire as common to 
 typhus and other diseases,^' and the measly eruption as 
 peculiar to it. Again, Roupell quotes Louis and Chomel in 
 support of his views as to the true exanthematous character 
 of typhus. One of his reviewers,^ reasoning on the generally 
 admitted difference of the French and British continued 
 fever, retorts Dr. Roupell's arguments as proof positive 
 against the truth of his theory, while, with praiseworthy 
 consistency (p. 103), he cites Chomel's statements regarding 
 the eruption in support of his own opinions. 
 
 ^ ' Arcli. de Med.,' ßme serie, t. vi, pp. 133-4-6, 148-9. 
 - ' Dictionaiy,' p. loio, art. " Tjpluis." 
 ^ 'Med. -Chirurg. Review,' vol. xxxi, p. 99. 
 
 13
 
 194 ON THE NATURE AND PATHOLOGY OF 
 
 I shall now endeavour, in proof of tlie two following" pro- 
 positions, to present, in small compass, the very numerous 
 statements of authors, to reconcile tlieir apparent contra- 
 dictions, and to give the results of my own observation 
 regarding the exanthema of typhus. The points I wish to 
 establish are : 
 
 First, That the rash in typhus is permanent ; that in all 
 cases it presents the two jDoriods, longer or shorter, according 
 to circumstances, of increase and decline ; that, in the more 
 severe cases, it may exhibit, during the period of increase, 
 four different states, being florid, dark, livid, and petechial ; 
 and finally, that it is quite different from vibices and purpura, 
 which are of rare occurrence. 
 
 Second, which partly flows from the foregoing, that the 
 abundance, and particularly the darkness of the eruption, 
 may be said to be proportional to the severity of the disease. 
 
 I. When I say that the rash is permanent, 1 mean that it 
 does not consist of successive eruptions of spots, each of which 
 disappears in the course of three or four days, but that the 
 same eruption continues throughout the disease. As the 
 accuracy of this position will be clearly bi'ought out in 
 treating" of the changes the eruption undergoes, I shall only 
 state that it was ascertained by surrounding a certain number 
 of spots with ink, and observing them carefully several times 
 daily. 
 
 Dr. Copland and Dr. Peebles, to whom he refers, lay 
 down the proposition tha.t the " eruption usually appears 
 from the 3rd to the 7th day of the fever, but may be delayed 
 till the 12th or 14th day.^' Dr. West, in his last paper, 
 mentions that in the Vienna fever of 1757, when the disease 
 ran its regular course, it appeared '' on the 4th, or, at latest, 
 on the 7th day.^'^ Montault (p. 154) refers to Drogart, 
 Biett, Rochoux, and Pringle, as having observed it generally 
 on the 4th, 5th, or 7th, and sometimes (according to Pringle) 
 on the 14th day. Gauthier de Claubry (p. 75) remarks, 
 " That of seventeen observers Avho make express mention 
 of it, four noticed it on the 4th, two on the 5th, eight in the 
 course of the 6th and 7th, and generally, all point out its 
 manifestation between the 7th and loth days." Dr. Roupell 
 ' * Edinburgh Jouraal,' No, 143, p. 295.
 
 TYPHUS AND TYmOID PEVEK. 
 
 195 
 
 maintains its almost uniform appearance on the 3rd or 4tli 
 day. Dr. Cowan, in liis ' Statistics of Fever and Smallpox 
 in Grlasgow,^ p. 24, says tliat it " generally makes its appear- 
 ance from tlie 4th to the gth day of the disease, occasionally 
 at a later pei'iod.'^ Dr. Henderson states that in 8 out of 12, 
 in whom the day on which it appeared could be ascertained, 
 it appeared from the 3rd to the 6th, in " the remaining 4 
 severally on the 7th, gth, and nth day." I have been able 
 to ascertain the exact date of the appearance of the eruption 
 in a much larger number than Dr. Henderson, to whose 
 statements, in addition to the following tables, I refer for 
 the proof of what I have advanced respecting its increase 
 and decline. The first table refers to the time of its appear- 
 ance, the second to the period at which it began to decline, 
 the third to the date of its final disappearance. 
 
 
 
 Jl.iles. 
 
 Females. 
 
 TotaL 
 
 appeared on the 2nd 
 
 day in 
 
 I 
 
 I 
 
 2 
 
 3rd 
 
 
 2 
 
 I 
 
 3 
 
 4th 
 
 
 3 
 
 2 
 
 5 
 
 5th 
 
 
 4 
 
 12 
 
 16 
 
 6th 
 
 
 4 
 
 9 
 
 13 
 
 7th 
 
 
 I 
 
 4 
 
 5 
 
 8th 
 
 
 2 
 
 I 
 
 3 
 
 9th 
 
 
 I 
 
 3 
 
 4 
 
 13th 
 
 
 
 
 I 
 
 I 
 
 18 
 
 34 
 
 From this statement it results that in more than half of 
 the entire number it appeared on the 5th and 6th days, and 
 that, in exactly three fourths, it appeared from the 4th to the 
 7th day. Taking an average of the whole, it appears most 
 commonly on or about the 6th day. I must, however, direct 
 attention to the fact that in not a few cases it was so very 
 copious, and in several so dark, on the 6th day, as to warrant 
 the belief that it had appeared some days before. 
 
 Dr. Henderson states that the eruption began to fade 
 "in II before the loth day; in 20 between the loth and 
 12th, inclusive; in one, as late as the i7th."^ The following- 
 table gives the results of my own observation. It refers only 
 
 i 'Report,' &c., p. 13.
 
 196 
 
 ON THE NATUEE AND PATHOLOGY OF 
 
 to 48 o£ the 52 cases above referred to, 4 liaviug died before- 
 the eruption began to recede. 
 
 
 
 Males. 
 
 Females. 
 
 Total 
 
 began to decline on tlie Sth 
 
 clay in 
 
 I 
 
 
 
 I 
 
 9tli 
 
 
 3 
 
 3 
 
 6 
 
 loth 
 
 
 
 
 5 
 
 5 
 
 nth 
 
 
 2 
 
 3 
 
 5 
 
 12th 
 
 
 I 
 
 4 
 
 5 
 
 13th 
 
 
 5 
 
 3 
 
 8 
 
 14th 
 
 
 3 
 
 3 
 
 6 
 
 iStli 
 
 
 I 
 
 3 
 
 4 
 
 1 6th 
 
 
 
 
 2 
 
 2 
 
 17th 
 
 
 
 
 2 
 
 2 
 
 1 8th 
 
 
 I 
 
 2 
 
 3 
 
 19th 
 
 
 
 
 I 
 
 I 
 
 17 
 
 31 
 
 48 
 
 It is evident from the above table that we cannot fix 
 any particular day, from the 9th to the 15th, inclusive, on 
 which, much more frequently than any other, the eruption 
 begins to fade. It did so, however, on one or other of these 
 days, in 39, or five sixths of the entire number, the average 
 of which, (i2'8), assigns the 13th as the day that the change 
 most commonly takes place. 
 
 The length of this paper, already too great, renders it 
 impossible, as its object happily renders it unnecessary, to 
 analyse the circumstances whereon the variations I have 
 noted depend, such as the age, the constitution, the strength, 
 the habits of the patient, and the greater or less intensity 
 of the disease, all of which have a material influence in 
 modifying its duration. 
 
 I shall now, in a third table, show the various dates of the 
 disappearance of the eruption, in 45 cases, 3 more having 
 died, very shortly after it began to recede. 
 
 
 
 Males. 
 
 Females. 
 
 Tola 
 
 It disappeared on the 13th day 
 
 in 
 
 . 
 
 3 
 
 3 
 
 14th 
 
 
 . 
 
 4 
 
 4 
 
 15th 
 
 
 2 
 
 I 
 
 3 
 
 1 6th 
 
 
 . 2 
 
 2 
 
 4 
 
 17th 
 
 
 . 
 
 2 
 
 2 
 
 iStli 
 
 
 . 2 
 
 5 
 
 - 
 
 19th 
 
 
 . 
 
 5 
 
 5
 
 TYPHUS AND TYPHOID FEVEE. 
 
 197 
 
 
 Males. 
 
 remales. 
 
 Total. 
 
 disappeared on the 20th day in 
 
 . I 
 
 2 
 
 3 
 
 2 ist 
 
 . I 
 
 I 
 
 2 
 
 22nd 
 
 • 3 
 
 2 
 
 5 
 
 nth, 12th,. 23rd, 
 
 24th, 
 
 
 
 25th, 26th, and 
 
 31st 
 
 
 
 days in 
 
 • 4 
 
 3 
 
 7 
 
 15 
 
 30 
 
 45 
 
 The differences iu tliis are still more striking than those 
 in the preceding table. It would be easy, were such a part 
 of my present purpose, to demonstrate that the long con- 
 tinuance of the eruption depends, in almost every case, on 
 its having been dark, livid, or petechial during the disease ; 
 but, as the proof of it would not aid me in my present inquiry 
 I go on at once to deduce some more practical inferences 
 from the data I have furnished. Where so many disturbing 
 forces are at work as those I have alluded to, it would be 
 vain to look for anything like an exact proportion between 
 the periods of increase and decline in the typhous exanthema. 
 Accordingly, I find, from a laborious analysis of the above 
 cases, that though in 8 the two periods agree exactly, 
 and in 8 others, very nearly, iu length, they vary, in the 
 remainder in all different proportions. As it would be quite 
 useless here to enter into details, I shall simply subjoin the 
 results of my calculations : 
 
 Shortest pe 
 
 i-iod of increase . 
 
 Days. 
 
 3 
 
 Longest 
 Average 
 
 
 13 
 
 7-08 
 
 Shortest 
 
 „ decrease . 
 
 2 
 
 Longest 
 
 )J !5 • 
 
 13 
 
 Average „ ,, . . 
 Shortest duration of eruption 
 
 4"45 
 6 
 
 Longest 
 Average 
 
 J> 
 
 24 
 1 1 "SP 
 
 These conclusions form a considerable contrast to Dr. 
 Cropland's statement, " The duration of this eruption is from 
 three to five days.'^ Dr. Henderson infers *^that the whole 
 duration of the eruption occupied commonly nine or ten 
 days," — a result which approaches much more nearly to that 
 I have arrived at. Though I could have adduced a much
 
 198 ON THE NATÜRL'] AND PATHOLOGY OP 
 
 greater number of facts rei^'arding the decline and disappear- 
 ance of tlie eruption, I liave preferred confining my attention 
 to those patients alone in whom the date of its commence- 
 ment also was ascertained, for, having been selected for 
 examination solely because they presented themselves in the 
 early stage of the disease, they form a perfect group, whence 
 general conclusions may with safety be drawn. 
 
 Before entering on the consideration of the various states 
 of the eruption, let me refer to some of tlie opinions put 
 forth respecting it. Valleix, I have already stated, holds 
 the eruption to be always dark, and persistent under pressure, 
 both during life and after death. " It is," says Copland, 
 '' of a florid, reddish, or reddish-j)ink colour ; disappearing 
 on pressure, but soon returning when pressure is removed. 
 This circumstance is sufficient to distinguish it from petechisB." 
 Again, " If petechias occur in this fever, they seldom are 
 observed before the 8th or loth day, and then this 
 eruption has usually disappeared. When the petechia3 are 
 earlier, or the eruption continues longer, so that both exist 
 togethei', they are quite distinct and different in their appear- 
 ances ; for the latter is never so dark or livid as the former 
 generally is." Further on, he remarks, " In the more 
 malignant cases, or when petechia appear early in the 
 disease, the colour of the eruption may, however, become 
 deeper." Still further, '' The petechial affection 
 may occur in the advanced stage of any fever 
 and is not in any sense of the word an eruption, as it has 
 been very improperly denominated by some writers. 
 The petechias or cutaneous ecchymoses vary in dimensions 
 from minute stigmata to large patches and vibices, and in 
 the deepness or shade of colour. . , . But the exanthe- 
 matous eruption attending true typhus . . . has been 
 confounded with petechise, with which it is often associated 
 in the advanced stages of the fever." These opinions agree 
 entirely with those expressed in his paper by Dr. Peebles. 
 Dr. Henderson (p. i6) has the following remarks: '^Purple 
 petechiöe, the result of ecchymosis, were frequently present 
 in the second week of the disease. In some cases they were 
 very abundant, but in very few exceeded the number of 
 typhoid maculae, which commonly existed along with them.
 
 TYPHUS AND TYPHOID FEVEE. 199 
 
 One vibex only was remarked in the whole number of cases 
 The petechias continued often distinct, though the eruption 
 was declining." To disprove, as far as my observation 
 enables me, what ajDpears to be incorrect in these opinions, 
 even though upheld by such high authority, is the task I now 
 propose to myself. 
 
 The statements of authors on this subject are very 
 numerous. Dr. West, in tracing the history of the eruption 
 downwards from the fifteenth century, cites Fracastorius and 
 Ambrose Pare, who both speak of the eruption assuming a 
 dark colour. Conradinus is more explicit. In the article 
 referred to,-^ I find these words: " In addition to these sym- 
 ptoms, however, spots like flea-bites appeared on the skin of 
 all the patients. In some cases, these spots were of larger 
 size than others ; occasionally they occupied the whole body, 
 but usually were confined to the chest, the spinal and inter- 
 scapular regions, and the arms ; and they were observed to 
 assume a livid or blackish colour in dying persons." Willis 
 (same paper, p. 289) mentions as one of the symptoms of the 
 epidemic among the troops near Oxford in 1643, an eruption 
 of spots, some of them small, and of a bright-red colour, 
 while others were larger and of a more livid hue. The 
 reviewer of Dr. Roupell, formerly alluded to, says," " The 
 rash is not accurately described by any of the authors cited, 
 so that it is impossible to say whether it was the same in all. 
 One author (Prmgle) does not even mention its existence." 
 Now, as it so happens that Pringle has given, both in his 
 work on ' Diseases of Armies,' and in his letter to Mead, a 
 description of the eruption so clear as to make it be referred 
 to by most writers on eruptions in continued fevers, it may 
 be as well to quote his own words, which have an especial 
 bearing on this and other portions of my subject. " There 
 are," says he, " certain spots, which are the frequent, but 
 not inseparable, attendant of the fever in its worst state. 
 These are less usual on the first breaking out in the hospitals ; 
 but when the air becomes more corrupted the spots are 
 common. They are of the petechial kind, of an obscure red 
 colour, paler than the measles, not raised above the skin, 
 
 1 ' Edin. Journ.,' No. 143, p. 282. 
 
 ^ ' Med. -Chirurg. Review,' vol. xxsi, p. 103.
 
 200 . ON TUB NATURE AND PATHOLOGY OP 
 
 of no regular shape, but confluent. Tlie nearer tliese spots 
 approach to a purple colour the more ominous they are, 
 though not absolutely mortal/' The most of the authors 
 quoted by Gautliier de Claubry mention the existence both 
 of the '' rosy and petechial eruptions/' the latter coming on 
 at a later period of the affection, and in adynamic patients. 
 
 Dr. Roupell, in speaking of the opinion of some authors, 
 that the " conversion of petochice into the rash is a common 
 occurrence," has evidently, as his reviewer remarks, said the 
 reverse of what lie meant to convey to his readers. My friend. 
 Dr. Staberoh, of Berlin, from observations of whicli I can 
 attest the accuracy, made in Glasgow Fever Hospital, where 
 I then resided, drew attention to the frequent conversion 
 of the rosy eruption into petechia3, in a paper published in 
 the ' Medical Gazette,' for March, 1838, and in reference to it 
 Dr. West has the following remarks : '^ My attention having 
 been called to the point by a paper of Dr. Staberoh, I have 
 endeavoured to ascertain, whether, as he asserts, tlie spots 
 often change into ordinary petechias, but have not yet been 
 able to satisfy myself upon the point, though, from one or 
 two cases which I have seen, in which the spots greatly 
 resembled petechias, I should think that his statement is 
 very probably correct." Dr. Staberoh, in his thesis on the 
 Exanthematic Typlius at Halle, in 1834, maintains the same 
 opinion. Having thus, by quotations, shown that my opinion, 
 so far from being original, has been partly recognised for 
 centuries, and has been fully developed, of late years, by 
 otber writers, it only remains for me to offer the fruits of my 
 own observation. 
 
 Having observed with care, several times daily, the cases 
 referred to by Dr. Staberoh, in whicli a considerable number 
 of spots were circumscribed with ink, I have seen the changes 
 referred to going on in the most gradual manner; indeed, 
 the fact was so clear that I find, in my daily reports of 
 numerous cases, taken months before kis arrival, and when 
 my attention was not particularly directed to the point, the 
 phrases, " pale, florid, darkening, dark, livid, petechial," 
 applied successively to the eruption at various stages of the 
 disease. In the details I am about to give the general 
 principle is all I Avisli or need to establish ; the periods at
 
 TYPHUS AND TYPHOID FEVER. 
 
 201 
 
 whicli tlie clianges take place I do not now seek to deter- 
 mine. Having" specified the four states of florid^ dark, livid, 
 and petecliial I would have it borne in mind that, when 
 florid, the eruption disappears readily under pressure ; when 
 dark, it still disappears, but more slowly ; when livid, semi- 
 petechial, or pseudo-petechial (as it has been called), it is 
 only partially effaced ; when petechial it .is not in the least 
 affected by pressure. In many cases, it remains florid 
 throughout ; in others, it presents one or more, and in not a 
 few, all these alterations ; and after it has reached its height 
 the process is inverted, and it passes through the various 
 phases of lividity, darkness, redness, and paleness, before its 
 evanescence. When death took place at the time the eruption 
 was petechial, the ecchymoses (for they are true ecchymoses) 
 remained after death — a circumstance noted by Dr. West, 
 and particularly insisted on by Valleix in the paper already 
 referred to. Dr. Henderson says (p. 12), ''In a few, the 
 tint was somewhat purple ; and this colour could be assumed 
 by an eruption that had formerly been scarlet.'" By including 
 in the following tables the deaths in the various groups of 
 cases, they will serve for reference, when I come to speak, 
 as I shall do presently, of the relation that subsists between 
 the states of the eruption and the gravity of the cases. 
 The colour of the eruption was : 
 
 
 
 Cases. 
 
 Deaths. 
 
 Rateof morlality 
 
 Pale througliout in 
 
 
 34 
 
 3 
 
 I in 11^ 
 
 Florid 
 
 
 25 
 
 2 
 
 I in 12^ 
 
 Darkisli iii 
 
 
 16 
 
 2 
 
 I in 8 
 
 Dark 
 
 
 32 
 
 8 
 
 I in 4 
 
 Livid or semipetecliial in 
 
 15 
 
 7 
 
 I in 2|- 
 
 Petechial 
 
 
 17 
 
 4 
 
 I in 41 
 
 ^39 
 
 26 
 
 5* 
 
 Hence it appears that the eruption was pale in about one 
 fourth; florid in between one sixth and one seventh; darkish 
 in between one eighth and one ninth ; livid in rather less 
 than one ninth ; petechial in about one eighth of the whole 
 cases. Dividing them, then, into two groups, we have the 
 following result :
 
 202 ON THE NATUllE AND PATHOLOGY OF 
 
 Cases Deaths. Hale of mortality. 
 Eruption light coloured in .59 5 i in 1 1 * 
 
 dark coloured .80 21 i in 34- 
 
 139 26 I in 5| 
 
 I have been thus minute in my subdivisions,, in order to 
 show more clearly the almost insensible gradations by which 
 the rash is transformed from its florid or esanthematous 
 into its petechial state ; and in order to demonstrate at once 
 its difference from purpura and vibices^ and the truth of my 
 concluding position. I met with purpura spots in three, 
 and vibices in only two cases. In one of the former, a 
 plentiful crop of purple spots appeared suddenly on the 14th 
 day, on the chest and belly, amid a "^pale, scanty, and very 
 small " eruption. The pulse, which had before gradually 
 increased in frequency, was 128 on the I2tli day; on the 
 13th, it fell to 116. It continued to fall steadily, by about 
 six beats each day, becoming gradually fuller and firmer ; 
 the intensity of all the other symptoms diminished as steadily, 
 and convalescence was completely established on the 21st 
 day. In another case, a large crop of very minute spots, 
 differing completely in colour from the erujDtion, which had 
 been petechial for days before, appeared on the i2tli day, 
 on the right arm, and faded away long before the eruption. 
 The pulse, 120 on the loth day, fell on the nth to 104, and 
 on the 13th to 96, and during the four following days to 54; 
 on the same day epistaxis occurred, and the violence of all 
 the symptoms diminished, but the severity of the attack left 
 the patient exceedingly weak, and convalescence was not 
 fairly established till the 31st day. In the third case, very 
 numerous spots, similar to those already described, appeared 
 around the left elbow on the loth day, amidst a " darkish'^ 
 eruption. On the same day the patient died. The coun- 
 tenance, which the day before was wild, flushed, and much 
 oppressed, is reported " languid, much better ; " and the 
 pulse had fallen from 136 to 128, and was of better strength, 
 but an intense bronchitis and the supervention of pneumonia, 
 with great pectoral oppression, proved fatal. The difference 
 in the appearance of' the spots is well described by Dr. 
 Staberoh. The spots of petechial eruption are ill-defined 
 and shaded off at their margins, and have a dusky, reddish-
 
 TYPHUS AND TYPHOID FEVER. 203 
 
 brown colour, wliile the spots of purpura, besides having 
 abrupt and very clearly defined margins, present a decided 
 shade of blue, which, as Dr. Staberoh remarks, renders the 
 name applied to them very appropriate. Vibices appeared 
 upon the chest in one case on the loth day, amid a pale 
 eruption, that became afterwards more mai'ked, while the 
 ecchymose.s grew paler. The pulse, on the 9th day 124, had 
 fallen to 112; the state of the patient improved rapidly, and 
 convalescence took place on the i8th day. In another, the 
 vibices were pretty numerous, large, and very irregular in 
 form, and appeared on the 12th day, amid livid and petechial 
 eruption; the pulse fell from 132, the number of pulsations 
 on the day before, to 122, and convalescence was complete 
 on the 2oth day. From these details it appears clearly 
 that purpura and vibices are of rare occurrence in typhus, 
 are quite distinct from the typhous eruption, and that, instead 
 of being attended with peculiar danger, they would actually 
 appear to be critical. We may also conclude that if, as Dr. 
 Copland insists, " the petechial affection is not in any sense 
 of the word an eruption" — "the exanthematous eruption is'^ 
 not only ^' often associated with" petechias, but is often itself 
 petechial. 
 
 I now proceed to my second proposition. Dr. West (loc. 
 cit., p. 141) says, that in the cases he observed "the abun- 
 dance or scarcity of the eruption was not at all in propoi'tion 
 to the severity or mildness of the different cases." He 
 considers petechia; not to be particularly ill omened" (an 
 opinion somewhat borne out by the facts stated above), "and 
 certainly by no means so much to be dreaded as the dark 
 and livid hue of the eruption, and of the skin generally, which 
 is sometimes observed." To the first assertion, so vague 
 and so general, I oppose his own words (at p. 290 of the 
 ' Edinburgh Journal ' for this year) , where, speaking of 
 Willises account of the epidemic that broke out in the spring- 
 of 1643 among the troops near Oxford, and was for some 
 time unaccompanied by eruption, he says, "About midsummer 
 the disease increased in fatality," and then goes on to give 
 the description of the eruption already referred to. I oppose 
 to it also the general fact that the eruption is seen in its 
 greatest perfection in extensive epidemics, during which the
 
 204 ON THE NATUEE AND PATHOLOGY OF 
 
 disease is mucli more violent and fatal ; and the fact_, that in 
 Glasgow, when the cases were few, the disease very mild, 
 and the deaths i in lo, or i in 12, the eruption, if present, 
 was never observed ; whereas, when the cases became more 
 numerous, the disease more malignant, and the deaths 
 amounted to i in 8 and i in 6|, the eruption became steadily 
 more and more abundant. Dr. Peebles accounts for the 
 scantiness of the eruption in Edinburgh, at the time he made 
 his observations, by typhus not being epidemic. Dr. Hender- 
 son states the deaths among those with abundant eruption 
 as I in 5 ; among those with scanty eruption as i in 8 "3. 
 Two of the three fatal cases in the latter class presented 
 ^^ extensive visceral disease of long standing;" while not one 
 o-f the thirteen in the former class had any such disease. 
 The duration of the cases was, on an average, between two 
 and three days longer in the one than the other. My own 
 observations, likewise, show the relation between the abun- 
 dance of the eruption and the severity of the disease. The 
 eruption was : 
 
 
 
 Cases. 
 
 Deaths. 
 
 Rate of mortality. 
 
 Copious 
 
 ^ Universally in 
 C Partially in 
 
 . 96 
 • 32 
 
 19 
 
 5 
 
 I in 5 
 I in 6'4 
 
 Scanty 
 
 . 
 
 II 
 
 i' 
 
 1 in II 
 
 The dark tint of the eruption is noted as ominous by all 
 authors. The quotations I have given above prove the 
 general opinion ; and I may likewise refer to most of the 
 authors cited by Dr. West, and Grauthier do Claubry, to 
 Dr. Tweedie (p. 73), and Dr. Henderson (p. 12). The 
 existence of a mortality in those with dark, three times 
 greater than in those with light-coloured eruption, in the 
 tables I have presented above, shows in the clearest manner 
 the truth of these opinions, and renders needless any further 
 comment. This fact ascertained, we cease to wonder at 
 Valleix's sweeping conclusions, drawn from six cases, five 
 of which were fatal. 
 
 Typhoid fever has also its eruption, — a circumstance much 
 insisted on by Gauthier de Claubry in proof of its identity 
 with typhus. It is generally agreed (Chomel, Louis, Gauthier 
 
 ^ In this one case tlie eruption was petechial, and, on inspection, I found 
 disease of old standing, and aneurismal dilatation of the aorta.
 
 TYPHUS AND TYrnOID FEVEE. 205 
 
 de Claubry, Montault), and my own experience leads me to 
 assert it, that it appears later tlian the exanthema of typhus, 
 but that is a point of very minor importance j the main 
 question is, are its characters the same ? According to all 
 the best authors on the subject (Chomel, Rayer, Biett, 
 Rochoux, &c.) it is distinguished from the morbilliform 
 eruption of typhus by being distinct, rounded, slightly elevated 
 above the skin, and of nearly uniform size. In only one case 
 (which I saw in the Hotel Dieu last winter) have I noticed 
 anything like an approach to the irregular, and very often 
 confluent, rash of typhus, which is generally level with the 
 skin, or if raised, is very slightly so, and that only during 
 the stage of excitement. In all the other cases of typhoid 
 fever in which I have seen the eruption I should say that it 
 appeared in small spots, rounded, and almost papular in form, 
 being considerably elevated in the centre. Dr. Perry, of 
 Glasgow, was the first whom I heard maintain the complete 
 difference of the two eruptions, and I am now fully satisfied 
 of the accuracy of that opinion, for the following reasons : 
 
 1. The typhoid eruption is not permanent. That the 
 typhous exanthema is so, has, I think, been shown by 
 abundant evidence; but it is generally agreed that the rash 
 in typhoid fever is " composed of several successive erup- 
 tions,"^ that its duration varies from three to seventeen days,^ 
 the mean duration being seven and a half, and that ^'each 
 rosy spot is not commonly visible for more than three or four 
 days, and sometimes less." I have often been able to verify 
 this remark. 
 
 2. I have never seen a single case in which the typhoid 
 eruption became petechial or even dark, and no author I have 
 consulted pretends that it does. On the contrary, it always 
 retains the same characters, the last crops (and I have seen 
 them appear the day before death, in cases where there was 
 the most complete prostration) being as florid as the first. 
 Reflections on the necessary relation between the state of the 
 blood and the appearance of the eruption, which I cannot 
 now develop, but which are strongly confirmed by the frequent 
 occurrence of a buffy coat, and a pretty firm coagulum, in 
 
 ^ Chomel, 'Lemons,' &c., p. 19 ; also Louis, vol. ii, p. 232, 241. 
 ' Chomel and Louis.
 
 206 ON THE NATUUE AND TATHOLOGY OF 
 
 typhoid fever_, will naturally suggest tliemselvos to every 
 mind. 
 
 3. It is beyond a doubt tbat tlicre is no relation between 
 tlie eruption and the severity of the cases. I confess tliat 
 I long felt inclined to believe tliat the more plentiful the 
 eruption the less serious the case. I was particularly led 
 to think so by the total absence or extreme scantiness of the 
 eruption (though carefully sought for) in the Glasgow epidemic 
 of 1836^ which was very deadly, and by afterwards finding- 
 it more ov less copious in sporadic cases presenting a much 
 less intense form of the affection. After further inquiry, 
 I find, that though in its fullest sense the opinion is incorrect, 
 it is to a certain extent true. From a careful perusal of the 
 valuable work of Chomel, I find that a large proportion of 
 the worst cases, and of those who died, had either a scanty 
 eruption or none at all ; and it appears from the lucid state- 
 ments of Louis,^ that it was wanting in g out of 35 fatal 
 ■cases, and that it was scanty {en petit nomhre) in 18, or three 
 fourths of the remaining 26, some of them presenting- only 
 five or six spots ; a number reckoned by Chomel (p. 1 8) of 
 no value, fifteen or twenty being necessary, according to 
 him, to " characterise the typhoid affection." Fifty-four of 
 fifty-seven patients who had severe attacks, but recovered, 
 had the eruption, and of the remaining three, two came to 
 the hospital on the 14th and 40th days of the disease. '^In 
 some cases," he adds, " there was only a small number of 
 spots." In twelve " the eruption was very abundant." 
 It was present " in all the cases where the affection was 
 slight," whence he infers, that " its cause is special," or 
 specific, and that it is not like other secondary phenomena, 
 proportioned to the gravity of the disease and the febrile 
 movement." Hence wo may at least conclude, that in severe 
 attacks of typhoid fever, the eruption is less frequent, and 
 generally less plentiful than in those that are less serious. 
 Does any one object that these reasonings prove not the 
 difference of the eruptions, but merely a different determi- 
 nation of one and the same eruption, in the one case to the 
 skin, in the other to the mucous surface, which has been 
 called ''the inverted skin?" — I reply that, according to this 
 ' Louis, vol. ii, 231, ct scq.
 
 TYPHUS AND TYPHOID FEVER. 207 
 
 hypothesis (for it is a pure hypothesis) ^ there sliould be in 
 typhus with scanty eruption a decided abdominal determi- 
 nation ; but the fact, as undeniable as it is conclusive, is 
 exactly the reverse ; for numberless cases of typhus with 
 scanty eruj)tion are remarkable only for their mildness and 
 the absence of any visceral complication. This is particularly 
 the case in children, in whom the eruption is seldom seen. 
 
 We may also conclude generally that the facts detailed 
 go against the opinion of Chomel (p. 336), that 'Hhe cutaneous 
 exanthema offers the same characters in the two affections; 
 the only differences being in the number of the sjDots, and 
 the time of their appearance," and that, on the contrary, 
 the typhous differs from the typhoid eruption in its form, 
 its duration, the changes it undergoes, and the relation it 
 bears, as to colour and quantity, to the severity of the 
 disease. 
 
 V. In the plan I laid down, I proposed to consider some 
 of the anatomical lesions. To enter on a comparison of the 
 whole pathological anatomy of the two diseases were a task 
 as tiresome as it would be barren of any definite results. 
 Instead, therefore, of inquiring into the state of all the 
 organs in all the different cavities, I shall at once meet the 
 question. Is the lesion of Peyer's glands so constantly met 
 with in typhoid fever, frequently, or is it ever, found in 
 typhus ? 
 
 Chomel (p. 339) appears to me to put the question in its 
 true light. His third general conclusion is as follows : 
 " If further observations demonstrate in typhus anatomical 
 lesions similar to those met with in the typhoid affection, 
 the identity of the two affections would be put beyond a 
 doubt.'' To the philosophic caution of the inference of the 
 French professor the following remark offers a strong contrast. 
 A reviewer of various works on typhus and typhoid fever, in 
 the ^British and Foreign Medical Eeview' for last year, after 
 asserting (p. 432), that the symptoms during life are the same, 
 and quoting a passage from Gauthier de Claubry (referring 
 to the experience of four out of twenty-two observers who 
 described the epidemics of army typhus during the wars of 
 the Empire as decisive of the question), thus proceeds, ^^We 
 do not know that any additional facts from the morbid
 
 208 ON THE NATURE AND PATHOLOGY OF 
 
 anatomy of tlie intestinal canal are required. In our own 
 country we do not require any argument to persuade us of 
 tlie identity of these supposed distinct diseases ; the evidence 
 is constantly before our eyes !" Montault, notwitlistauding 
 the assertion of his reviewer that his remarks are valueless, 
 points out clearly the absence of the intestinal affection in 
 typhus, and cites numerous authors to that effect. Roupell 
 considers the absence of this lesion, which he fully admits, 
 as accidental. Tweedie combats strenuously the opinions of 
 Broussais (p. 57), and adduces the frequent absence of 
 intestinal lesion as proof of their incorrectness. I remarked 
 at the outset that, in the cases detailed by Dr. Tweedie, 
 there were evidently two kinds of fever, the one distinguished 
 from the other during life, by difference of intensity and 
 duration, and after death by the lesions observed. In point 
 of fact, I find thirteen cases in which ulceration of Peyer's 
 glands had taken place, and nine in which there was no 
 intestinal lesion whatever, but general congestion. Dalmas, 
 in his account of what he heard and leai^ned (not saw) at 
 Dublin, cannot deny that the lesion is frequently absent ; 
 but only says, ^*^it is perfectly well known" there. So it 
 was in Glasgow, but even to me, a perfectly inexperienced 
 observer, the distinctive symptoms were well known also. 
 Gauthier de Claubry, evidently feeling the force of Chomel's 
 remark, has laboured hard, throughout a very large portion 
 of his work, to get rid of this very strong objection to his 
 opinion. Reveille Parisc, on whose testimony he lays much 
 weight, observed in those who died at Saragossa, " some 
 gangrenous points in the interior of the intestines, and on 
 the exterior, violet patches" (p. 18). Ducastaing (p. 16) 
 found in many of those who fell victims at Gaeta in 1802, 
 "the mucous membrane ulcerated in several points." Tresat, 
 at Walcheren, in i8og, found '^ gangi'cne of some parts of 
 the intestinal canal" (p. ig). Tort, at Dantzick, in 1813, 
 found "the small intestine sprinkled with gangrenous eschars " 
 (p. 23). Gilles de la Tourctte, at Torgau, in 181 3, found 
 '^serous and bloody effusions, inflammations, ecchymoses, gan- 
 grenous spots of the mucous and serous membranes" (p. 24). 
 MM. Laurent and Ardy, Magnin, and Fauverge, mention 
 inflammation, ulceration, gangrene in some points, violet
 
 TYPHUS AND TYPHOID FEVER. 209 
 
 patches^ scu'rliöus indurations of the mucous membrane of 
 the small gut. as occurring in the Majence epidemic of 1 8 1 3, 
 (p. 26—7). Thouvenel^ in the department de la Meurthe^ the 
 same year, found '^ generally some gangrenous spots in several 
 parts of the membranes of the intestines/' (p. 35). In the 
 epidemic of the Salpetriere in 18 14, Pellerin, "in adynamic 
 fever with diarrhoea, which,^' says Gauthier de Claubry, "he 
 appai-ently believes a distinct disease in this circumstance," 
 describes ulcerations that seem to correspond veiy closely 
 with those found in typhoid fever, as " often/' not always, 
 met with. 
 
 After the foregoing investigations, are we not warranted 
 in considering it, with Pellerin who witnessed it, " a distinct 
 disease ? " Chomel, also, with his customary caution, when 
 speaking (p. 337—8) of the same epidemic, remarks that he 
 " cannot place entire confidence in his recollections." If such 
 disease as is daily found in the intestines of persons dying 
 of typhoid fever, had been present, it could not, I should 
 think, have been easily forgotten. Is it, then, really on such 
 statements as these, on the existence of " violet stains " and 
 "gangrenous spots" (which might, for aught we know to 
 the contrary, have been the effect of decomposition, in a 
 disease that often terminated with frightful rapidity), that 
 Gauthier de Claubry and his reviewer would rest the decision 
 ■of the question at issue?- It was but yesterday that I saw, 
 at M. Earth's rooms, large elliptical patches of ulceration in 
 the jejunum of a female who had died of puerperal fever, 
 with rupture of the uterus and peritonitis, — ulcers which, 
 had they been found in a patient who had presented the 
 ordinary symptoms of typhoid fever, would certainly have 
 been looked upon as characteristic of the disease. Is, then, 
 puerperal fever identical with the typhoid affection ? I also 
 saw a few days since, at M. Earth's, in a portion of gut taken 
 from a patient who had, I believe, died of phthisis, large 
 patches, of no determinate shape, extending around the whole 
 calibre of the tube, the mucous membrane being in these 
 parts immensely swollen; raised a couple of lines above the 
 surrounding surface, traversed by deep ruga3, and having a 
 greenish- black colour, with the characteristic gangrenous 
 fcetor. Is it beyond the range of possibility that such may 
 
 14
 
 210 ON THE NATURE AND PATHOLOGY OF 
 
 have been the state of the intestines in the *army epidemics 
 referred to ? Is it not rather highly probable that, where 
 everything indicated a deeply altered and corrupted state of 
 the blood, and local gangrene was of frequent occurrence, 
 the gut as alleged by all the observers cited, may have been 
 actually sphacelated ? All that I have in view in these 
 remarks is to demonstrate that, even were the existence of 
 such lesions proved beyond a doubt, the alteration of the 
 glands of Peyer, and the isolated follicles, now called charac- 
 teristic, is very far from being proved thereby. 
 
 But are there no facts that bear against the reasonings of 
 the French essayist ? On the contrary, there are many. 
 Lombard has graphically described his surprise on finding 
 no lesions whatever in several cases he saw inspected while 
 in Scotland and Ireland. We have seen the supposition 
 Gauthier de Claubry has recourse to in order to explain away 
 his testimony ; and, even granting that " the circumstances 
 of misery and exhaustion,^' in which, according to him, the 
 people of Scotland are placed, do, as he supposes, produce a 
 strong resemblance in the prevailing fever to army typhus 
 (p. 143), does he advance one step towards a removal of the 
 difficulty by gaining such an admission ? Nay, rather, if 
 M. Gauthier de Claubry has made out his position, that the 
 intestinal lesion is present in typhus as well as in typhoid 
 fever, whence this allusion to army typhus to explain the 
 want of intestinal lesion — an allusion by which he demolishes 
 the structure his work was intended to raise, and unwittingly 
 discloses his own distrust in his own opinions ? Again, 
 M. Delbosc (cited at p. 38), in his account of the epidemic 
 at Alby in 1823, mentions only "a^ rosy colour of the peritoneal 
 tunic," and M. Keraudren and the Toulon physicians, "though 
 their attention was specially directed to that point by the 
 questions addressed to them by the Academy of Medicine,^ 
 never observed any intestinal lesion in the typhous epidemic 
 at Toulon in 1829—30. I have already referred to Dr. 
 Twecdie's data, and have cited M. Dalmas's silence as im- 
 partial evidence, though in the United Kingdom very few 
 require evidence to convince them, that in Dublin, as else- 
 wherCp a form of fever exists, of highly malignant character, 
 
 ^ Chomel, p. 338.
 
 TYPHUS AND TYPHOID FEVER. 2U 
 
 and most extensively fatal_, in which no intestinal lesion is 
 found even on the most ca7'eful inspection. Dr. Alison, of 
 Edinburgh (from whom I cannot quote accurately, not having 
 access to his work), corroborates the experience of other 
 observers.^ 
 
 I now proceed to give some more circumstantial details 
 upon this interesting subject. Dr. West^ gives the results 
 of ten inspections. In five (I merely speak of the state of 
 the bowel) "there was no morbid appearance whatever ;^^ 
 in the other five " there was increased vascularity of the 
 intestinal canal, extreme in one instance.'^ ''Once the glands 
 of Peyer appeared enlarged, and twice there was very con- 
 siderable enlargement of the solitary glands ; but I never," 
 says he, " found them ulcerated. Once the mucous mem- 
 brane of the ceecum was very much softened and congested, 
 and there was slight abrasion of the surface of some of the 
 congested patches." Dr. Eeid^ states, that of loi cases 
 examined in the Edinburgh Infirmary, by his predecessor, 
 ths late Dr. Home, " the elliptical patches were well defined 
 in 29 ; they were more or less ulcerated in 7 of that 
 number and in 2 out of the 7, perforation had taken 
 place." He next gives* a summary of the morbid appear- 
 ances in 41 cases inspected by himself. In 24, " Peyer' s 
 glands were apparent and distinctly defined;" in 6, ''scarcely 
 visible;" in 11, invisible to "the naked eye." In 4 only 
 were they " distinctly elevated ; " and in 2 of the 4, " this 
 elevation was to no great extent, and limited to a few patches." 
 In 2 only was there " any appearance of ulceration." In 4, 
 the solitary glands were " distinctly visible." Regarding 
 the connection of the symptoms during life with the post- 
 mortem lesions, he says,^ " In 9 cases only out of the 24, in 
 which the elliptical patches were distinctly visible, were there 
 any abdominal symptoms during life, and in some of those 
 
 ^ Dr. Alison Las published no separate work, but Observations, &c., in 
 the twenty-eighth volume of the 'Edinburgh Medical and Surgical Journal,' 
 P- 233.— Ed. 
 
 * ' Edin. Journal,' vol. 1, p. 132-3. 
 
 3 Eeport, &c., p. 33. 
 
 ^ Ibid., pp. 30,31. 
 
 » Ibid., p. 34.
 
 212 ON THE NATURE AND PATHOLOGY OF 
 
 cases these certainly could not be referred to any affection 
 of the elliptical patches of Peyer." "In. one case in wliich 
 they were not visible, the bowels are stated to have been 
 rather loose, the stools watery and dark coloured. In other 
 two cases there was considerable abdominal tenderness, 
 without diarrhoea/' 
 
 I shall preface with a few remarks tke two following and 
 concluding tables, whicli give the results of my own observa- 
 tion. They refer to twenty-two inspections, — but a small 
 number, it is true, yet made witb as great care and attention 
 to accuracy as I could bestow on them. The solution of the 
 interesting question. Is there any connection between the 
 abdominal symptoms during life, and the state of the intes- 
 tinal follicles in typhus? may be attempted in different ways. 
 We may compare the symptoms, whether positive or negatiA^e, 
 with the mucous follicles, as regards (i) their number, and (2) 
 tkeir degree of development. And after having, as far as 
 our data enable us, determined these points, we must not be 
 unmindful of the objections that may be urged, as, for instance, 
 that our terms are vague ; that our cases are too few to draw 
 conclusions from; that absorption of morbid matter may have 
 taken place before death, or, it may be, that deatb has arrived 
 before its deposition was possible. I shall meet some of these 
 objections beforehand. The cases, I acknowledge, ai'e few, 
 but I maintain that they are a fair sample of hundreds that 
 occur yeai'ly, and at the same time direct attention to the 
 numerous facts I have already cited. To take away all 
 vagueness from the terms I employ, I make the following 
 statements respecting the state of the intestinal follicles. 
 It was very rare, in the cases of typhus which I either in- 
 spected or saw inspected, during a two years' residence in 
 Glasgow Infirmary, to see these glands elevated a quarter 
 of a line above the surrounding mucous membrane, and in 
 tke vast majority it was very difficult to determine whether 
 they were really elevated or not, the slight roughening or 
 irregularity of their surface often causing a visual deception. 
 When, therefore, we speak of the elevation of the aggregate 
 glands in typhus we are no longer occupied, as in typhoid 
 fever, in the measurement of palpable magnitudes, but for 
 the most part with elevations, which French pathologists.
 
 TYPHUS AND TYPriOID FEVER. 
 
 213 
 
 as I have frequently witnessed, scarcely reckon any deviation 
 from tlie healthy state. To avoid overlooking, not one, but 
 many, of these (enlarged?) glands often requires very minute 
 attention. The other objections I shall leave to be answered 
 by the facts about to be adduced, only remarking that the 
 removal by absorption of the morbid matter from the follicles 
 is a very rare termination, even in typhoid fever. Chomel 
 mentions two cases in which that process had probably taken 
 place,^ and I cannot see why it should be more common and 
 more speedy in typhus. The first of the following tables 
 refers to the number of follicles met with in the small gut ; 
 the second to their state of development. 
 
 •No. of 
 enlarged 
 fuUicles. 
 
 cc 
 
 Ü 
 
 DiarrlioDa. 
 
 ,0 
 
 Tjmpanitcs. 
 
 Abdominal pain. 
 
 State of follicles. 
 
 s 
 
 a 
 
 
 'S 
 
 a 
 
 
 
 w 
 
 3 
 
 
 
 '<, 
 
 5 
 c5 
 
 ■S 
 
 i 
 
 
 := 
 > 
 
 ■3 
 
 CO 
 
 None . 
 I to 5 
 5 to lo 
 lo to 15 
 15 to 20 
 20 to 30 
 30 to 40 
 40 to 50 
 
 I 
 4 
 4 
 4 
 3 
 4 
 I 
 I 
 
 I 
 2 
 
 I 
 
 I 
 
 3 
 
 I 
 2 
 I 
 I 
 I 
 
 I 
 
 2 
 I 
 3 
 
 I 
 
 I 
 I 
 
 I 
 
 I 
 I 
 
 I 
 I 
 
 2 
 
 2 
 
 2 
 2 
 I 
 I 
 4 
 
 I 
 I 
 4 
 
 2 
 
 I 
 
 2 
 
 3 
 3 
 
 I 
 
 I 
 I 
 2 
 
 I 
 I 
 
 2 
 2 
 
 3 
 
 I 
 
 2 
 2 
 
 I 
 
 4 
 
 2 
 
 22 
 
 4 
 
 10 
 
 8 
 
 6 
 
 6 
 
 10 
 
 9 
 
 9 
 
 4 
 
 2 
 
 8 
 
 5 
 
 6 
 
 
 Cases. 
 
 Diarrhoea. 
 
 
 
 Tympanites. 
 
 Abdominal pain. 
 
 a 
 
 ? 
 
 
 — 
 
 
 
 
 
 Intestinal foUicles. 
 
 
 a 
 
 ■■g 
 
 C3 
 
 
 ;-• 
 
 
 
 
 
 
 
 S 
 
 s 
 
 
 ^ 
 
 n 
 
 
 ^ _ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a 
 
 a 
 
 so 
 
 
 s 
 
 
 3 
 
 
 
 
 
 o 
 
 o 
 
 ^ 
 
 Ü 
 
 !zi 
 
 M 
 
 -< 
 
 1 
 
 Distinctly elevated in . 
 
 2 
 
 
 
 I 
 
 I 
 
 I 
 
 
 
 I 
 
 2 
 
 
 
 _ 
 
 Very slightly elevated . 
 
 8 
 
 I 
 
 4 
 
 3 
 
 I 
 
 3 
 
 4 
 
 3 
 
 4 
 
 I 
 
 Not elevated 
 
 n 
 
 — 
 
 2 
 
 3 
 
 2 
 
 I 
 
 2 
 
 
 3 
 
 2 
 
 Scarcely seen 
 
 6 
 
 2 
 
 3 
 
 I 
 
 I 
 
 I 
 
 4 
 
 4 
 
 I 
 8 
 
 I 
 4 
 
 21 
 
 3 
 
 10 
 
 8 
 
 5 
 
 5 
 
 II 
 
 9 
 
 ^ Observ. 14 and 15» pp. 169, 173.
 
 214 ON THE NATURE AND PATHOLOGY OP 
 
 Thus we see that 4 only of the 23 in whom diarrhoea was 
 spontaneous rank in the above list. In one of the 4, the 
 diarrhoea depended on an attack of simple enteritis, wliich 
 came on after partial convalescence, and carried off the 
 patient on the 34th day. No trace of follicular disease was 
 found on inspection, but "'universal softening of the mucous 
 membrane from the duodenum to the rectum.^^ Two of the 
 remaining 3 may almost be said to have presented no trace 
 of follicular disease, for the three or four follicles observed 
 in eachi were barely perceptible to the naked eye. In the 
 fourth, fourteen Peyer's glands, scarcely at all elevated, were 
 detected. But what chiefly concerns us to notice is the striking 
 fact, that, as the number of enlarged follicles increases, tlie 
 cases of spontaneous diarHioea diminish, and those in wbom 
 consecutive diarrhoea and costiveness were observed become 
 more numerous. In fact, not one of those in whom tlie 
 greatest number of enlai'ged follicles was observed, but was 
 either constipated, or had diarrhoea brought on by medicine, 
 during life. This confirms our former deductions, agrees 
 entirely with those of Valleix, and shows that the appearances 
 observed in typhus depend upon local irritation and not on 
 specific disease. 
 
 It will also be observed that in 10 of tlie 22 (including 
 5 of those in whom from 15 to 30 enlarged glands were 
 observed) the feel of the abdomen was natural tbrougliout 
 the disease. Of the 6 in whom the belly was slightly tym- 
 panitic, that symptom was observed only one day in four 
 patients (the one in whom the greatest number of enlarged 
 follicles was found being among them) ; in one with forty 
 enlarged glands, it was present during two days ; the sixth 
 was the patient who died of enteritis. Of the. six, on the 
 other band, who presented a high degree of tympanites, in 
 not one were there so many as twenty, and in one whose 
 abdomen was excessively distended scarcely a trace of fol- 
 licular disease was detected. 
 
 There seems, at first sight, to be more connection between 
 tbe presence of abdominal pain and the number of altered 
 glands, but this is only apparent, for a reference to the 
 figures given above sbows that, in 8 of the 9 in whom 
 the pain was acute, not more than twenty were found in the
 
 TYPHUS AND TYPHOID FEVER. 215 
 
 wTiole course of tlie gut ; tliat^ of the 9 who complained 
 of slight pain they were either not at all, or very slightly 
 affected in 6 ; and that, if 2 of those in whom they were 
 noticed in large numbers (twenty to thirty), had slight pain, 
 2 more of the same group had no pain at all, at any period 
 of the disease. The concluding part of the table proves that 
 quite as little analogy exists between the number of follicles 
 and their degree of development. As a fitting commentary 
 on what I have now advanced, I find' that in the only case 
 in which considerable elevation of Peyer^s glands (about 
 half a line), and a few ulcers (not follicular) in the caecum, 
 were observed, the bowels were obstinately constipated, the 
 feel of the belly was natural throughout, and the abdominal 
 pain was either exceedingly slight or absent, till within a 
 few hours of death, having come on after the administration 
 of a clyster, composed of equal parts of turpentine and castor- 
 oil. 
 
 These remarks are still further confirmed by a reference 
 to the second table, in which the symptoms are considered 
 with respect to the degree of development of the follicles. 
 The same dependence of the intestinal lesion on local irritation, 
 the same entire disproportion between the extent of the lesion 
 and the intensity of the symptoms, are brought out so clearly 
 by it as to render any further reflections needless. The 
 utter futility of the objection founded on the possible absorp- 
 tion or non-deposition of morbid matter, will appear from the 
 following facts. Comparing the number of follicles with the 
 days of death, I find that, of those belonging to the first 
 group, one died on the 12th, another on the 13th, a third on 
 the 14th, and a fourth on the i6th day. Of the second 
 group, two died on the 12th, another on the 17th, and a 
 fourth on the 36th day. Of the third, one died on the loth, 
 one on the 14th, the other two on the 21st and 24th days. 
 The three belonging to the fourth group died severally on 
 the 1 3th, 1 5th, and 1 9th ; those in the fifth, on the i oth, 
 nth, and 13th, the two in the 6th and 7th, respectively on 
 the nth and 22nd days of the fever. Thus, then, of two 
 who die on the same day of the affection, one presents scarcely 
 a trace of disease, another as many as thirty enlarged glands. 
 In one who dies on the nth day, no less than forty Peyer's
 
 216 ON THE NATüßE AND PATHOLOGY OP 
 
 glands are observed^ while in otliers wlio die on the i2th> 
 13th, I4.ih., and i6th, scarcely any morbid appearance is 
 detected ; in another, who dies on the 22nd, no less than 
 forty-five, while in a seventh, who dies on the 24th, only 
 ten or eleven Peyer's glands are obscurely visible. 
 
 Again, if -we consider the development of the glands, in 
 reference to the day of death, we find that, of the first group, 
 one died on the loth, another on the nth day; of the second, 
 one on the loth, another on the nth, a third on the 13th, 
 a fourth on the 15th, and the remaining four, respectively, 
 on the 17th, 19th, 24th, and 36th days; of the third, one on 
 the nth, another on the 13th, a third on the 14th the 
 remaining two on the 21st and 22nd days; of the fourth, 
 three died on the 12th, and the remaining three severally 
 on the 13th, 14th, and i6th days. Thus two die on the loth 
 and nth days with Peyer's glands distinctly elevated (in 
 one of them to the extent of about half a line) ; they are 
 scarcely discernible in four who die on the 12th and i3tli 
 days ; while they are in a state of slight elevation in eight,, 
 who die on all different days between the loth and the 36th.- 
 Does this, I ask, look like the steady course of a constant 
 lesion, depending upon a constant and specific cause ? 
 
 The solitary glands were visible, in small number, in three 
 cases ; in one, in the small, in two, in the large intestines. 
 I have, however, seen them very numerous, both in the one 
 and the other, though they were never larger, and seldom 
 so large as a pin's head. They were white, sometimes 
 surrounded with a vivid red areola, and each had a small 
 black point in its centre. The aggregate glands, situated 
 on the free border of the gut, were of all sizes from two or 
 three lines to two or three inches in length, and varied from 
 a couple of lines to nearly an inch in breadth. They were 
 sometimes white, sometimes greyish, sometimes slate-coloured,, 
 frequently dotted over with small black points, often reticu- 
 lated, while sometimes neither the one nor the other appear- 
 ance was noticed.- It is a remarkable fact that, in several 
 cases, the glands were much more numerous in the jejunum 
 than the ileum, and that in two there were none near the 
 ileo-caecal valve. Not unfrequently, the mucous membrane 
 around them was pale, at other times they were situated amid
 
 TYPHUS AND TYPHOID FEVER. 217 
 
 patclies of very dark congestion, in wliicli case they partook 
 more or less of the dark colour of the surrounding membrane. 
 Sometimes, but very seldom, the mucous membrane itself 
 was reddened, and injected with minute vessels ; the con- 
 gestion of the veins of the submucous cellular tissue was, 
 on the contrary, veiy common. 
 
 No one denies the very frequent affection of the mesenteric 
 glonds in typhoid fever. The experience of every one who 
 has seen the inspections of patients cut off by that disease 
 must confirm the facts stated by Chomel, Louis, and Petit 
 and Serres. Though very rare in typhus, it is nevertheless 
 sometimes found. I find it noted by Dr. Tweedie in two 
 cases (i and 44). In the former, " the lungs and abdominal 
 viscera were healthy, excepting the mesenteric glands, which 
 were enlarged and partially affected with suppurations of a 
 scrofulous character " (p. 108). In the latter, " there was- 
 no ulceration of the intestines, but the glands of the mesentery 
 were enlarged.''^ Of my own cases, the mesenteric glands 
 were enlarged in four; in one very slightly, in two in a 
 greater degree, in a fourth to a large extent, but not sup- 
 purated. In the first, death took place on the nth day, 
 and twenty or thirty Peyer's glands, not at all elevated, 
 were found in the small gut ; one of the next two presented 
 eight very slightly developed, the other none at all ; and in 
 the fourth, there were nineteen very slightly elevated. In 
 all of those, then, in whom the enlarged folficles were very 
 numerous, including the only patient in whom they were 
 considerably elevated, the mesenteric glands were unaffected. 
 
 I have been enabled, by the kindness of Dr. Eeid, to 
 present the reader with a much larger mass of information. 
 From the publication of the Report till the end of June, 
 thirty- three cases of fever were inspected in the Edinburgh 
 Infirmary. Of that number only two presented the charac- 
 teristic lesion of the intestinal follicles met with in typhoid 
 fever. In both of them the lardaceous deposit {jplaqiie 
 ganfree) was most distinctly seen, and both the aggregate 
 and solitary glands were affected in great numbers, the latter 
 forming the whitish "flattened tumours^' so well described 
 by Louis. Neither of the patients belonged to Edinburgh ; 
 both were workers on the Edinburgh and Glasgow Railway,
 
 218 ON THE NATURE AND TATHOLOGY OP 
 
 and were sent from Liulitligow. If, then, dothinenteritis is 
 tlie same disease, and depends on tlio same causes, as typlius, 
 how does it happen that the former is produced at Linlithgow 
 and at Anstrnther, and not in Edinburgh, where the latter 
 is constantly occurring, and where so many circumstances 
 favorable, not only to its production, but (by the hypothesis) 
 likewise to that of dothinenteritis, are always at work. The 
 duration of these cases is also remarkable. The one, it 
 appears, had been four, the other five, weeks ill. One of 
 them had convalesced, but had a relapse, of which he died ; 
 and, on dissection, the intestinal follicles and mesenteric 
 glands were the only parts diseased, so that the relapse 
 cannot be referred to any lesion of any other organ. It is 
 further remarkable that the aggregate glands were in a 
 state of advanced ulceration, while most of the solitary glands 
 around them were quite entire. In the remaining 31 cases — 
 
 Peyer's glands were distinctly elevated, but not ulcerated, in . 4 
 
 „ „ visible, but not elevated, in . . 9 
 
 „ „ scarcely visible in . . .7 
 
 „ „ not visible in . . .11 
 
 31 
 
 The solitary glands were slightly developed in two of the 
 above cases. The mesenteric glands were healthy in 25, 
 slightly enlarged in 4, considerably enlarged and softened 
 in I, and in a 6th increased in size, and partially converted 
 into chalky matter. Dr. Reid also informed me that, in a 
 man who died lately of the effects of compound fracture, 
 Peyer's glands were more distinctly diseased than in any 
 case of typhus he had met with. 
 
 Having thus entered pretty minutely into the pathological 
 anatomy of typhus, I put it to every one who has ever seen 
 the two diseases, or read the descriptions given by the best 
 authors, of the lesions so constantly observed in typhoid 
 fever, whether those found in the former disease can with 
 any truth be called '^ perfectly identical " with those of the 
 latter. That the existence of trifling intestinal disease in 
 typhus attests its general family resemblance to typhoid 
 fever, as the presence of organs in a rudimentary state shows 
 the analogy subsisting between individuals of different species
 
 TYFHITS AND TYPHOID FEVER. 219 
 
 in tlie animal kingdom, might be more readily admitted ; 
 but that tliey are one and tlie same species, numerous well- 
 established facts seem most clearly to disprove. If asked 
 to describe shortly the pathology of typhus I might sum it 
 up in these words — general cong'estion, no prominent local 
 disease — a congestion so general and so excessive as is rarely, 
 if ever, met with in typhoid fever or any other disease — 
 a congestion singled out by most authors as one of its leading 
 characteristics — a congestion that is evident, during life, by 
 the livid skin and petechial eruption, and is found, after 
 death, to have aifectcd more or less every organ in the 
 animal economy — a congestion so constant as to be often 
 passed over as almost valueless, but which future researches 
 may prove to be the grand peculiarity of typhus ; and which, 
 in common with many other considerations, directs attention 
 to the blood as the essential seat of the disease. If required, 
 on the other hand, to give a brief account of the pathology 
 of typhoid fever, I should be inclined to sum it up in these 
 words — prominent local lesion, comparatively little general 
 congestion. 
 
 VI. From the treatment of the two diseases we can infer 
 but little. The interesting discussions held at various times 
 on the subject in the Academie de Medecine,^ strikingly 
 show the discordance of sentiment that prevails in Franco 
 on the treatment of dothinenteritis. One upholds the pur- 
 gative system as the best and the only proper one, another 
 condemns it as fraught with the greatest danger ; one insists 
 that the rational method, which consists in combating sym- 
 ptoms as they arise, is the only rational one, but another 
 condemns it as most irrational, because it kills one in three ; 
 one strongly recommends the frequent use of the lancet, 
 according to his formula, even in advanced stages of the 
 disease ; while another, condemning not only the lancet, but 
 all treatment whatever, advocates a method in the purest 
 sense expectant, and unlimited faith in the workings of 
 nature, any attempt to interfere with them being attended 
 with evil results. And every one has facts on his side. 
 
 ' See more particularly those on Delarroque's Memoirs in the ' Bulletins 
 del'Academie' for March 14th, 21st, and 28th, and April 4th and nth, 
 183/". Also Bouillaud's statements at vol. i, p. 250.
 
 220 ON THE NATURE AND PATHOLOGY OF 
 
 The most remarkable statements^ perhaps, of any, are those 
 of Professor Bouillaud, who, employing his " bleeding 
 formula " (viz. small bleedings repeated two or three times 
 daily, sometimes even during- the adynamic stage, when the 
 patients presented " fuliginous teeth and tongue, and the 
 last degree of prostration"), and including only those cases 
 that were somewhat serious, found a mortality among his 
 patients of one in 6*5.^ Again, at one of the meetings in 
 March, 1837,^ he declared, that, '^ counting all the cases, 
 he had lost only one in 24, and excluding all the slight cases, 
 one in 16 or 17." Who that is acquainted with typhus, and 
 has seen the sudden and alarming asthenia that often follows 
 the abstraction of a few ounces of blood during a state of 
 great excitement and oppression, but must feel convinced 
 that, treated after M. Bouillaud^s method, 99 out of every 
 100 would die? Gauthier de Claubry, while he concludes, 
 from his own experience of typhus, and the statements of 
 numerous distinguished authors whom he cites that " blood- 
 letting (p. 153) may be useful, if not absolutely indispensable 
 in certain cases, indifferent in a great number, hurtful in 
 many others " (an opinion he shares with Pringle, Hilden- 
 brand, and the immense majority of British physicians), con- 
 fesses (p. 167) that the general opinion is in favour of its 
 use in typhoid fever ; and besides referring to the constant 
 employment of it in the beginning of typhoid fever by Louis 
 and Chomel, states, that " twenty years of an extensive 
 practice, and of observations made in the hospitals of a large 
 city, as also a comparison of the results of the private practice 
 of a great number of physicians," have led him to adopt a 
 similar treatment. As to the use of purgatives, I may state 
 that while in Glasgow they were g'enerally used in typhus, 
 the marked difference in the state of the bowels in typhoid 
 fever led to the general use of opium, either alone, or com- 
 bined with mercury and chalk. All, in short, that we can 
 infer from the practice at present in use is, that the treatment 
 generally proscribed in the one is generally adopted in the 
 other disease. 
 
 On a review, then, of all that has been advanced, it' would 
 
 ' ' Seance de TAcademie,' Octoter i6th, 1835. 
 " Sec ' Bulletins de I'Academie,' vol. i, p. 520.
 
 TYPHUS AND TYPHOID FEVER. 221 
 
 appear that typhus and typhoid fever present important 
 differences, as regards their probable origin, their proximate 
 causes, their course, many of their symptoms, their diseased 
 appearances, and the treatment appKed in each. Are they 
 then identical, or are they not ? I feel that it would be pre- 
 sumptuous in me to hazard a direct reply ; nor do I demand 
 an answer in the affirmative merely on the faith of what 
 I have stated. All I can ask or wish for is careful, extensive, 
 and minute inquiry, without prepossession or love of system, 
 and a satisfactory solution must soon be arrived at. 
 
 ''Notwithstanding all the works," says Chomel (p. 338), 
 ''which the' last few years have produced on the typhoid 
 affection, its identity with typhus, though probable, is not 
 yet certain ; and yet there are few questions of which the 
 solution would be so highly important." I have accordingly 
 attempted in the preceding pages to concentrate attention, 
 as far as lay in my power, on the leading peculiarities of the 
 two affections; I have endeavoured, by frequent reference 
 to the works of approved authors, by collecting together 
 valuable facts hitherto widely scattered, and by adding the 
 results of my own observation, to bring as large a mass of 
 information as possible to bear on the question in debate ; 
 I have attempted — with what success others must judge — to 
 establish certain important distinctions between the two 
 diseases ; I have particularly sought to found my conclusions 
 on practical knowledge rather than theoretical reasonings j 
 and if I have contributed towards the elucidation of this 
 obscure subject, or shall be successful in drawing the attention 
 of abler and more experienced observers to its investigation, 
 my trouble is moi^e than repaid.
 
 MEMOm OF DR. A. P. STEWAIIT. 
 
 De. Alexander Patrick Stewart was born at Bolton, 
 East Lothian, on August 28tli, 1813. He was the son of the 
 Eev. Andrew Stewart, M.D., the minister of the parish, 
 who before entering the ministry had acquired considerable 
 reputation as a physician, especially by his treatment of 
 consumption. His mother, Margaret, was the daughter of 
 the tenth Lord Blantyre. He received his general education 
 in the Faculty of Arts of the University of Glasgow, where he 
 studied in the class of Sir Daniel Sandford, and was dis- 
 tinguished as a good Greek scholar. From 1828 to 1830 he 
 travelled with his family on the Continent, and acquired a 
 thorough knowledge of the French language. On his return 
 he entered as a student of the Medical Faculty of the 
 University of Glasgow, and graduated as Doctor of Medicine 
 in 1838. He held the appointment of House-Surgeon at the 
 Glasgow Infirmary, where Dr. Perry was one of the physicians. 
 And it was here that he made those observations which 
 convinced him of the specific distinction of typbus and 
 typhoid fever. After leaving Glasgow he pursued his studies 
 for about eighteen months at Paris and Berlin. He then, in 
 1839, settled in Loudon where he continued to practise till 
 his death. In April, 1840, he communicated the results of 
 his researches on fever to the Medical Society of Paris, and 
 his paper, the present memoir, was published the same year 
 in the fifty-fourth volume of the ' Edinburgh Medical and 
 Surgical Journal.'
 
 MEMOIR. 223 
 
 In 1850 Dr. Stewart was appointed Assistant Physician, 
 and in 1855 Physician, to the Middlesex Hospital, where he 
 also held in succession the Lectureships of Materia Medica 
 and Medicine. In 1866 he retired from the Middlesex Hos- 
 pital and was subsequently elected Consulting Physician. 
 At the Middlesex Hospital Dr. Stewart was remarkable for 
 the minuteness and accuracy of his observations and his great 
 kindness to the patients. 
 
 He was elected a Fellow of the Royal College of Physicians 
 of London in 1855 and an Honorary Fellow of the King's 
 'and Queen's College of Physicians of Ireland in 1867. 
 
 In 1850 he became a member of the British Medical Asso- 
 ciation, and continued during the rest of his life to take an 
 influential part in its proceedings. He was Secretary of the 
 Metropolitan Counties Branch from 1858 to 1874, and was for 
 twenty-nine years a member of its Council. He was also a 
 Vice-President and member of the General Council. On his 
 retirement from the office of Secretary the members presented 
 him with a testimonial, which with characteristic generosity 
 he applied to the formation of a fund for the recognition 
 and encouragement of researches into the origin and spread 
 of epidemic disease. 
 
 In connexion with the Association Dr. Stewart took an 
 active part in promoting medical reform, and gave much time 
 and attention to sanitary questions. He published several 
 papers on medical and sanitary subjects, among which may 
 be mentioned one on Cholera in the Middlesex Hospital, 
 which appeared in the ' Medical Times and Gazette,^ in 1854. 
 And one on the Workings of Some Provisions of the Laws 
 relating to Public Health, which was read before the Metro- 
 politan Counties Branch of the Medical Association in 1867, 
 and afterwards published in a separate form. But by far 
 his most important work, and the one on which his reputation 
 mainly depends, is the present treatise. 
 
 Dr. Stewart was a man of much, though intermittent.
 
 :224 MEMOIR. 
 
 energy^ of acute observation, of clear itleas witli great facility 
 in their expression. His liigli integrity, his warm heart, and 
 his genial disposition, caused him to be universally beloved 
 and respected. His religious convictions were strong, and 
 he was an earnest member of the Presbyterian Church in 
 which he held the office of an Elder, and in connexion with 
 which he devoted much time to religious and charitable 
 works. His life may be said to have been thoroughly con- 
 sistent with the principles he professed. 
 
 Though in consequence, perhaps, of a certain innate 
 deficiency in habits of business-like punctuality, he never 
 attained to that leading position in practice which his high 
 qualities merited, he has left behind him an unblemished 
 reputation, and his name will always be associated with one 
 of the great discoveries of medicine. 
 
 Dr, Stewart, who was never married, died at his house in 
 Grosvenor Street July 17th, 1883, having nearly completed 
 his seventieth year. 
 
 Much controversy has taken place as to whom the 
 discovery of the distinction between typhus and typhoid 
 fever is to be attributed, and as to the share Dr. Stewart 
 had in determining this question ; but, as so often happens 
 in disputes as to priority, it will be found on impartial inves- 
 tigation that the discovery was arrived at gradually, successive 
 observers adding fresh links to the chain of argument till at 
 last the conclusion was securely established. 
 
 Although it cannot be claimed for Dr. Stewart that he was 
 the first to make out the distinctions between typhus and 
 typhoid, nevertheless at a time when the great majority of 
 observers regarded them either as the same disease or at 
 most only well-marked varieties, his own observations, 
 made at Glasgow from 1836 — 38, and at Paris in 183g, con- 
 vinced him of their essential distinction. And in the present 
 memoir he demonstrated this more fully and conclusively 
 than had been done before, at least in this country ; for in
 
 MEMOIR. 225 
 
 America Messrs. Gerliard and Pennock, in a paper published 
 by Dr. Gerliard in the ' American Journal of Medical Science ' 
 in 1837, had fully described all the more important points 
 of difference, and perhaps they have the strongest claims to 
 be considered the first to have clearly proved the complete 
 distinction between the two diseases. Nevertheless, all the 
 leading facts and conclusions had been established before by 
 gradual steps. 
 
 The distinction between the slow nervous fever and the 
 putrid jail fever had been observed in England since early 
 in the eighteenth century. In the middle of the century 
 De Haen described accurately the rose rash of typhoid. 
 And Pringle, in his controversy with him, pointed out its 
 difference from the petechial rash of the jail fevers, and also 
 the different class of persons liable to be affected by the two 
 forms. In 1810 Hildenbrand, who regarded the two diseases 
 as entirely distinct, showed how they differed in contagious 
 properties. The essential lesions of typhoid fever were 
 gradually established by French pathologists, especially 
 Bretonneau, who invented the term dotliienentei'itis, though 
 he regarded the disease as a specific fever, and not as Brous- 
 sais had done, a mere inflammatory affection. In 1829 Louis 
 gave the name of typhoid to the dothieneuteritis of Breton- 
 neau, but in France it was generally regarded as identical 
 with the typhus of England, and in England dothieneu- 
 teritis as an occasional complication of typhus. 
 
 In 1835 Dr. Peebles, who was familiar with the contagious 
 typhus of Italy, pointed out its characteristic rash to Dr. 
 Perry, of Glasgow, Dr. Stewart being present, and from this 
 time Dr. Perry taught the difference between contagious 
 typhus and dothieneuteritis, and he appears to have been the 
 first in this country to have done so ; thoug'h in his paper, 
 published in 1 836, he does not seem to have regarded dothien- 
 euteritis as a specific fever accompanied by a rash of its own, 
 but as an affection which might complicate other diseases as 
 
 15
 
 226 MEMOIE. 
 
 typhus and smallpox^ or occur independently. Subsequently 
 he appears to have recognised and taught the distinction 
 between tlie two rashes. 
 
 In 1836 Dr. Lombard, of Geneva, who had studied fever 
 both on the Continent and in this country, published a paper 
 in the ' Dublin Medical Journal,' in which was maintained for 
 the first time that two separate and distinct fevers occurred 
 in Great Britain, one contagious typhus and one identical 
 with the dothienenteritis or typhoid fever of the French. But 
 he did not discriminate between the eruptions and symptoms 
 of the two. 
 
 The progress of these doctrines, notwithstanding \hQ con- 
 clusive arguments of Lombard, Gerhard, Shattuch, H. C. 
 Barlow, Stewart and others, was very slow, and in this 
 country it was not till the publication of Sir William Jenner's 
 papers in 1849, 1850, and 1853, that they obtained any- 
 thing like general acceptance. 
 
 On the whole, from this very brief resume of the question, 
 I think it will be evident that to no one observer can any 
 exclusive merit be ascribed. To Dr. Stewart belongs the 
 credit of being one of the first to see clearly the truth and 
 to have supported it by arguments which appear now to be 
 absolutely convincing.
 
 MOVEABLE KIDNEY IN AVOMEN. 
 
 Dr. LEOPOLD LANDAU, 
 
 PEIVAT-DOCENT IN THE TINIVEESITT OF BEBLIX. 
 
 WITH NINE WOODCUTS. 
 
 TRANSLATED AND EDITED WITH NOTES BY 
 
 FRANCIS HENRY CHAMPNEYS, M.A., 
 
 M.B.OxoN., F.R.C.P., 
 
 ASSISTANT LF.CTURKR ON OBSTF.TRICS, AND ASSISTANT OBSTETRIC PHYSICIAN TO ST. GEOUGE'S 
 
 IIOSriTAL ; EXAMINEE IN MIDWIFERY IN THE UNIVERSITY OF OXFORD; 
 
 LATE RADCLIFFE FELLOW IN THE UNIVERSITY OF OXFORD.
 
 TRANSLATOR'S PREFACE. 
 
 The scope and interest of the ensuing work are by no 
 means expressed by the limited description on the first page. 
 Dealing professedly with a single abnormal condition^ it 
 includes a great portion of the anatomy and physiology of 
 the abdominal cavity, and some of the pathology of the 
 pelvis. Interesting as such a Avork must be to every 
 medical man, it is doubly so to the physician, the focus of 
 whose work lies in the pelvis and lower abdomen, and it is 
 a welcome addition to his knowledge at a time when the 
 subject of uterine displacement seems to be approaching a 
 more rational estimation. 
 
 The scientific value of the treatise is great ; its literary 
 value would have been greater had some of the references 
 and all the quotations been revised. The latter having been 
 found almost invariably inaccurate, are given in this trans- 
 lation direct from the original sources. 
 
 The Translator, who has found the usual difficulties in 
 the way of producing a version at once idiomatic and precise, 
 begs to assure his readers that any faults which may appear 
 are due to anything rather than want of care. 
 
 London, 1884.
 
 PEEFACE. 
 
 The significance of moveable kidneys in their pathological 
 and therapeutical relations has not yet been rendered suffi- 
 ciently clear in spite of many valuable works. 
 
 It has been in part wrongly interpreted, in part over- 
 looked. By most persons it is regarded without serious 
 clinical interest as an anatomical curiosity, the diagnosis of 
 which leads to nothing further than the relief of the patient 
 from the fear of a presumably serious malady. A view directly 
 opposed to this has been lately promulgated, namely, that 
 moveable kidney is a disease dangerous to life, which must 
 be removed as quickly as possible by extirpation. 
 
 In the presence of this difference of opinion it is worth 
 every doctor's while to obtain clear views on this disease, so 
 often seen and so often mistaken. For the gyntocologist 
 especially, the knowledge of this malady is all the more 
 important since it attacks women by preference and stands 
 in a far more intimate relation to affections of the female 
 sexual organs than is commonly supposed. 
 
 The observation of numerous cases of moveable kidney 
 has led meto conclusions differing in many respects from the 
 views hitherto entertained, and I have thought it advisable 
 to embody them in a systematic treatise on this disease. 
 
 LANDAU. 
 
 Berlin ; 
 
 July 16, 1881.
 
 CONTENTS. 
 
 PAGE 
 1. HiSTOEY AND LiTEEATUEE . • • • ^33 
 
 II. Definition and Nomenclatuee . • • 236 
 
 III. TopoGEApnicAL Anatomy .... 236 
 
 Position of the kidneys, 237 ; relations of the kidneys to 
 adjacent organs, 238; mode of fixation of the kidneys, 241. 
 IV. Statistics ...... 244 
 
 V. Pathological Anatomy .... 247 
 
 VI. Etiology and Pathogenesis .... 263 
 Anatomical causes : influence of tumours of the liver and 
 spleen, 264 ; of caries of the lumbar vertebral column, 265 ; 
 of absorption of fat from the Capsula adiposa, 265 ; of the 
 abdominal walls and pendulous belly, 266 ; of menstruation, 
 268 ; of sexual disorders, 268 ; of hydronephrosis, 269 ; relation 
 of sexual disorders to hydronephrosis, 269 ; physical causes, 
 273 ; acute injury, 273 ; repeated injury, 274 ; influence of 
 stays, 275 ; reasons for the frequent occurrence of moveable 
 kidney on the right side, 276 . 
 
 VII. Symptoms . . . . . .281 
 
 Arising from the nervous system, 283 ; from the great vessels, 
 285 ; from the digestive tract, 285 ; from incarceration of 
 the kidney, 290 ; from secretion and excretion of the urine, 
 300 ; hydronephrosis of a moveable kidney, 307 ; intermit- 
 tent hydronephrosis, 312 ; relations to pregnancy and 
 labour, 316. 
 
 VIII. Objective Signs . . . • .318 
 
 Inspection, 318 ; percussion, 318 ; palpation, 320 ; ausculta- 
 tion, 322. 
 
 IX. Diagnosis . . . . • .322 
 
 Differential diagnosis from tumours of the liver, 324 ; tumours 
 of the gall-bladder, 325 ; carcinomata of the colon, of the 
 pylorus and pancreas, 326 ; fsecal tumour, 327 ; moveable 
 spleen, tumours of the spleen, of the ovary and uterus, 327-8 ; 
 phantom tumour, 329 ; diagnosis of adhesions ; of symptoms ' 
 of strangulation, 330 ; of hydronephrosis, 330.
 
 232 CONTENTS. 
 
 PAGE 
 
 X. Peognosis . . . . ^. . 332 
 
 Xr. Tbeatmext ...... 333 
 
 Of uncomplicated moveable kidne}^ 334 ; extirpation thereof, 
 338 ; treatment of complicated moveable kidnej, 340 ; of 
 strangulated moveable kidnej, 340 ; of hydronephrotic 
 kidney, 342. 
 
 XII. Oeigixal Obseevations .... 344 
 
 Table, 356. 
 
 XIII. Kefeeences ...... 358
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 I. History and Liteeatüee. 
 
 Although the congenital alterations in the position and 
 form of the kidney had at an early date excited the attention 
 of medical men^ especially the anatomists^ acquired moveable 
 kidney remained long unknown. Frangois Pedemontanus (i) 
 is the first who speaks of a dislocation of the kidney arising 
 from internal and external causes (percussio), without, how- 
 ever, attaching special importance to this anomaly. 
 
 Eiolan (2) was the first to set forth the clinical import- 
 -ance of the disease to which he gave the name of disloca- 
 tion of the kidney. His description of this disease is far 
 too characteristic for me to neglect to repeat it in this place : 
 ^' Quamvis renes adipis glutine videantur teuaciter affixi 
 lumbis, interdum tamen luxantur et antrorsum procumbunt; 
 interdum in hypogastrium delabuntur, non sine vitx detri- 
 mento ; hoc ita verum est, ut nullo modo sit dubitandum. 
 Id potissimum accidit, non tantum liquata pinguetudine, qua 
 sunt obvoluti, sed etiam ex pondere, ubi tam grandes sunt, ex 
 tumore vel calculo in cavitate concluso, ut suis retinaculis in 
 sua sede contineri nequeant, tumque ibi aliquamdiu sub- 
 sistnnt, sed tandem 2^iit'^'cscu}it et ahscessiim]jatiuntur. 
 (Renes) comprimunt psoam et nervös ad crura descendentes. 
 ^Si vena reseretur, aut rumpatur, urinas cruentas 
 funduntur : et quoniam renes communicant per nervös stoma- 
 •chicos cum ventriculo, eormn affectihus condolescit aut com- 
 patitur nauseabundus aut vomituriens.'^ 
 
 ^ Tliis sentence is incorrectly quoted by Landau.
 
 234 MOVEABLE KIDNEY IN WOMEN. 
 
 Notwithstanding this suggestive description, certaiuly 
 founded on excellent observation, the disease, " moveable 
 kidney," remained entirely unknown till the beginning of the 
 present century or was regarded only as an anatomical 
 curiosity, even by Haller (3), for instance, who, in the case 
 of a woman who had died from dropsy and had suffered 
 during life from a tumour above the navel, found the kidney 
 filled with water in the lower part of the abdominal cavity. 
 
 Baillie (4) mentions a tumour which he had observed four 
 or five times, loose, in the region of the kidney of one or 
 other side, which could be moved upwards and downwards 
 by slight pressure with the hand, and which was pretty firm, 
 and generally had the shape and size of a kidney. The 
 patients concerned were very little inconvenienced and their 
 general health little if at all disturbed. In women, as 
 Baillie mentions, the tumour was often mistaken for an 
 enlarged ovary ; but it had not its shape and could not, 
 moreover, be felt in the situation in which such a body can 
 be usually felt. The author in question had no opportunity 
 of making an autopsy, and was doubtful as to the nature 
 of the tumour, but was inclined to regard it as a moveable 
 kidney. 
 
 The contributions on this affection by Otto (5), Meckel (6), 
 and Poi'tal (7), which were certainly very imperfect, remained 
 entirely unnoticed. 
 
 The first accurate post-mortem records associated with 
 clinical descriptions were furnished in four cases by Aberle 
 (8). He Avas followed by Girard (9) and King (10), who 
 each observed one case of moveable kidney. King himself 
 made an attempt even at that early date to remove the 
 moveable tumour, but failed to find it after opening the 
 abdominal cavity. The woman concerned felt herself, strange 
 to say, better after this abortive attempt to extirpate her 
 kidney than before.^ 
 
 But a somewhat more general acquaintance with this 
 malady dates from the publication of the excellent Avork on 
 kidney diseases by Bayer (11), Avho himself observed several 
 cases of moveable kidney. Then followed the publication of 
 
 ^ A similar relief from symptoms is not unknown after other unsuccessful 
 essaj's in abdominal snrj^ery. — Translatoe.
 
 MOVEABLE KIDNEY IN WOMEN. 235 
 
 single cases by Braun (12), Brocliin (13), Urag (14), 
 Fetters {15), Oppolzer (16), Hare (17), and Henocli (18), so 
 tliat Fritz (19) in 1859 was already able to collect 35 cases 
 from the literature of tlie subject. 
 
 The knowledge of the clinical symptoms of moveable 
 kidney was next substantially enriched by Dietl (20), who 
 pointed out the frequency of moveable kidney and particularly 
 of a chain of symptoms caused by it, which had been till 
 then but little regarded. It is true that Dietl only con- 
 sidered this complaint as one Avhich occurred with particular 
 frequency in the Polish race. 
 
 Stress was laid by Becquet (21) on the intimate relation 
 between the sexual life of the female and the production of 
 moveable kidney, while Chroback (22) referred to the 
 connection between hysteria and mobility of the kidneys. 
 
 We are indebted to Rollet (23) for the first monograph on 
 the pathology and therapeutics of this affection. In 5500 
 patients of Oppolzer's clinique this author found 22 cases, 
 and described 10 of them. He himself mentions that this 
 number does not nearly represent the total of those actually 
 present, since some of these patients only present themselves 
 in the out-patient department (Ambulatorium) without being 
 admitted to the wards ; some to whom this affection causes 
 no special discomfort, never come under medical examina- 
 tion ; and, finally, the frequency with which cases occur in 
 the wards is influenced by deliberate choice of the cases 
 admitted. 
 
 Among more recent works must again be particularly 
 mentioned the important publications of Durham (24), 
 Lancereaux (25), Trousseau (26), Gueneau de Mussy (27), 
 Fourrier (28), Henderson (29), Howitz (30), Oerum (31), and 
 Keppler (32). 
 
 Isolated cases have been published by Gueterbock (33), 
 V. Dusch (34), Keckeis (35), Wilks (36), Edwin Day (37), 
 Gilewski (38), Ehrle (39), Hosier (40), Drysdale (41), 
 Schnitze (42), Steiger (43), Pieper (44), Wiltshire (45), 
 Schiff (46), Heslop (47), Flemming (48), Gontier (49), 
 Thun (50), Ferber (51), Mac Evens (52), Herr (53), 
 Tzschaschel (54), Jago (55), Kliipfel (56), Peebles (57), 
 Defontaines (58), Grout (59), Cabarellas (60), Kovatsch (61),
 
 236 MOVEABLE KIDNEY IN WOMEN. 
 
 Hertzka (62), Le Ray (63)^ Stiller (64), Pitois (65), Sclienker 
 (66), and Hunter (67). 
 
 Lastly, attention must be called to the appropriate sections 
 in tlie handbooks on kidney diseases by Rayer, Vogel, Rosen- 
 stein and Ebstein. 
 
 II. Definition and Nomenclature. 
 
 By tlie name wandering kidney is understood that patho- 
 logical change in the position of the kidney under which 
 it is permanently or temporarily removed from its normal 
 situation and manifests a greater or lesser amount of 
 mobility. This anomaly has been also called *' Moveable 
 kidney,'' ''Descent," " Displacement," " Prolapse," " Ecto- 
 pia " of the kidney. The older authors speak of " Dislo- 
 •cation of the kidney," and, from the analogy of dislocations of 
 the limbs, of " Spontaneous " and " Traumatic" dislocations. 
 The French sometimes use the phrase " rein flottant," the 
 English " floating " or '*' moveable kidney." 
 
 A moveable kidney may become fixed in an abnormal 
 situation and is then called " fixedly dislocated " (fix dis- 
 locirt). Kidneys which are dislocated and fixed are mostly 
 congenital anomalies (for instance the so-called " horse-shoe 
 kidney," and the " kidney lying deep down in the pelvis "), 
 and are combined with other malformations, such as abnormal 
 positions of the intestines and low insertion of the vessels. 
 These congenitally dislocated kidneys, which are only in rare 
 cases found moveable, and may now and again indeed give 
 rise to disorders of labour, are generally unimportant clini- 
 cally, and, having already been often sufficiently described, 
 will not in this place bo further considered. 
 
 III. TOPOGRAI'HICAL AnATOMY. 
 
 With a view to the better comprehension of the pathology 
 of acquired moveable kidney, it seems advisable, as in the 
 case of descent and prolapse of the female genital organs, to 
 direct our special attention to the normal position of the
 
 MOVEABLE KIDNEY IN WOMEN. 237 
 
 kidney and the forces wliicli maintain it in this position. 
 The accounts of the old anatomists, which have mostly found 
 their way into the modern text-books, give only imperfect 
 explanations on both these points. At one time pathological 
 conditions have been taken for normal, at another too little 
 regard has been paid in the treatment of many kidney 
 diseases (which was till lately considered hopeless) to certain 
 intimate anatomical relations between them and the neigh- 
 bouring organs. 
 
 Thus, Haller (68) says that the kidneys may lie on both 
 sides of the vertebral column alongside of some four vertebrae 
 between the eleventh (thoracic) and fifth lumbar, while Vogel 
 (6g) says that the kidney in its normal situation may project 
 as far as the iliac crest or even farther into the false 
 pelvis. 
 
 Among recent productions may be named the valuable, 
 works of Eayer (70), the excellent representation of the 
 topography of the abdominal cavity by Sappey (71), Luschka 
 (72), and Küdinger (73) ; and the works of Pausch (74), and 
 His (75). These works, as well as investigations on the dead 
 subject, have been followed in the ensuing description. 
 
 Position of the Kidneys. 
 
 The kidneys lie against the posterior wall of the upper 
 part of the abdomen, and are partly within the bony cavity of 
 the thorax close to the transverse processes of the vertebral 
 column, their inner border having* an average distance of 
 seven and a half centimetres from the middle line. They 
 extend on either side from the lower border of the eleventh 
 thoracic vertebra to the lower border of the second lumbar 
 vertebra. Pansch is correct when he speaks of an " average ^' 
 position of the kidney, for its boundaries are not absolutely 
 fixed, the variations from the average boundaries are, how- 
 ever small, and differences of even the height of a vertebra 
 are to be considered pathological. 
 
 The majority of authors say that the right kidney lies 
 lower down than the left. Thus Bauhin^ (76) says : 
 *' Horum dexter proxime Hepati subiacet propter eius molem 
 
 ' Incorrectly quoted by Landau. — Tbanslatob.
 
 238 ]\rOVEABLE KIDNEY TN AVOMEN. 
 
 ill liomine altero est iuferiov, ipsi tanquam iiobiliorl cedens, 
 et ad tertiam luraborum vertebraiii suo fine descendit." 
 Spigel^ (77) says: ^' Incnmbunt roues sima sui parte mus- 
 culoruraj quos il^ooc Hippocrates vocavit, . . , capitibus. 
 Iiiaequalis etiam utrinsque positio est, ciim laevus 
 dextro elatior sit, iion taiiieu dimidia sui parte." 
 
 These autliors are followed by those of later date in as- 
 cribing the cause of the lower position of the right kidney 
 to the liver. Few only, as Legendre, Luschka, R-üdinger, 
 Sappey and His, assert that both kidneys are nearly on the 
 same level. Pansch (78) , indeed, found the left kidney slightly 
 lower than the right in every third subject. Certain it is 
 that the difference of level between the right and left kidney, 
 if any difference exists at all, is but trifling, as observations 
 made on the cadaver make certain. The less regard need bo 
 paid to the influence of tlir lirry on the position of the kidne}', 
 since, as recent investigations by Braun (79) and His {80) 
 show, the liver is normally so extremely soft (like fat or 
 cellular tissue) that it ;jields to the movements and displace- 
 ments of neighbouring organs. The flexibility and softness 
 of " fresh liver-tissue " is so great that it is much nearer the 
 truth to say that the shape of the liver depends on the 
 volume of adjacent organs, as is shown by their impressions 
 on it (faciccula renalis, &c.), than to say that the liver is 
 capable of regulating their shape. I lately had an opportu- 
 nity of satisfying myself of the softness of the liver in the 
 living body, in the course of two operations for hydatids of 
 that organ, and it felt under these circumstances more like a 
 flaccid cyst than a solid gland. 
 
 Relatiovs of the Kidneys io culjdccht orr/ans. 
 
 The anterior surface, in the fretus lobed, in the adult 
 smooth, convex, directed a little forwards and outwards, is 
 covered by the peritoneum iu its whole extent. On the rlr/Jit 
 side two-thirds or three-fourtlis, or sometimes even the whole 
 of the kidney lies beneath tlie liver and therefore to a greater 
 or less extent beneath the ascending colon or hepatic flexure 
 of the colon (flexura coli dextra), and more or less close to 
 ' THCorrectly quoted by Landau. — Tbanslatob.
 
 MOVEABLE KIDNEY JN WOMEN. 
 
 239 
 
 tlie vertical portion of tlie duodenum and the vena cava in- 
 ferior. On tlie left side the anterior surface of the kidney 
 is covered in its upper third by the spleen, and in its lower 
 two-thirds by the descending colon or splenic flexure of the 
 colon (flexura coli sinistra). Its inner border abuts on the 
 extremity of the cardiac end of the stomach. Part of it 
 lies beneath the pancreas, which is indented by it and the 
 renal vessels. 
 
 Fro. I {nflcr Sappey). 
 20 12 19 
 
 1. Superior horizontal limb of the 
 
 duodenum turned to the right 
 side with the pyloric end of the 
 stomach. 
 
 2. Vertical limb of the duodenum. 
 
 3. Inferior horizontal limb of the 
 
 duodenum, bounded on the left 
 by the superior mesenteric artery 
 and vein. 
 
 4. 4. Head of the pancreas. 
 
 5. Body of the pancreas. 
 
 6. Tail of the pancreas. 
 
 7. 'J. Its main duct. 
 
 8. Accessory duct. 
 
 Q. Left lobe of the liver. 
 
 10, II. Right lobe of the liver. 
 
 11. Lobus Spigelii. 
 
 13. Obliterated umbilical vein. 
 
 14. Gall-bladder. 
 
 15. Hepatic duct. 
 
 C 25 
 
 16. Cystic duct. 
 
 17. Common bile-duct, opening, to- 
 
 gether with the pancreatic duct, 
 into the Ampulla Vateri (common 
 gall and pancreatic duct) and the 
 duodenum. 
 
 18. Portal vein, covered on the right 
 
 by the common bile-duct, and on 
 the left by the hepatic artery. 
 
 19. Cceliac axis. 
 
 20. Hepatic artery. 
 
 21. Coronary artery of the stomach. 
 
 22. Cardiac end of the stomach. 
 
 23. Splenic artery. 
 
 24. Spleen. 
 
 2$. Left kidney. 
 
 26. Right kidney. 
 
 27. Inferior mesenteric artery and 
 
 vein. 
 
 28. Vena cava inferior.
 
 240 MOVEABLE KIDNET IN WOMEN. 
 
 The 'posterior surface^ which is iieavly flat, inclined a little 
 inwards and broader than the anterior, lies acjainst the crnra 
 of the diaphragm which separate it from the last rib^ the 
 last intercostal space, and the lowest part of the pleural 
 cavity. It is separated from the quadratus lumborura muscle, 
 against which it also lies, by the anteinor layer of the 
 aponeurosis of the transversus abdominis muscle, and by the 
 two branches of the lumbar plexus (? the ilio-hypogastric 
 and ilio-inguinal nerves. Translator). The i(j)per third and 
 Komeiimes the u-pper half of each hidney lies therefore above 
 the lower limit of the p)leural cavity. 
 
 The external surface, which is convex and directed a little 
 posteriorly, corresponds to the angle of separation formed by 
 the two layers of the fascia propria of the peritoneum. This 
 border also is separated above by the diaphragm from the 
 twelfth rib and last intercostal space, and lies below against 
 the aponeurosis of the transversus abdominis muscle and the 
 outer border of the quadratus lumborum. 
 
 The internal border (Hilum) which is concave, directed a 
 little forwards, rounded above and below, and concave in the 
 middle, abuts on the psoas major. According to Sappey it 
 is covered below by coils of the small intestine. I have, 
 however, frequently found nothing but large intestine 
 covering it. 
 
 The internal border (? of the right kidney. — Translator) 
 is bounded above and to the right by the vena cava inferior 
 and vertical portion of the duodenum. 
 
 The iip)per end of the kidney is ratlier greater in circum- 
 ference, more curved and nearer to the vertebral column, 
 than the lower. It corresponds to the intervertebral disc 
 between the eleventh and twelfth thoracic vertebrje. 
 
 The lower end is bounded by the intervertebral disc 
 between the second and third lumbar vertebra?. 
 
 The average length of the kidneys, according to Sappey, 
 amounts in women to 12"2 centimetres, their breadth to 6*9 
 centimetres, their thiclmess to 2*8 centimetres ; according to 
 Pansch they are IQ-'S — 11 centimetres long. 
 
 The vei<iht of the kidneys varies considerably, averaging, 
 according to Sappey, 170 grammes; of forty kidneys the 
 lightest weighed 107 grammes, the heaviest 284 grammes.
 
 MOVEABLE KIDNEY IN WOMEN. 241 
 
 Their specific gravity, as I Lave found hy several determina- 
 tions, is greater tliau that of any of the solid abdominal 
 glands. 
 
 Mode of Fixation of the Kidney. 
 
 The kidney, firmly surrounded by a tunica propria, lies 
 comparatively loose in the envelope, called by Riolan (8i) 
 memhrana adiposa, by Haller (82) cai^suht adiposa, the name 
 now in common use. This capsule, however, in the foetus 
 and young subject contains no fat, but consists entirely of 
 connective tissue. It arises from the lamina fibrosa of the 
 fascia propria peritonei which on reaching the kidney divides 
 into two layers, one of which runs with the peritoneum 
 transversely over the anterior surface of the kidney, while 
 the other passes on the posterior surface beneath the pelvis 
 and vessels of the kidney, in which situation it joins the 
 anterior layer again. Englisch (83) describes this membrane 
 lying behind the renal vessels as a layer consisting of closely 
 compressed compact connective tissue running inwards, and 
 passing partly into the adventitiaof the aorta, partly into the 
 fascia lying over the pars lumbalis diaphragmatis. According 
 to Englisch this layer contributes in a special manner to the 
 fixation of the kidney and acts as a proper lig amentum 
 snspevsorimn renis. At the upper end of the kidney these 
 two layers join again and separate the kidney from the 
 supra-renal body ; from the lower end of the kidney they 
 pass as far as the brim of the pelvis, becoming thinner and 
 thinner in their course. The anterior layer is intimately 
 connected with the peritoneum by a fine connective tissue 
 destitute of fat ; the posterior, on the other hand, is some- 
 what loosely united to the posterior abdominal wall and all 
 surrounding parts. The capsule of the kidney is connected 
 to its tunica propria by loose connective tissue with lai'ge un- 
 dulations. It is not until the eighth to the tenth year that 
 the wide meshes of the connective-tissue capsule begin to be 
 filled with fat, the abundance of which frequently stands in no 
 sort of proportion to the panniculus adiposus elsewhere. It 
 provides the kidney with a soft cushion, protects it against the 
 pressure of adjacent viscera, and by virtue of its softness and 
 mobility permits a moderate amount of change of position. 
 
 16
 
 242 MOVEABLE KIDNEY IN WOMEN. 
 
 The Capsula adiposa, connected as it is with the peritoneum 
 in front and secured as it is to the abdominal walls behind 
 and at the sides, represents the kidney's immediate means 
 of fixation, and justly deserves the title of ligamentum renis 
 conferred on it by Bartholin. 
 
 In addition to the above, the kidneys are maintained in 
 position indirectly by the mesocolon which is short and tense, 
 attached to the posterior abdominal wall, and is sometimes 
 only indicated ; this to a certain extent opposes its descent 
 inwards and downwards after the manner of a barrier. Any 
 movement of the kidney outwards and downwards, or out- 
 wards and upwards, is prevented by the renal vessels which 
 are tensely, and the aorta and vena cava which are almost 
 immoveably fixed. 
 
 The kidney is still further protected by lying close to that 
 very part of the vertebral column which is not affected to 
 any considerable extent by flexion, extension, or lateral 
 movements of the body, this region being according to Meyer 
 (84) the section from the ninth thoracic to the second lumbar 
 vertebrge which must be regarded as a nearly immoveable 
 mass. Lastly, the enclosure of the greater part of the 
 kidneys within the bony cavity of the thorax protects them 
 from lateral and anterior pressure. Haller happily compares 
 the spot where the kidneys lie to a nest in the folloAving 
 words : ^ '' Renes ponuntur ad utrumque latus spince dorsi . 
 quasi in cavato sibi nido." 
 
 Apart from these anatomical fact oi's there are also 2ihy sic al 
 conditions which oppose the descent of the kidneys, especially 
 the adspiratory force of the diaphragm and the intra-abdominal 
 jjressure pi'oduced by the normal act of straining. If one of 
 these factors is eliminated in experiments on the dead subject 
 as may be done by opening the abdominal cavity or removing 
 the diaphragm, the kidney is seen almost invariably to sink 
 slightly by virtue of its weight. In spite of this, the anato- 
 mical fastenings are so strong, that Sappey found as a result 
 of 24 experiments in which the cadaver was raised ujDright, 
 that the kidneys remained immoveable in 21, and in3 only sank 
 2 centimetres. Though the descent of the kidneys is ascribed 
 by Sappey in these experiments solely to their weight, it 
 ' Incorrectly quoted by Landau.
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 243 
 
 must not be forgotten that their weight cannot come into 
 operation nntil the abdominal pressure is eliminated by 
 opening the abdominal cavity and removing the abdominal 
 viscera. 
 
 Fig. 2 {öfter Sappey). 
 
 1. The two kidneys. 
 
 2. Capsula fibrosa, by wbich tliey 
 are fixed to the posterior wall of 
 the abdomen. 
 
 Pelvis of the kidney. 
 
 Ureter. 
 
 Renal artery. 
 
 Renal vein. 
 
 Suprarenal body. 
 
 8. The liver, raised, in ordor to 
 show the relations of its lower 
 surface to the right kidney. 
 
 Gall-bladder. 
 
 Terminal portion of the portal 
 vein. 
 
 Origin of the common bile-duct. 
 
 The spleen, turned outwards, in 
 
 order to show the relations of 
 its inner surface to the lefd 
 kidney. 
 
 13. Semicircular pouch on which the 
 
 lower end of the spleen rests. 
 
 14. Abdominal aortM. 
 
 15. Vena cava inferior. 
 
 16. Left spermatic artery and vein. 
 
 17. Kight spermatic vein opening into 
 
 the vena cava inferior. 
 
 18. Subperitoneal fibrous layer or 
 
 fascia propria, dividing at the 
 convex border of the kidneys 
 into two folds, to form their 
 sheath. 
 
 19. Lower end of the quadratus lum- 
 
 borum muscle.
 
 244 MOVEABLE KIDNEY IN WOMEN. 
 
 Thus during life the kidneys remain almost immoveablj 
 fixed. Even deep inspiration does not depress them, 
 although they lie against the crura of the diaphragm, to a 
 great extent above the lowest limit of the pleural cavity. 
 Under these circxim stances, as is shown by experiments on 
 animals as well as by palpation in suitable cases in human 
 beings, the most that occurs is a slight rotation of their 
 upper part forwards round their transverse axis. I have 
 searched in vain in the physiological handbooks for any note 
 on this point, in Pansch alone I found a short remark to the 
 same effect as that just made. 
 
 IV. Statistics. 
 
 Notwithstanding the numerous publications mentioned 
 above, moveable kidney is a complaint still often overlooked 
 or wrongly interpreted, and of far more frequent occurrence 
 than is generally imagined. Since, moreover, as I shall 
 show, many maladies which are really secondary results of 
 moveable kidney are imagined and described as diseases siii 
 generis, statistics never so carefully prepared cannot fail tO' 
 be affected by many sources of error. Although, however,, 
 tliey do not for this reason permit us to draw final conclu- 
 sions as to the frequency of moveable kidney, other infer- 
 ences deduced from them as to its mode of production are- 
 nevertheless valuable, and I therefore append a short 
 collection of cases in point, of Avhich I have personally 
 observed 42. 
 
 The complaint has been most frequently observed in. 
 patients between 30 and 40 years of age, as is shown by the 
 followiug data :
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 245 
 
 Autlior. 
 
 No. of 
 cases. 
 
 I — lO 
 
 lO — 20 
 
 20 — 30 
 
 Age. 
 30— 40 '40— 50 
 
 50 — 60 60 — 70 
 
 Aberle 
 
 4 
 
 _ 
 
 
 
 
 
 2 
 
 
 
 
 
 2 
 
 Raver 
 
 7 
 
 — 
 
 
 
 I 
 
 2 
 
 4 
 
 — 
 
 — 
 
 Dietl 
 
 9 
 
 — 
 
 
 
 2 
 
 3 
 
 4 
 
 — 
 
 — 
 
 Rollet . 
 
 22 
 
 — 
 
 2 
 
 6 
 
 II 
 
 I 
 
 I 
 
 I 
 
 Keppler . 
 ^Steiner . 
 
 II 
 ,3 
 
 I 
 .3 
 
 
 
 2 
 
 5 
 
 
 
 2 
 
 I 
 
 — 
 
 Hirschsprung . 
 
 2 
 
 2 
 
 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 Landau . 
 
 42 
 
 — 
 
 — 
 
 4 
 
 20 
 
 10 
 
 7 
 
 I 
 
 lOO 
 
 6 
 
 2 
 
 '5 
 
 43 
 
 21 
 
 9 
 
 4 
 
 It affects women by preference. 
 
 Author. 
 
 No. of cases. 
 
 Women. 
 
 Men. 
 
 Aberle 
 
 Ray er .... 
 
 Dietl . . . . 
 
 Rollet .... 
 
 Henoch 
 
 Lancereaux . 
 
 Jago .... 
 
 Kowatscli 
 
 Schnitze 
 
 Gucneau de Mussj 
 
 Thnn .... 
 
 Kliipfel 
 
 Fourrier 
 
 Steller 
 
 4 
 
 7 
 
 9 
 
 22 
 6 
 8 
 5 
 5 
 3 
 
 12 
 
 4 
 3 
 
 6 
 
 3 
 
 3 
 
 7 
 
 8 
 
 18 
 
 4 
 
 8 
 
 3 
 
 II 
 
 3 
 3 
 
 6 
 
 3 
 
 I 
 
 
 
 I 
 
 4 
 2 
 
 
 
 
 
 
 
 
 
 I 
 
 I 
 
 
 
 
 
 
 
 97 
 
 87 
 
 10 
 
 Ebstein's collection consisted of 96 cases, 82 in women 
 and 14 in men ; Fritz's, of 35 cases, 30 in women, 5 in men ; 
 Lancer eaux's, of 64 cases, 55 in women, 9 in men ; Hare's^ 
 of 23 cases, 20 in women, 3 in men. The above numbers 
 added together give 314 cases, 273 in women, and 41 in men, 
 a proportion which may be taken as nearly representing the 
 truth, although in this total certain cases are counted more 
 than once. This proportion would turn out still more in 
 favour of the women if we were to include in the 'above 
 collection the data of authors whose practice lies exclusively
 
 246 
 
 MOVEABLE KIDNEY IN WOMEN, 
 
 among women. Thus Hoivitz observed 34 cases, Chrohack 
 19, and I myself 42. Dietl stated the proportion of women 
 to men as 100 to i, but this is certainly an exaggeration. 
 
 The 7-ight kidney is the one most commonly found 
 moveable. 
 
 Author. 
 
 No. of 
 
 Kidneys moveable. 
 
 
 cases. 
 
 Kight. 
 
 Left. 
 
 Both. 
 
 Aberle . ^ . , 
 
 4 
 
 4 
 
 
 
 Eayw 
 
 
 7 
 
 5 
 
 I 
 
 I 
 
 Dietl . 
 
 
 9 
 
 8 
 
 — 
 
 I 
 
 KoUet . 
 
 
 22 
 
 18 
 
 3 
 
 I 
 
 Henoch . 
 
 
 6 
 
 5 
 
 
 I 
 
 Grueneau de Mussy 
 
 
 }2 
 
 II 
 
 I 
 
 . — 
 
 Jago 
 
 
 5 
 
 5 
 
 — 
 
 — 
 
 Schultze . 
 
 
 3 
 
 3 
 
 — 
 
 — 
 
 Kowatsch 
 
 
 5 
 
 5 
 
 — 
 
 — 
 
 Thun . 
 
 
 4 
 
 3 
 
 I 
 
 — 
 
 Klüpfer . 
 
 
 3 
 
 3 
 
 — 
 
 — 
 
 Fourrier . 
 
 
 6 
 
 .5 
 
 — ' 
 
 I 
 
 Keppler . 
 
 
 II 
 
 10 
 
 I 
 
 — 
 
 Oenim-Howitz 
 
 
 34 
 
 28 
 
 4 
 
 2 
 
 Landau . 
 
 
 42 
 
 39 
 
 I 
 
 2 
 
 
 
 173 
 
 152 
 
 12 
 
 9 
 
 If we add to these 5 other cases of double moveable kidney 
 {Philiiojpson, Wiltshire, He^lop, Schiff, SchenJcer, and Hunter, 
 having observed one case apiece) we get 178 cases of move- 
 able kidney, 151 right-sided, 13 left-sided, and 14 bilateral. 
 
 Author. 
 
 Cases 
 collected. 
 
 Kidneys moveable. 
 
 Right. 
 
 18 
 31 
 65 
 
 Left. 
 
 Both. 
 
 Hare .... 
 
 Lancereaux 
 
 Ebstein .... 
 
 23 
 43 
 91 
 
 5 
 5 
 
 14 
 
 7 
 12 
 
 157 
 
 114 
 
 24 
 
 19 
 
 An opposite proportion is observed in congenital malposi- 
 tion of the kidney, which, as we learn from the statistics 
 of Willis and Griiher, is far more frequently found on tho 
 left side.
 
 MOVEABLE KIDNEY IN WOMEN. 247 
 
 Most of the women with moveable kidney had had several 
 children, as is shown by the subsequent table of my observa- 
 tions. Out of 42 cases observed by me, only 2 concerned 
 women who had never borne children. 
 
 With regard to the station in life and occupation of 
 patients with moveable kidney, it must be remarked that 
 most of them belong to the labouring class, as would be 
 naturally expected to be the case with hospital in-patients 
 and out-patients, who furnish our material for observation. 
 This complaint is, however, by no means confined to the 
 poorer class, as is shown by the six cases published by 
 Henoch, which one and all concern persons of fairly good 
 position. 
 
 V. Pathological Anatomy. 
 
 Little attention has hitherto been paid at post-mortem 
 examinations to the changes produced by moveable kidney. 
 It is true that the old classical anatomists, Eustachiiis, 
 Bauhin, Morgagni, Riiysch, and HalJer, quote cases of kid- 
 neys lying low down, horse-shoe kidneys, abnormalities in 
 the renal vessels, &c., but they do not give much more infor- 
 mation about the conditions in acquired moveable kidney as 
 regards pathological anatomy, than the recent textbooks and 
 handbooks on renal diseases and special pathology. Cruveil- 
 liier contents himself with the statement that the kidneys 
 not only leave their situation but also rotate on their axis. 
 BoJcitanshj is even less explicit in specially mentioning the 
 congenital abnormalities of position. 
 
 Moreover, in the monographs of Rollet, Le Ray, and Defon- 
 taines, we look in vain for an explicit account of the condi- 
 tions as regards pathological anatomy, so that we are driven 
 to study isolated post-mortem records as the only means of 
 arriving at a better understanding of the subject. How 
 scanty these are, however, is best recognised by the fact that 
 Burliam only found two cases of displacement of the kidney 
 in 1600 autopsies, and that of these one was congenital. In 
 the same way Schul.tze found only five cases of moveable 
 kidney in 3658 autopsies in the Charite Hospital of Berlin
 
 248 MOVRADI.K KIDNEV IN WOMEN. 
 
 between 185g and 1866, and of these he unfortunately gives 
 no description. By the kindness of Geheimrath Professor 
 Dr. Virchow I was permitted to look through the post- 
 mortem records of the Charite between the years 1870 and 
 1879 containing about 6000 autopsies, and among them I 
 found moveable kidney only four times noted, and even then 
 withovit any special statement about it. 
 
 This slender result, however, can surprise no one who re- 
 members that moveable kidney as such never produces a fatal 
 result, and rarely gives any indication either to the clinical 
 physician or to the pathological anatomist to specially inves- 
 tigate on the dead subject the amount of the mobility of the 
 kidneys. Since, in addition to this, a moveable kidney, 
 even in well-marked cases, is frequently in the habit of re- 
 turning to its normal position during life under the condi- 
 tions of dorsal decubitus, and still more so immediately after 
 death (see below), even well-marked cases are very apt to 
 escape our observation during an autopsy conducted in the 
 usual manner, particularly as it usual to remove the kidneys 
 from the abdominal cavity before removing the intestines and 
 other abdominal viscera. 
 
 In the last place, however, moveable kidney sometimes 
 gives rise to complications of such a nature that its presence 
 can no longer be seen but only inferred in the cadaver ; this 
 is the case in many peri- and para-nephritic abscesses, hydro- 
 and pyo-nephroses, thromboses of the vessels, &c., which are 
 regarded as diseases sid generis, whereas their proper place 
 belongs to the pathology of moveable kidney. 
 
 Considering, thei'efore, the rarity of post-mortem records 
 it would seem not superfluous to enumerate them in this 
 place, scattered as they are, and collected with much laboui\ 
 In the performance of this task it is evident that the most 
 accurate and sei'viceable accounts date from the period ante- 
 cedent to the microscope, whereas in the autopsies dating 
 from more recent times, the coarser naked eye changes which 
 concern us in this place are generally neglected.
 
 MOVEABLE KIDNEY IN WOMEN. 249 
 
 (i) Moveable Kidney on the rigid side, violent (jasiric pain. 
 Death in consequence of apoplexy. (Aberle, 1820). 
 
 A man, thirty-two yeai's of age, who had suffered for 
 many years from severe abdominal and digestive disturbances, 
 had been much distressed for the last thi'ee years by a tumour 
 in the abdomen, situated in the right hypochondriac and 
 umbilical regions, which drove him to the use of various, and 
 sometimes injurious remedies. This supposed tumour could 
 be squeezed upwards at the patient's pleasure, when he lay in 
 a particular position in bed, especially in the morning. 
 Under these circumstances, a firm, smooth, not tender body, 
 of the shape and size of a hen^s egg, could be felt more or 
 less to the right, somewhat above and near to the navel, 
 Avhicli however, wdieu not fixed from above by the pressure 
 of the hand, slipped away again from the examining finger, 
 often quite suddenly, and retired to the right side, backwards 
 and upwards beneath the liver. By degrees the tumour 
 grew and could be pushed in front of the bodies of the lum- 
 bar vertebrge. As the diagnosis i-emained doubtful, the 
 physicians refrained from active measures ; the patient how- 
 ever fell a victim to a consumptive disease and died with 
 symptoms of apoplexy. 
 
 At the autopsy, with the exception of the softening of the 
 right corpus striatum, &c., the several organs were found 
 healthy ; " the tumour however w' as formed by the right 
 kidney which was found very moveable in its normal position 
 in the right loin, from whence it could be very easily dis- 
 placed in front of the bodies of the lumbar vertebrse beneath 
 the duodenum downwards and foi-wards, that is to say, in the 
 very same direction in which the supposed tumour appeared 
 and disappeared again during" life. Its vessels were com- 
 paratively long; the cellular capsule of this kidney (fascia 
 renalis) was completely destitute of fat, the hepatic flexure 
 of the colon was unusually distant from the liver, and de- 
 pressed somewhat towards the middle of the abdominal 
 cavity." 
 
 The kidney seemed to Aherle congeuitally predisposed to 
 mobility, and this tendency appeared to him to have been 
 encouraged by the repeated attempts to i-ender the tumour
 
 250 MOVEABLE KIDNEY IN WOMEN. 
 
 apparent. The length of tlie vessels seemed to liim to j^rove 
 the congenital predisposition. 
 
 (2) Moveahle Kidney on the right side. Remarkable dis- 
 placement of the large and small intestine. (Aberle, 
 1841.) 
 
 At the autopsy of a woman sixty-six years of age who had 
 died after several apoplectic attacks, the opening of the ab- 
 dominal cavity at once disclosed a body on the right side of 
 the umbilical region glistening through the peritoneum 
 which lay over it, destitute of fat and quite loose. This 
 body was kidney-shaped and on closer examination proved 
 to be in fact the right kidney lying somewhat obliquely in 
 front of the psoas in such a position as to turn its concave 
 border somewhat upwards. Besides this, the ascending 
 colon and right part of the transverse colon were so much 
 depressed from the right hypochondriura towards the hypo- 
 gastric region, that no ascending colon could be found in 
 this region, but the cgecum passed at once into the transverse 
 colon, which ran down towards the pelvis and then up 
 towards the spleen in the shape of a V to pass through the 
 splenic flexure into the descending colon. Again, on turning 
 the liver up, the duodenum itself, somewhat depressed, was 
 very distinctly seen through the anterior layer of the obliquely 
 placed transverse mesocolon, between the liver and meso- 
 colon. The stomach descended more obliquely than usual 
 towards the duodenum from left to right. The small intes- 
 tines and part of the great omentum were for the most part 
 depressed in the abdominal cavity. The left kidney was in 
 its normal position. 
 
 I have found a similar observation with regard to the 
 situation of the colon in Sandifort (85) in the section ; De 
 praeternaturali diversarum partium statu, in cadavere mulieris 
 viso.^ " Colon ex caeco enatum, juxta renem dextrum adscen- 
 dens, et ad hepar pertiugens, mox reflectebatur, juxta caecum, 
 ad pelvis marginem usque descendens, inde ad ventriculum 
 et lienem adscendebat, denique, iterum descendens, pelvim 
 intrabat. . . . Ren dexter sanus, sinister morbosus." 
 ' Incorrectly quoted by Landau.
 
 MOVEABLE KIDNEY IN WOMEN. 251 
 
 The colon therefore lay in the same position as in the 
 former case except that the same displacement had been here 
 produced by a hydronephrosis on the left side. 
 
 (3) Moveable Kidney on the rigid side ; comjprcsdon of the 
 vena cava; thrombosis of the vena cava; oedema of the 
 right lower extremity ; death in consequence of tubercular 
 2)leurisy (Girard, 1837). 
 
 A woman, forty-seven years of age, had suffered for twenty 
 years from febrile symptoms and chest troubles which showed 
 themselves by violent attacks of coughing, shortness of 
 breath, and palpitation. She lost flesh rapidly, and six 
 months previously, after a particularly violent attack of 
 coughing, became conscious of severe abdominal pain. For 
 the last month the right leg had been greatly swollen. The 
 patient died with the symptoms of cojisumption. 
 
 At the post-mortem, besides pleurisy on the right side, 
 cavities, &c., the right lower extremity was swollen to twice 
 the size of the other, the abdominal viscera healthy, the left 
 kidney in its normal position. The right kidney showed a 
 remarkable abnormality. The peritoneum, instead of merely 
 covering its front surface, enveloped the whole kidney except 
 the hilum and thus formed a sort of true mesentery about 
 two inches long. The kidney also floated in the abdomen 
 at the level of the third lumbar vertebra and at the inner 
 side of the ascending colon, which, distended with gas, 
 pressed the kidney forcibly against the vena cava inferior. 
 The vein showed at this spot a considerable constriction with 
 a dilatation below to nearly double its size. From the heart 
 to this constriction it was healthy in its course ; but below 
 this point it showed ti'ue areolar or cavernous tissue like that 
 of the penis, which filled the whole calibre of the vessel, and 
 reached to within two or three inches of the groin. The 
 femoral and saphenous veins were of the normal diameter. 
 The right kidney itself presented no special point of interest.
 
 252 MOVEABLE KIDNEY IN WOMEX. 
 
 (4) Moveable Kidney on the right side ; neuralgia of the 
 leg ; death from entero-colitis and peritonitis (Rayer, 
 1841). 
 
 A woman, fifty-one years of age, who had been employed 
 at hard work in a tobacco factory for thirteen years, and had 
 lost flesh rapidly, stated that ever since a fall she had 
 suffered from severe pains in the right leg and in the right loin, 
 radiating as far as the labium majus. Nothing but rest on 
 her back relieved the pains, and as soon as the patient tried 
 to turn in bed they returned violently in the region of the 
 right kidney. 
 
 Bimanual examination easily detected the kidney, which 
 quickly slipped out of the fingers, the patient at the same 
 time experiencing a pain radiating to the right knee. Con- 
 stipation is present ; the urine contains no albumen. 
 
 Ten days after she came into the hospital symptoms of 
 peritonitis appeared, and she died of marasmus two months 
 later. 
 
 At the post-mortem the voluminous and very congested 
 liver was seen to extend low down, and a narrow and thin 
 band of it, which lay against the right lateral wall of the 
 abdomen, reached as far as the iliac crest. Its growth had 
 displaced the right kidney, which lay superficially at the 
 sides but more anteriorly in front of the vertebral column — 
 pressed from above downwards but still more from behind 
 forwards — in the obtuse angle formed by the iliac vein and 
 vena cava, both of which were closely apposed to it. Exter- 
 nally it was bounded by the prolongation of the liver, but 
 only at its outermost border ; its anterior surface was exposed 
 only in the lower half, the upper half being covered by the 
 liver ; posteriorly it lay on the projecting angle formed by 
 the muscles occupying the lower part of the abdomen and 
 the upper part of the pelvis, and rising partly below and 
 partly above the iliac crest. Its inferior extremity reached 
 as far as the middle of the fibro-cartilage between the fourth 
 and fifth lumbar vertebrae. 
 
 It follows from the above relations that the lower end of 
 the right kidney lay in the immediate neighbourhood of the 
 anterior abdominal wall, and on a plane obliquely inclined
 
 MOVEABLE KIDNEY IN WOMEN. 25.> 
 
 from before backwards ; this explains the ease with which it 
 could be felt with the liaud aud pressed backwards. Its 
 mobility was increased by extreme looseness of its connec- 
 tions and peritoneal investment ; the condition of the vessels 
 Avas similar^ except that the transition to them was more 
 direct and shorter. 
 
 The left kidney occupied its normal position (?). It was 
 packed away much deeper at the side and behind the verte- 
 bral column, and projected downwards as far as the fibro- 
 cartilage between the third and fourth lumbar vertebrae, thus 
 lying not much higher than the right which seemed to be 
 displaced more markedly forwai'ds thau downwards. 
 
 The right kidney weighed 80 grammes, the left 150, the 
 right was 0*4 centimetres shorter than the left. The shape 
 of the right was slightly altered, its upper end was pressed 
 against the liver, and actually flattened by contact with it ; 
 besides this it showed an anterior convexity and a posterior 
 concavity, corresponding to its position on an oblique plane, 
 double-inclined and convex anteriorly. 
 
 The left kidney showed marked increase of its tubular 
 substance. 
 
 The right supra-renal body was found in its normal 
 position. 
 
 (5) Double moveable Kidney (WilliaiQ Roberts, 1852) (86). 
 
 In a phthisical, very thin woman, both kidneys were very 
 plainly felt through the abdominal walls, the right much lower 
 than the left. 
 
 At the autopsy the right kidney was found lying loose 
 one and a half inches below the liver, and attached only by 
 its vessels and ureter ; it was entirely destitute of fat. The 
 left kidney had a normal position, but lay an inch lower (than 
 usual) . The artery and vein of the right kidney were half 
 an inch longer than those of the left. 
 
 (6) Moveable Kidney on the rigid side ; scliirrlms of the uterus ; 
 hydroncjjhrosis (Braun, 1853). 
 
 In a woman, fifty years of age, suffering from cancer of
 
 254 MOVEABLE KIDNEY IN WOMEN. 
 
 the womb and ascites^ a solid moveable tumour was made 
 out during life in tlie umbilical region. Deatli occurred witli 
 symptoms of coma. 
 
 At the autopsy a large steatoma was seen on the right 
 side near the umbilicus, enveloped in a yellowish white mass. 
 On opening this, the right kidney could be seen lying in it, 
 enlarged, pale, soft, in a state of fatty degeneration, the 
 cortical substance being hardly brownish-red and bloodless. 
 The renal vessels tore when it was disturbed, and the renal 
 artery alone showed any remaining firmness of texture ; the 
 nreter was distended to the size of a finger, and filled with 
 fluid down to the bladder. 
 
 Braun's opinion was that the mobility of the kidney was 
 due to the pressure and maceration of the abdominal glands — 
 that this was the cause of the ascites — and that the tenesmus 
 and relaxed state of the abdominal contents had lai'gcly con- 
 tributed to the displacement of the kidney. 
 
 (7) Moveable Kidney on the rigJtt side; adhesionfi hetween it 
 and the liver, gall-bladder, and transverse colon ; hydro- 
 ncjohrosis ; uterine infarct ; niultilocular ovarian cyst 
 on the right side (Urag, 1857). 
 
 In a very thin woman, sixty-five years of age, a tumour 
 ■could be felt under the anterior edge of the right lobe of the 
 liver. It ran obliquely above and inwards, downwards and 
 outwards ; its shape was oval, the upper border convex, the 
 side flatter ; it seemed elastic, well defined, moveable, 
 sinking and rising with respiration, and in shape resembled 
 the kidney. It would not rotate on its axis, but could bo 
 pushed as far as the middle line, into the right renal region, 
 and also somewhat downwards, though these manipulations 
 were painful to the patient. Compared with the left lumbar 
 region the right was sunken and tympanitic on percussion ; 
 if the tumour was pushed into the right loin it became full 
 in appeai'ance and dull to percussion. The quantity of urine 
 secreted in twenty-four hours amounted to 1190 cubic centi- 
 metres, its reaction was acid, it was slightly turbid, deeply 
 yellow without deposit, its specific gravity was 10 15. 
 
 The woman died in consequence of bronchiectasis. At
 
 MOVEABLE KIDNEY IN WOMEN. 255 
 
 the post-mortem the right kidney was found lying in imme- 
 diate contact with the anterior border of the right lobe of the 
 liver and adherent to it as well as to the gall-bladder and 
 transverse colon by dense connective tissue, the adhesions 
 permitting the kidney to be pushed back into its normal 
 situation and also as far as the middle line or into the umbi- 
 lical region (mesogastrium), though not without dragging on 
 the liver. The outer border of the kidney looked upwards, 
 the upper extremity inwards, the lower extremity outwards, 
 the liilum downwards ; the kidney was twelve centimetres 
 long, seven broad, four thick ; the peritoneum investing it, 
 as well as its capsule, thickened. The capsule was distended 
 irregularly and in the shape of vesicles (blasig), it felt elastic 
 and fluctuating. The substance of the gland had entii'ely 
 disappeared, and in its place was found a colourless clear 
 thin fluid, enclosed by the empty septa (Fächern), of the 
 capsule which was shining and smooth internally. The renal 
 vessels were elongated and contracted, the pelvis thickened 
 and four and a half centimetres broad, the ureter as far as 
 the bladder was two centimetres in diameter, its mucous 
 membrane reddish-grey, thickened and granular. The left 
 kidney was firmly seated in its normal position, it was in an 
 early stage of hydronephrosis. 
 
 The size of the uterus corresponded with the third month of 
 pregnancy. The posterior wall, which was four centimetres 
 thick was chiefly answerable for its increased bulk. Its 
 tissue was yellowish-red, soft, infiltrated with pus. The 
 cavity was small, and occupied by glairy mucus. The pos- 
 terior wall of the bladder was closely adherent to the uterus, 
 and on pressing the uterus pus escaped into the bladder from 
 several points ; the opening of the right ureter was closed, 
 the opening of the left narrowed. In the right ovary were 
 five serous cysts, the smallest as large as a chestnut, the 
 largest as big as a lemon ; a cyst the size of a hazel-nut 
 lay at the brim of the pelvis. 
 
 Urag attributes the hydronephi'osis to the pressure of the 
 uterus on the ureter.
 
 256 MOVEABLE KIDNEY IN WOMEN. 
 
 (8) Moveable Kidney on the left side ; neuralgia of the leg 
 hydrone'phrosls mistaJxen for an ovarian titnioiir. {' Bul- 
 letins de la Societe Auat./ 1854, s. le Jinj, p. 32.) 
 
 In a woman forty years of age, mucli reduced in liealtli, 
 who complained of violent boring pains in the lumbar reg'ion 
 and left leg, a large hard tumour was found to the left of the 
 linea alba and reaching nearly to the false ribs. Bimanual 
 examination detected the same tumour in the left fornix 
 vaginas. The uterus was descended and moveable ; on pres- 
 sing it upwards very restricted movements were produced in 
 the tumour which was largo and hardly moveable by itself. 
 The tumour was taken to be a malignant tumour of the left 
 ovary. 
 
 At the autopsy it was found to be the kidney elongated 
 and enlarged to three times its size, lying with its lower ex- 
 tremity on the fundus uteri and the left broad ligament. It 
 lay in the iliac region a little obliquely from above down- 
 wards and from without inwards. It was nineteen centi- 
 metres long by seven broad. It vv'as decolorised, lobed ex- 
 ternally, soft, and giving mai'ked fluctuation at the level of 
 the hilum, or rather over the whole inner border. Section 
 disclosed large, inter-commiTnicating spaces, which were in 
 fact the dilated infuudibula and pelvis. These dilatations 
 contained a turbid serous fluid Avithout any gritty or calca- 
 reous deposit. The mucous membrane of the excretory 
 ducts was very thick and covered in its whole extent as far 
 as the bladder with false membranes, giving it the appear- 
 ance of shagreen or of the back of a calf^s tongue. 
 
 The ureter was also hypertropliicd, its calibre uniform and 
 nowhere occluded except at the hilum, where it Avas closed 
 by false membranes. Tlie renal substance Avas also changed, 
 the cortical part being amyloid and uniformly greyish-white. 
 The pyramids of Malpighi were distinguishable only in the 
 upper and middle parts of the kidney, by their triangular 
 outline and pale red colour, but their striated appearance 
 was almost completely lost. 
 
 It is unfortunate that no observation is made, in this as 
 in most of the accounts in point, as to the origin and condi- 
 tion of the renal vessels, nor as to the position of the colon
 
 MOVEABLE KIDNEY IN WOMEN. 257- 
 
 -and its relation to the kidney, so tliat it is impossible to set 
 at rest the doubt whether this might not have been a case 
 of congenital displacement. 
 
 (9) Moveable Kidney on tlie left side, icith extreme mobility ; 
 displacement of the colon (Durham, i86q). 
 
 At the autopsy of a woman thirty-four years of age the 
 left kidney was seen to project remarkably. The descending 
 colon lay much nearer the middle line than usual and instead 
 of formintr the siofmoid flexure on the left side, it ran across 
 the lumbar vertebraB into the pelvis to the right of the sacrum. 
 Slight pressure caused the kidney to slip into its usual posi- 
 tion, and closer examination proved it to be moveable not 
 only with extreme ease but also to a great extent. 
 
 When the patient moved in various suitable ways and 
 under gentle manipulation the kidney glided away with 
 equal case across the vertebral column and under the ribs, 
 or even somewhat to the right side into the iliac fossa. On 
 •closing the abdominal cavity and palpating the lumbar region 
 the kidney was felt as a smooth, oval, half-elastic tumour, 
 which slipped away when pressed by the fingers. 
 
 The peritoneum was abnormal. Instead of passing over 
 the anterior surface of the kidney it only just touched the 
 lower part of its inner edge, and then after forming the des- 
 cending mesocolon, again came into contact with the outer 
 border of the kidney. Moreover, the lesser cavity of the 
 peritoneum (sac of the omentum) reached so far towards 
 the left side as to cover the posterior surface of the spleen, 
 iind so far downwards as to be in contact with the upper 
 border of the kidney. The kidney had no distinct mesen- 
 tery (mesouephron). In the loin hardly any fat was found 
 but only loose cellular tissue. The absence of fat partly ex- 
 plains the mobility of the kidney. The renal vessels had 
 their normal origin, but were perhaps longer than usual. 
 The loft supra-renal body moved with the kidney only to a 
 limited extent. 
 
 17
 
 258 MOVEABLE KIDNEY IN WOMEN. 
 
 (lo) Moveable Kidney on the right side. Adhesions to the 
 liver; parametritis of the left side (Lancereaux). 
 
 In a woman aged forty-one who was a drunkard, had suf- 
 fered from frequent vomiting and covigh, and was very thin, 
 a moveable kidney could be very easily made out on the 
 right side of the abdomen. 
 
 After the patient's death from erysipelas of the faoe the 
 right kidney was found not against the quadratus lumborum 
 muscle but tightly pressed against the right side of the ver- 
 tebral column. It was much smaller than the left kidney 
 and slightly lobed. Its right border was adherent to the 
 liver which was rather large. 
 
 The posterior wall of the uterus was adherent to Douglas's 
 pouch by old false membranes, which were confined to the 
 right half of the posterior surface of the right broad liga- 
 ment. The inflammation had extended along the ureter as 
 far as its upper extremity. The right ovary which was in- 
 volved in this focus of inflammation, was two or three times 
 as large as the left, the tube was sinuous, its end was closed 
 and adherent to the peritoneum opposite the posterior fundus 
 vaginse, and enlarged to the size of a nut. 
 
 (ii, 12) Moveable Kidneys on the right side (Lancereaux). 
 
 In a consumptive woman, aged sixty years, the right 
 kidney was found astride (a cheval) of the second and third 
 lumbar vertebrse, covered with peritoneum. The vessels and 
 ureter appeared normal, somewhat elongated ; the liver was 
 congested and seemed to have pressed the kidney downwards, 
 though it could be presumed that the kidney had changed 
 its position previously. The right ovary was unchanged, but 
 the uterus was studded with fibrous tumours. 
 
 A woman who died with stenosis of the mitral valve 
 showed a condition precisely similar. 
 
 (13) Moveable Kidney on the rigid side (Mosler, 1866). 
 
 A Avoman, aged thirty-six, died of double pneumonia after 
 amputation of the thigh. Grohe, who made the autopsy, 
 found the followin«:: conditions :
 
 MOVEABLE KIDNEY IM WOMEN. 259 
 
 Liver enlarged. On turning it up, the right kidney, 
 wliicli was, however, very deeply situated, at once came into 
 view. The kidney was rotated half round so as to bring its 
 outer convex border almost entirely horizontal and looking 
 downwards and on a level with the crest o£ the ilium, the 
 hilum looking upwards and inwards. The right renal vein 
 ran obliquely upwards and opened into the vena cava inferior 
 at a somewhat acute angle. The ureter which was entirely 
 covered at its origin by the kidney, first describing a slight 
 curve, ran upwards over the trunks of the great vessels, and 
 then passed towards the pelvic cavity as usual. The diameter 
 of the vein, artery, and ureter was normal, no special altera- 
 tions attributable to the abnormal position of the kidney 
 could be made out. The only difference between the kidneys 
 was that the right was somewhat smaller than the left. The 
 right kidney was 4f in. long, 2| in. broad, ig in. deep ; the 
 left was 5g in. long, 2| in. broad, if in. deep. 
 
 (14) Moveable Kidney on the rir/ht side (Jago). 
 
 In a woman who had lost much flesh from obstinate 
 vomiting, a moveable kidney was discovered on the right 
 side. Pressure against its lower end made it slip away from 
 the hand upwards, and the upper end could be pressed to 
 right or left. Pressure on the upper end drove the tumour 
 plainly, but only a little, downwards. If seized with the 
 whole hand it could be pushed upwards, but the hilum could 
 not be reached. If pressed downwards, it was so smooth that 
 it slipped away. 
 
 At the autopsy the kidney could be displaced from the loin 
 to the extent of two inches above and three inches below, 
 this mobility not being restrained by the vessels. The peri- 
 toneum was adherent to the whole anterior surface of the 
 kidney, and to part of its lateral and posterior surfaces, but 
 did not enclose the emerging vessels so as to form a mesen- 
 tery (mesonephron). The peritoneum passed somewhat 
 loosely from the kidney to the adjacent organs in the loin.
 
 260 MOVEABLE KIDNEY IN WOMEN. 
 
 (15) Moveable Kidney on the right side; caries of the 
 thoracic spine ; formation of a mesentery (niesonephron) 
 (Henderson). 
 
 A woman, aged fifty, liad long observed a moveable 
 tumour in the lower abdomen, which could be felt in the 
 right side of the hypogastric region, disappeared beneath the 
 liver on slight pressure, and reappeared on bending forwards. 
 There was caries of part of the vertebral column of some 
 years' standing. 
 
 The patient died of pneumonia. At the autopsy the bodies 
 of the fifth and sixth thoracic vertebras were found to be so 
 far destroyed that two fingers could be introduced into the 
 vertebral canal. The right kidney was suspended and quite 
 moveable in a prolongation of the peritoneum like a mesen- 
 tery ; it was quite normal in size and structure. The left 
 kidney was loosely attached, but not moveable. The 
 liver appeared normal, except that it was rather small. 
 
 (16) Moveable Kidney on the right side; caries of the fourth 
 
 litmhar vertebra (Ebstein). 
 
 In the body of a woman fifty years of age and much 
 emaciated^ the right kidney was found lying across the verte- 
 bral column on the usual level with the hilum looking back- 
 wards and upwards, the convex boi'der looking downwards 
 and forwards, the capsule of fat entirely absent ; the kidney 
 which was of normal shape could be displaced as far as the 
 brim of the pelvis. 
 
 (17) Moveable Kidney on the leftside; caries of the first to 
 
 the third lumbar vertebrx (Culliugworth) (87). 
 
 In the body of a ballet-dancer, thirty-two years of age, 
 who had had nine children, the psoas muscle was found 
 almost completely destroyed ; the left transverse process and 
 the loft half of the body of the second lumbar vertebra had 
 disappeared, the tips of the transverse processes of the first 
 and third lumbar vertebra) were also carious, the kidneys
 
 MOVEABLE KIDNEY IN WOMEN. 261 
 
 and their calices dilated ; on the inner and posterior side, 
 where they were connected to the lumbar vertebrjB, an open- 
 ing was found forming a communication between the diseased 
 vertebrae and the renal tumour. 
 
 The ureter had been occluded by a perforated piece of 
 carious bone ; and this perforation could only have happened 
 subsequently to the dislocation downwards of the kidney. 
 
 Other post-mortem records were useless on account of 
 excessive brevity or of inaccuracy. Those which have just 
 been quoted establish the fact that moveable kidney both in 
 life and after death is found by preference on the right side 
 and in women. Again, moveable kidney presents no constant 
 condition either during life or after death, but varies in 
 respect of its position and degree of mobility. The first 
 observation of Aherlc, in which the kidney felt diiring life to 
 the right of the umbilicus was found after death in its normal 
 position, is very instructive. In this case, unless special 
 attention had been given during the autopsy to the question 
 of its mobility, the moveable kidney would certainly have been 
 overlooked, as perhaps often happens. 
 
 The kidney is usually covered by small intestine and lies 
 near the vertebral column in the region of the second to the 
 fifth lumbar vertebra9, and, besides being displaced from its 
 normal position, is rotated on one or two of its axes. In 
 some cases its outer border is turned upwards, its upper end 
 inwards, its lower end outwards, so that the hilum looks 
 inwards instead of dow^nwards [JJrag) ; in others it lies in an 
 exactly opposite position, transverse in the abdomen with the 
 hilum upwards {Mosler). It is rare for the lower end to be 
 directed forwards {Raijer) ; most frequently it lies obliquely 
 from above and externally downwards and inwards. 
 
 In correspondence with this, the position and relation of 
 the renal vessels and ureter to each other and the neighbour- 
 ing organs is changed. The lower down the kidney lies the 
 acuter the angle between the renal vessels and the vena 
 cava and aorta must be, and the more curved must be the 
 ureter ; the more the kidney is rotated round one of its axes, 
 the more must the calibre of the vessels and ureter be 
 narrowed by torsion. Little attention unfortunately has
 
 262 MOVEABLE KIDNEY TN WOMEN. 
 
 liitherto been paid to these changes in the cadaver, the vessels 
 being only now and then described as elongated and 
 narrowed. 
 
 The kidney which is moveable is in many cases remarkably 
 small and light, in Avhich case the other is hypertrophied by 
 way of compensation. In Ray er' s case the moveable kidney 
 weighed 80 gi'ammes, the other 150 grammes. It is usual 
 for the kidney which is not moveable to be more deeply situ- 
 ated than normal. In some cases the kidney substance is 
 itself degenerated, sometimes by fatty change, sometimes by 
 the contraction of connective tissue within it, and it is some- 
 times in a state of hydronephrosis. Quite recently numerous 
 cases of sarcomatous moveable kidneys have also been 
 reported, as for instance by Wolcott (88), Kocher (89), 
 Jessop (90), Czerny (91), Lossen (92), and Barker (93). 
 Under such pathological circumstances as these, indeed, 
 the mobility of the kidney is so far the lesser evil that it is 
 not considered. 
 
 Hydronephrosis of moveable kidneys has been mentioned 
 it is true, but not brought into any closer connection with 
 the mobility of the kidney. Sinioyi indeed stated expressly 
 so late as 1876, that up to that time no case of hydronephrosis 
 in a moveable kidney had been described. 
 
 The Capsula adiposa shows a pretty constant condition, 
 being destitute of fat in many cases where there is no great 
 degree of general emaciation. The capsule of the kidney is 
 then like an empty bag, which is bulged forwards by the 
 kidney as far as its size and the looseness of the cellular 
 tissue permit. By this means a kind of mesentery of the 
 kidney, a mesonephrou, is found, which is sometimes very 
 long {Girard, Oerum-Hoivitz, ^'c). This mesentery has been 
 erroneously regarded by many authors [Portal, Rollet, 
 Ebstein, ^c.) as a congenital cause of moveable kidney. 
 
 Again, the hepatic and splenic flexures of the colon are 
 found almost constantly displaced, being either bodily 
 depressed downwards and inwards together with their mesen- 
 teries, or having the two layers of the mesocolon separated 
 by the kidney which has in a sense migrated between them. 
 A similar effect is produced by hydronephrosis, or, in the 
 case of the broad ligament, by the growth of tumours of the
 
 MOVEABLE KIDNET IN WOMEN. 263 
 
 ovary or uterus within its substance. In this respect, therefore, 
 hydronephrosis and moveable kidney behave alike, as the 
 foregoing post-mortem records show, except that in the case 
 of hydronephrosis the two layers of the meso-colon are kept 
 apart by its constant growth, whereas in the case of move- 
 able kidney it is the movements of the kidney which separate 
 them (conf. the observations of Aberle and Sandifort). The 
 displacement of the colon has also been erroneously regarded 
 as a congenital cause of moveable kidney. 
 
 Moveable kidney produces no effect on the solid organs 
 near it, thus even the supra-renal bodies are constantly found 
 in their normal position. 
 
 Among other pathological changes observed in the dead 
 subject are adhesions, contracted by the kidney with neigh- 
 bouring i^arts. A favourite spot for these adhesions is 
 the lower border of the liver, the gall-bladder and transverse 
 colon. 
 
 It is rare for a moveable kidney to produce thrombosis 
 of the vena cava inferior by compression {Girard). 
 
 VI. Etiology and Pathogenesis. 
 
 If an attempt were made to explain the causes and mode 
 of pi^oduction of moveable kidney from post-mortem appear- 
 ances only, the scarcity and incompleteness of post-mortem 
 records would yield but imperfect results. Besides this, it 
 would be impossible thus to decide the question whether the 
 changes discovered after death were causes or consequences 
 of moveable kidney. In this way indeed the length of the 
 renal vessels, the presence of a mesenteiy of the kidney 
 (mesonephron), and the displacement of the colon have been 
 considered actual causes of moveable kidney, while accurate 
 observation shows that they are just as much results of move- 
 able kidney, or that both pathological conditions are possibly 
 consequences of a third common cause. Finally, there may 
 be present during life certain anatomical disturbances which 
 have an important bearing on the pathology of moveable 
 kidney, and yet cannot be recognised either by post-mortem 
 examination or by examination of the fully formed patho-
 
 264 MOVEABLE KIDNEY IN WOMEN. 
 
 logical specimen, such for instance as compression, torsion of 
 vessels, and pressure on nerves. 
 
 We have already seen that the kidney, lying as it does 
 in the Capsula adiposa, against the quadratus lumborum 
 muscle, and for the most part within the bon}^ enclosure of 
 the thorax, is maintained in its position directly by physical 
 pressure, as for instance by the intra-abdominal pressure, as 
 well as by its anatomical attachments. ^As soon, therefore, 
 as one of these factors fails, the kidney may become 
 moveable. 
 
 Anatomical Causes. 
 
 Many authors {Bayer, Eollet) have mentioned the pressure 
 exercised by neighbouring oi'gans when enlarged (especially 
 tumours of the liver and spleen) as important causes of 
 moveable kidney ; but this is erroneous. It is true that 
 moveable kidneys have been found in patients with ague or 
 splenic leuka3mia or hypertrophy or tumours of the liver, but 
 the well-established fact that they are not constantly found 
 in these diseases proves that the mobility of the kidney can- 
 not be laid to their charge. Since, moreover, tumours of 
 the liver and spleen grow downwards over the anterior 
 surface of the kidney and not in the direction of the long 
 axis of the kidney, such tumours would tend to maintain the 
 kidneys in their position rather than to depress them. The 
 only tumours which could displace the kidneys by virtue of 
 
 ' [The logic of tliis sentence as it stands seems doubtful ; the author 
 probably means that all the factors are necessary and no more than are neces- 
 sary to maintain the position oi" the Icidney. But this again is not proved. 
 It seems more probable, from the analogy of other organs, that one or 
 more factors are essential and generally sufficient, the others coming into 
 play only in case of failure of the first. Thus in a railway train the screw- 
 couplings are generally sufficient, but thö chain-couplings are added in case 
 of their failure. Or take the case of the uterus, whose descent is not pre- 
 vented by the perineum unless its ordinary means of attachment fail ; the 
 perineum generally does not deserve to be described as one of the means of 
 preventing descent of the uterus. This may be seen any day in women 
 whoso Perineums are completely gone, the uterus nevertheless remaining 
 high up in the pelvis. The question belongs to a large and important 
 department. — Tbanslatoe.]
 
 MOVEABLE KIDNEY IN WOMEN. 265 
 
 their position are tumours of tlie suprarenal bodies and 
 pancreas, examples of which are furnished by Bayer and 
 Bonnet. 
 
 A similar effect is produced on the mobility of the kidney 
 by tumours of its own substance, such as sarcomas, carci- 
 nomas, and hydronephroses. In this case the mobility is 
 produced by the great stretching and relaxation which the 
 capsule — the most important attachment of the kidney — 
 sometimes suffers through the inci'ease in weight and size 
 produced by these tumours. 
 
 This is seen typically in cases of caries of the last thoracic 
 and first lumbar vertebra}, and in psoas abscesses (Hender- 
 SOD, Ebstein, Culligworth), in which the kidney is deprived 
 of its firm base of support. 
 
 One of the most important and frequent causes of mobility 
 is absorption of fat from the Capsula adiposa and relaxation 
 of the peritoneum. The absence of the fat round the kidney 
 can of course only produce mobility in cases in which it was 
 previously present in considerable quantity and then became 
 rapidly absorbed. If, however, the fat is only slowly re- 
 moved, an accommodation takes place, and the kidney main- 
 tains its position just as it does in very young subjects who 
 have never had any fat in the capsules of their kidneys. In 
 the other case, however, after a rapid absorption of the fat, 
 the capsule looks like a relaxed Avide-meshed envelope, easily 
 capable of being hodily dragged down from the posterior 
 wall of the abdomen, and within which it is easy for the kid- 
 ney to descend. We see here just the same conditions as 
 we do in the skin, Avhich can be lifted up from the muscles 
 in folds whose size is greater the more rapidly and thoroughly 
 the panniculus adiposus has been absorbed. 
 
 It generally happens, however, that at the same time as 
 the fat round the kidney is being absorbed, that in the peri- 
 toneal structures and the abdominal walls is also becoming 
 absoi'bed, so that the means by which the kidney is indirectly 
 secured are also deprived of their strength, and under these 
 circumstances^ slight bearing down efforts, such as those 
 
 ' [Here for the first time in this treatise we meet with the very important 
 Imt very obscure question of the " Intra-abdominal pressure." That there 
 is such a force, that it varies, that it has laws of its own, that its effects are
 
 266 MOVEABLE KIDNEY IN WOMEN. 
 
 wliicli occur dui-ing defoecation, are sufficient to dislocate the 
 kidney downwards. 
 
 We ought not therefore to bo surprised at finding among 
 those suffering from moveable kidney a large number who 
 have recovered from acute febrile diseases, such as enteric 
 fever and ague, or who are still suffering from chronic and 
 rapidly emaciating affections such as phthisis, &c. Thus out 
 of nine of BiefVs cases, severe ague aiid enteric fever had 
 preceded the moveable kidneys in four. 
 
 A conspicuous part in the pi'oduction of moveable kidney 
 is also played, especially in women, by affections of the 
 ahdominal ivalh, which are exposed normally in pregnancy 
 and pathologically in the numerous cases of tumours of the 
 genital organs, to serious alterations in compactness, firmness 
 
 important, and that it is not always positive, has been definitely proved by 
 Matthews Duncan and Schatz ; but beyond this very little is practically known. 
 And at the outset difficulties meet us. In the first place it seems certain 
 that hernia, descent of the uterus, and descent of the abdominal organs 
 are conditions due to closely allied if not identical causes (this will be dis- 
 cussed again later on, p. 357). In this class of cases the intra-abdominal 
 pressure would seem to be increased. But increased intra-abdominal pressure 
 is equivalent to diminished specific gravity or increased buoyancy of the 
 intra-abdominal organs, which (in the case of the kidnej's for instance) would 
 mean diminished tendency to descend. 
 
 "With regard to the efEort of straining as being an exciting cause of descent 
 of the kidneys this explanation seems more than doubtful ; for if the kidney 
 is squeezed downwards by the diaphragm with a certain force, it is squeezed 
 upwards by the abdominal muscles with an equally great force, besides the 
 increased buoyancy produced by increase of the intra-abdominal pressure 
 which would tend rather to lift than to depress it. 
 
 The effect of jerks and falls and perhaps vomiting is a question of impetus 
 and belongs to a different category ; their effect in dislocating the kidney, 
 especially when the abdominal muscles are not braced, is easily explained. 
 
 The only possible mode of reconciling facts with regard to the conditions 
 of the intra-abdominal pressure in our present state of ignorance would be 
 to regard the kidney (and other abdominal viscera) as generally having a 
 tendency to descend, even when their buoyancy was at its greatest, and to 
 regard the apparent increase in the intra-abdominal pressure in hernia, 
 descent of the uterus, &c., rather as the result of diminished resistance to 
 a generally positive pressure, witli which the weight of the viscera would 
 co-operate. Against tliis view would have to be put the occasional high 
 position of floating pelvic tumours and of the pregnant uterus. It is not, 
 however, proved that the intra-abdominal prcssui-e is the same in all parts of 
 the abdominal cavity even at the same time. — Tkanslatob.]
 
 MOVEABLE KIDNEY IN WOMEN. 2(37 
 
 and elasticity. True it is that it is normal for the abdominal 
 walls which have been physiologically stretched during 
 pregnancy, to make as good a recovery as the womb ; but 
 in cases where the lying-in has gone wrong, where labours 
 and abortions have succeeded each other rapidly, they become 
 flabby, shrivelled, and thin, and pendulous belly, which is 
 here so injurious, is apt to follow, with or without divari- 
 cation of the recti muscles. If now the intra-thoracic pres- 
 sure is increased (i.e. if the diaphragm is forced dowti), as 
 in lifting, in difficult defsecation, or severe efforts of any sort, 
 the efficient means of fixing the abdominal contents furnished 
 by well-braced abdominal muscles fails, and the descent of 
 the kidney is opposed by diminished resistance. But the 
 subjects of pendulous belly are just the persons who are also 
 predisposed to severe bearing down efforts, inasmuch as they 
 are usually much constipated. Finally, however, where 
 pendulous belly is present, the action of the intra-abdominal 
 pressure, which normally presses with equal force on all the 
 viscera, is reversed, inasmuch as the bowels which occupy 
 the loose sac formed by the abdominal walls exercise trac- 
 tion on the sujDcrjacent parts, including the kidneys, when 
 the patient stands upright. Tlie^ fatter and heavier the ab- 
 dominal walls, the greater the pendulous belly and the 
 greater therefore this traction. This is the obvious explana- 
 tion of the occasional great difficulty of breathing in persons 
 with pendulous belly, the traction of the viscera impeding 
 the normal expiratory movement of the diaphragm. But by 
 the frequently recurring distension of the abdomen, whether 
 physiological or pathological, the peritoneum also is relaxed, 
 and in pendulous belly the anterior peritoneal layer of the 
 capsule of the kidney, and with it the kidney, is subjected 
 to direct traction. 
 
 The injurious effect of the above-named causes is confii'med 
 by clinical observation. The vast majority of women affec- 
 ted with moveable kidney have borne many children, and, as 
 shown by the appended table of my own observations, it is 
 striking how frequently their deliveries had followed each 
 other closely. Among the forty-two cases observed by me 
 
 > [It is, however, a fact that hernia and allied conditions are commoner iu 
 thin, flabby individuals than in fat ones. — Tüanslatoe.]
 
 268 MOVEABLE KIDNEY IN WOMEN. 
 
 only two are nulliparae, and of these one had carried a large 
 ovarian tumour for eighteen years, and had acquired pendu- 
 lous belly after I had removed it. Similar observations 
 of cases in which the abdomen had long been distended 
 by tumours or ascites are contributed by Oeriim-IIowitz 
 and Rollet. Ruptures are frequently found in women along 
 with moveable kidney, as observations by Rayei; &c., show. 
 
 Menstruation, again, has been namedby Bcqiiet, Lancereaux, 
 Fourrier, and others among the influences contributing to the 
 production of moveable kidney. According to these authors 
 every menstruation produces congestion of the kidney and its 
 capsule, and therefore increase of its volume, through a con- 
 nection between the ovarian and renal plexuses, which connec- 
 tion, however, has yet to be proved. The relaxation of the 
 capsule,'its distention at next menstruation, 'and so on, gradually 
 enlarge it to such a degree that the kidney becomes moveable 
 within it. Although clinical symptoms show that a connec- 
 tion between moveable kidney and menstruation exists, and 
 that the renal and uterine vessels are closely connected (as 
 the investigations of Virchoiv (94) prove), a direct relation of 
 cause and effect between menstruation and moveable kidney 
 must be rejected, for, on the above theory no woman who 
 menstruates should fail to have a moveable kidney. 
 
 There are, however, a series of other influences, hitherto 
 too little regarded, which demonstrate the dependence of 
 moveable kidney on the sexual department of a woman's 
 organism, besides such causes as repeated pregnancy, tumours 
 of the lower abdomen, &c., which have already been meii- 
 tioned: — tliese are the numerous displacements of the generative 
 organs, the descents, prolapses, and inversions of the vagina 
 and uterus. In the first place these affections have important 
 causes in common with moveable kidney, such as impeded 
 involution of the generative organs post partum, relaxation 
 of the peritoneum, and rapidly repeated deliveries ; this is 
 proved by their pathology. In the second place, however, 
 descent of the genital organs favours the descent of the 
 kidney by direct traction. Since the female generative 
 organs are directly connected with the kidneys by the peri- 
 toneum as well as by the ureter, which runs close to the body 
 of the uterus and in the substance of the upper third o£ the
 
 MOVEABLE KIDNEY IN WOMEN. 269 
 
 vagina, this traction is increased by tlie bladder whicli is 
 usually prolapsed in these affections. It either happens that 
 the kidney yields to this traction, or that the ureter becomes 
 closed by it. 
 
 Finally, a whole series of diseases of the female sexual 
 organs contributes directly to the production of moveable 
 kidney by inducing hydronephrosis which relaxes the capsule 
 of the kidney. In consequence of the intimate mutual rela- 
 tions existing, as we shall see, between moveable kidney and 
 hydronephrosis on the one hand, and between affections of 
 the female generative organs and moveable kidney, as we 
 have already shown, on the other hand, it seems imperative 
 to consider very briefly the relation between certain affec- 
 tions of the female generative organs and the production of 
 hydronephrosis. 
 
 Relations of Sexual Disorders to the production of 
 Hydronephrosis. 
 
 Even Walter (95) explained the frequency of hydrone- 
 phrosis in women by the circumstance that they possess more 
 organs capable of pressing on the ureters and thus giving 
 rise to accumulation of urine, than men. 
 
 Morgagni (96) had already called attention to the mutual 
 relations between the pregnant uterus and the kidney, 
 remarking on a case in point : " Inter caetera autem detri- 
 menta quae mulieribus afferunt cruciatus nephritici, non 
 dubito, quin abortus, aut non infroquens et foetus, et matns 
 interitus sit referendus. Cum enim uterus crescens ureteres 
 premendo, minus per hos facilem reddat urinae defluxum, et, 
 quod consequitur, nonnihil in renibus eam moretur. 
 . ." &c. 
 
 Cases, again, are not rare in which an autopsy has shown 
 compression of the ureter by tumours of the uterus and ovary. 
 
 A far inore frequent cause of hydronephrosis is cancer of 
 the uterus, in which hydronephrosis is almost one of the 
 regular phenomena, as Virchow, Sdxinger, and others have 
 shown.
 
 270 MOVEABLE KIDNEY IN WOMEN. 
 
 Freunci} (97) and Hildehrandt^ (98) have convincingly 
 
 ^ [Freund, Deutsche Naturforscher- Versammlung, Ivarlshad, 1862 ; 
 ' Verhandlungen der gynäkologisclien Section,' S. 119. 
 
 The whole reference to this paper (which I succeeded in finding in the 
 library of the Eoyal Society, after a fruitless search in those of the Royal 
 Medical and Chirurgical and Obstetrical Societies, the College of Surgeons, 
 and the British Museum) is as follows : 
 
 " Amtlicher Bericht über die sieben und dreissigtste Versammlung Deuts- 
 cher Natiu'forscher und Aei'zte in Karlsbad im September, 1862," Karlsbad, 
 1863, S. 295. 
 
 "According to Dr. Freund hydronephrosis is often found in cases of 
 retroflexion of the uterus : its causes are : 
 
 " I. Actual narrowing of one or both ureters, e.g. from chronic changes in 
 the pelvic cellular tissue. 
 
 " 2. Dislocation of the uterus may cause kinking (Knickung) of the 
 ureters. The ureter is often fastened to the side of the uterus after peri- 
 metritis ; this would explain the symptoms of hydronephrosis during life, 
 namely, violent pains in the loins passing downwards along the iireters, 
 pains in the lower extremities, headaches, frequent desire to pass water, 
 dyspeptic troubles — which have been hitherto, according to Dr. Freund, 
 wrongly attributed to hysteria. The symptoms of hydronephrosis are inter- 
 mittent, the quality of the iirine resembles that in catarrh of the bladder. 
 Dr. Freund believes that pyelitis is a frequent sequela ; he mentioned a case 
 which ended in cure. After kinking of the ureters hydronephrosis onl}' 
 occurs on the right side ; after narrowing of the ureters, on both sides. 
 
 " As the 3rd cause. Dr. Freund cites atrophy and hypertrophy of the pelvic 
 contents ; the former often extending to the bones, the general suffering 
 small. The origin of both is problematic." 
 
 This seems nothing more than a collection of general statements ; the 
 ' Official Report ' contains not a single fact in favour of the theory laid down 
 in the text.] 
 
 - \_HildebraniU, 'Volkmann's Sammlung Klinischer Vorträge,' Band i, 
 Abth. 3, Gyn. No. 5, " Ueber retroflexion des Uterus." 
 
 " Frau H., who had suffered from annoying urinary troubles besides the 
 usual symptoms of retroflexion, was sent to me by her family doctor to be 
 examined for a somewhat voluminous soft tumour above the left Poupart's 
 ligament. I found retroflexion, and gave as my opinion that the tumou-r 
 was to be regarded as a dilatation of the ureter in consequence of the retro- 
 flexion. My diagnosis was verified easily and promptly. I first replaced 
 the uterus with the sound, then introdiiced the cathether and drew off the 
 water, pressing on the abdominal walls at the same time. The tumour 
 diminished as I did so from the size of a child's head to that of an apple." 
 
 This case seems far from proven. To have proved Hildebrandt's point it 
 would surely have been as well to pnss the catheter before roi)lacing the 
 uterus ; by his method he has destroyed the proof that the retroflexion bad 
 any connection with the urirary symptoms. 
 
 I have quoted both passages at length to enable readers to judge for
 
 MOVEABLE KIDNEY IN WOMEN. 271 
 
 proved that the common retroflexions of the uterus produce 
 hydronephrosis by kinking (Knickung) and downward drag- 
 ging of the ureters. 
 
 A rarer cause of hydronephrosis in connection with the 
 female generative organs is mentioned by Stadtfeldt (99), viz. 
 the compression of the ureter by parametric cicatrices. I 
 find a similar observation in Sandifort (100). Significant 
 cases in point have been quite recently communicated by 
 Frankel and Jfaass (loi) and by Schottelius (102). The latter 
 found in a woman forty-three years of age the pelvis of the 
 left kidney dilated into a sac holding six litres of fluid, 
 the ureter somewhat dilated and tortuous, but admitting the 
 passage of a probe as far as the bladder. The hydronephro- 
 sis was due to a displacement of the uterus, and fixation of 
 the left ureter by dense connective tissue, the result of 
 former parametritis, to the cervix, above the opening of the 
 ureter into the bladder. 
 
 Parametritis may therefore produce obstruction of the 
 ureter in two ways, either through direct compression of the 
 corresponding ureter by the deposit, or by contraction of the 
 cicatricial tissue drawing the uterus to its own side and thus 
 dragging on the opposite ureter and occluding its calibre. 
 
 A hwrnatometra may also produce hydronephrosis by com- 
 pression of the ureter in the same way as a parametritis, as 
 Tiingel (103) has shown. 
 
 One of the most important causes of hydronephrosis how- 
 ever, though hitherto little regarded, is descent of the female 
 generative organs first indicated by Virchoiu (104) . It seems all 
 the more necessary to consider this cause in the present 
 place, inasmuch as we have already recognised descent of 
 the female generative organs as a cause of moveable kidney 
 itself ; so that the relations of descent of the female genera- 
 tive organs to moveable kidney are twofold, contributing as 
 it does directly through traction on the one hand, and indi- 
 rectly through the jDroduction of hydronephrosis on the other 
 hand, to the mobility o£ the kidney. 
 
 We owe the first observation in which descent of the 
 
 themselves how far they consider that retroflexion of the uterus has been 
 " convincingly proved " to he a cause of hydronephrosis. Descent of the 
 uterus, with or without retroflexion, is anotliin- matter. — Translator. ]
 
 "272 MOVEABLi] KIDNEY IN WOMEN. 
 
 female generative organs was recognised as a cause of hydro- 
 neplirosis and confirmed by an autopsy, to Virchow liimself, 
 who found in a woman, forty-three years of age, the subject 
 of an irreducible procidentia, the ureters much constricted as 
 far up as the sacro-iliac synchondrosis, and the pelvis of the 
 kidney dilated. This condition was explained by Virchow 
 from the circumstance that the base of the trigoTie, that is 
 the spot where the ureters open, was drawn forwards beneath 
 the symphysis pubis, necessitating compression and there- 
 fore obstruction to the passage of urine. Virchow remarks, 
 " The possibility of such obstruction, and the production of 
 hydronephrosis in cases of prolapsus uteri of this kind, is well 
 worthy of attention in practice, though not hitherto men- 
 tioned. It stands on the same footing as the hydronephrosis, 
 which so very often accompanies cancer of the womb, and 
 which is also usually disregarded.'^ This hint by Virchow 
 has, however, attracted little notice, for apart from his own 
 observation I have been able to find only one solitary notice 
 of the same kind by Philij^ps (105), who found in a 4 para 
 thirty-five years of age (who had suffered since her first 
 oonfinement from procidentia of the uterus and died coma- 
 tose), the capsule of the kidney adherent, the glandular 
 substance much contracted, the pelvis dilated, the pyra- 
 mids flattened and changed into cavities, hardly a quarter of 
 the glandular substance left, the mucous membrane of the 
 urinary passages thickened, the ureters dilated to the thick- 
 ness of a finger. The ureters and bladder contained milky 
 purulent urine, the muscular tissue of the bladder was hyper- 
 trophied, the uterus lay in front of the vulva as large as an 
 apple. The procident mass consisted of the neck and part 
 of the posterior Avail of the bladder in front, and of the pos- 
 terior vaginal wall and greatly thickened peritoneal covering 
 of Douglas's pouch behind. The orifices of the ureters were 
 found beneath the pubic arch and had thus been exposed to 
 a considerable pressure. 
 
 Although in this case the mechanical cause of tlie pro- 
 duction of the hydronephrosis doubtless consisted in com- 
 pression of the ureters against the pubic arch, as is proved 
 by the dilatation of the ureters down to their vesical 
 orifices, in other cases it seems to consist in occlusion of the
 
 MOVEABLE KIDNEY IN WOMEN. 273 
 
 ureters by tractioa (sucli as may bo produced by stretcliing 
 an india-rubber tube) liiglier up than tlie point of application 
 of tbe traction, as can be seen in Virchoiv's case.^ 
 
 Physical' causes. 
 
 We Lave so far studied tlie primary clianges in tlie 
 direct or indirect means of fixation of the kidney as produ- 
 cing its mobility, but in all cases pressure from above or 
 traction from below must contribute to its development. 
 These i^hysical influences are competent, by themselves and 
 ■without any 2)'>'(ivious anatomical changes of im])ortance, to 
 produce moveable kidney. 
 
 Thus acute injury is frequently cited as a cause. In this 
 case, of course, just as in cancer of the breast, the bare state- 
 ment of the patient that a tumour developed in the abdomen 
 after a fall or a blow, &c., should not be implicitly believed. 
 In the case of moveable kidney as well as in cancer of the 
 breast, it is an external occurrence which first directs a 
 patient's attention to the existence of the malady. The oc- 
 currence of this luxatio traumatica rents is established by 
 trustworthy observations. Thus observations are quoted by 
 Mayer, Henoch, Ferher and Le Bay, in which this complaint 
 was acutely produced by a fall from a carriage or from 
 horseback, or by a blow on the side. If it is remembered 
 that isolated ruptures of the liver, spleen or kidney have 
 been found after severe injuries, the possibility of the oCca- 
 
 * [Attention should be called in this place to a remarkable class of cases 
 in which marked dilatation of the ureters and hydronephrosis occur. These 
 may be described as cases of urinary obstraction from irritation. The first 
 division of the class concerns the subjects of incontinence of ui"Ine. Three 
 cases are recorded by Dr. Alexander James, ' Edinburgh Medical Journal,' 
 1878, p. 135, in which death occurred, and in the two of these in which 
 a post-mortem examination was obtained dilatation of the ureters and double 
 hydronephrosis was found. The second division concerns the subjects of 
 extroversion of the bladder, in which affection a similar condition is gene- 
 rally found {Cliampneys, ' St. Bartholomew's Hospital Reports,' vol. xvi, 
 1880, p. Ill) in spite o£ the absence of any structural obstruction to the 
 ureters. In both of these cases the obstruction is spasmodic, and the com- 
 parison of tlie two classes shows that its seat must be the orifices of the 
 ureters. The bearings of this on the previous remarks in the text are 
 obvious. — Teanslatob.] 
 
 18
 
 274 MOVEABLE KIDNEY IN WOMEN. 
 
 sional occurrence of isolated ruptures of tlie capsule of tlie 
 kidney by a blow or its " contrecoup '"^ will not be doubted. 
 I myself liave seen two patients in whom careful investigation 
 proved the sudden appearance of an abdominal tumour, in 
 one case after carrying a heavy weight with the trunk bent 
 sidewaySj and in the other case after a fall, in both cases 
 without any predisposing anatomical cause. 
 
 In a similar fashion other authors have seen moveable 
 kidneys actually develop in the course of labour after severe 
 bearing down ; but in these cases it is questionable whether 
 a moveable kidney already produced had not been pushed 
 up during pregnancy by the growth of the uterus, and 
 merely reappeared after delivery. 
 
 This complaint, however, is more frequently induced by 
 repeated injury, especially by the shock of cough in bronchitis, 
 pleurisy, whooping-cough, and particularly when favoured 
 by other factors, such as the rapid emaciation of phthisis. 
 Even lUolan and Portal drew attention to the importance of 
 this influence, and they have been confirmed by the obser- 
 vations of Le Bay, Drfontaine, Olivier, Keppler, and Bayer. 
 I myself cannot doubt, when I consider that the kidney lies 
 above the lowest part of the pleura, that every pleurisy with 
 effusion must necessarily depress the kidney, so that under 
 these circumstances, violent concussion of the diaphragm 
 may very easily produce mobility of the kidney. 
 
 But repeated exertions, such as prolonged and severe 
 labour, lifting great weights, carrying heavy children, violent 
 straining at stool, may act in the same way as fits of cough- 
 ing in loosening the attachments of the kidney and thus 
 contributing to its mobility.^ Literature contains many 
 vouchers for their occurrence. Thus a patient under my 
 care, in whom no predisposing* anatomical cause of moveable 
 kidney could be ascertained, had been used to carry heavy 
 burdens on the hips, with the trunk bent sideways.' 
 
 ' [The steady squeeze, presumably equal in all directions, produced b}' any 
 of the above methods is surely a very different thing from shocks, such as 
 that of coughing, blows, or falls. This has been remarked in ä previous 
 note — Tkanslatoe.] 
 
 •^ [This uusymmetrical position may have been a very important factor in 
 the case. — Tuanslatok.]
 
 MOVEABLE KIDNEY IN WOMEN. 275 
 
 Finally^ tlie stays have been quoted from the most various 
 quarters as an important factor in the production of move- 
 able kidney. Gruveilhier especially remarks ; " J'ai ren- 
 •contre plusieurs fois chez les femmes qui usent de corsets 
 fortement serres^ le rein droit dans la fosse iliaque du meme 
 Gote. Ce deplacement arrive, lorsque par la pression exercee 
 par le corset siir lofole, le rein est force de I'espece de löge 
 qu'il occupe a la face inierieure de cet organe, a peu pres 
 
 -comme un noyau entre les doigts qui le pressent." 
 
 If we consider, however, that many women who have 
 inoveable kidney have never worn stays and that only a few 
 of those who wear stays get moveable kidney, it follows that 
 this article of clothing, as such, is guiltless of the production 
 -of moveable kidney. Neither can the laced bodices (Schniir- 
 leibchen^) on which blame is laid by Müller -Warnech be 
 allowed to rank as causes. This author, as well as Bartels, 
 assumes that lacing of the bodice will directly compi-ess tbe 
 kidneys ; but this assumption is incorrect, for the bony 
 thorax, within which the kidneys lie, and round the lowest 
 
 .part of which the laces are braced, is far too rigid to pass 
 on the pressure to the subjacent organs. The damage 
 which the articles of apparel mentioned above do neverthe- 
 less inflict consists far more in this, viz. that too tight 
 lacing round the thorax prevents its expansion on inspira- 
 
 .tion and obliges the diaphragm to descend deeper by way of 
 compensation and thus to depress the subjacent organs, the 
 liver, spleen and kidneys. Again, the bodices (Schniirmiedei^^) 
 may produce an injurious effect directly on the kidney in 
 cases in which the kidney has already become moveable and 
 lies against the anterior abdominal wall. It is especis^lly 
 
 .important to remember that, when once a kidney has become 
 moveable, a number of other factors contributing to the 
 
 -further development of its mobility come into play, which, so 
 long as the kidney remains in position, have absolutely no 
 effect in producing its displacement. This is true, for 
 
 • l^Schniirleih, Schnilrviieder, are articles of clütliing unknown in Eng- 
 lland. They are laced bodices of simple construction, and worn still very 
 
 generally. The lower orders wear them often outside their other garments. 
 '. Similar bodices are worn outside by the Italian peasantry, and form part of 
 
 the proper dress of Margaret in ' Faust.' — Tkanslatok.]
 
 276 MOVEABLE KIDNET IN WOMEN. 
 
 instance^ of the movements of the spinal column, which, as 
 we have already seen, is to be regarded as immoveable only 
 in the region occupied by the kidney in its normal position. 
 Besides, a well-fitting pair of stays, which is only used for 
 supporting the breasts and strings of the garments, is, as we 
 shall see, much more calculated to prevent than to produce 
 mobility in a normally placed kidney. 
 
 It now remains to state plainly the causes which especially 
 contribute to the mobility of the o^ight kidney. This position 
 is all the more forcible inasmuch as, with the exception of 
 sudden violence aifecting one side, the causes of mobility 
 hitherto considered act equally on both sides of the body. 
 
 (a) The assumption that the right kidney is the larger and. 
 heavier is disproved by numerous determinations by Rayer 
 and 8aj)pey. 
 
 (6) Gueneau de Mussy assigns the usual tendency of the 
 uterus to rise in pregnancy towards the right side as a cause, 
 without further explaining the connection. 
 
 (c) Lancereaux thinks that there is possibly a special con- 
 nection between the right ovarian and renal plexus, produ- 
 cing at every menstrual period congestion and consequent 
 expansion of the capsule of the right kidney. 
 
 {d) Cruveilhier in this connection also makes stays answer- 
 able for depressing the right kidney, on the ground that their 
 pressure squeezes the kidney beneath the liver, just as a 
 slippery cherry-stone is flipped between two fingers, whereas 
 the left hypochondrium, occupied as it is by the spleen and 
 cardiac end of the stomach, bears the pressure of the bodic& 
 with impunity. 
 
 (e) According to Mtiller-Warneclc also the liver, and 
 therefore the " right kidney which normally lies distinctly the 
 lower down,'^ are sjDCcially affected by laced bodies. This 
 supposition is, however, not to the purpose, for normally the 
 right kidney lies very slightly if at all lower down than the 
 left, so that the left kidney being deprived of the protection 
 of the bulky liver must be much more exposed to pressure 
 than the right. 
 
 (/) Other authors make the liver alone answerable for the 
 frequency of moveable kidney on the right side, but finally 
 acknowledge with Rollet that : " The reason why the right
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 277 
 
 kidney becomes moveable far oftener tban the left is not as 
 yet sufficiently explained." 
 
 (g) It seems, however, to me that the explanation of this 
 peculiar relation ought not to be sought, as has hitherto been 
 the case, in causes which would seem to imply that the right 
 
 Fia. 3 (after Sappey). 
 
 Lower surface of the liver. 
 
 Gall-bladder. 
 
 Section through the diaphragm. 
 
 Posterior surface of the stomach 
 
 turned up. 
 Tiobus Spigelii. 
 
 Cceliac axis and hepatic artery. 
 Coronary artery of the stomach. 
 Splenic artery. 
 Spleen. 
 Pancreas. 
 
 Superior mesenteric vessels. 
 Duodenum. 
 
 13. Upper end of jejunum. 
 
 14. Lower end of small intestine passing 
 
 into colon. 
 
 15. Mesentery. 
 
 16. Ca3cum. 
 
 17. Vermiform appendix. 
 
 18. Ascending colon. 
 
 19. 19. Transverse colon. 
 
 20. Descending colon. 
 
 21. Sigmoid flexure. 
 
 22. Rectum. 
 
 23. Urinary bladder.
 
 278 MOVEABLE KIDNEY IN WOMEN. 
 
 kidney is exposed to greater pressure than the left. Other- 
 things being equal, the left kidney would be much more- 
 easily displaced laterally in the left hypochondrium which is 
 not occupied by firm abdominal glands, than the right, for- 
 the right kidney could only be displaced by more intense- 
 pressure or traction from under the liver, which occupies the- 
 whole of the right hypochondrium. But the different 
 behaviour of the right and the left kidney seems to mo- 
 te be best explained by the differences in their modo of 
 attachment. 
 
 1. The ^ifpev end of tJte descending colon lies higher and 
 is attached to the ribs further to the left and farther down 
 (seitlicher und tiefer) than the ascending colon. Whereas 
 the ascendiug colon lies against the middle of the right 
 kidney, the descending colon lies against the external convex 
 border of the kidney. Hence it follows that the loft kidney,, 
 although placed on the same horizontal level as the right, 
 is fastened to the j^osterior abdominal wall both higher up 
 and more firmly (höher hinauf und stäi-ker) than the right.^ 
 
 2. The descending colon and the splenic flexure are tauter 
 (straffer) and shorter in their attachment to the posterior 
 abdominal wall than the ascending colon and hejxdic flexure ;.. 
 in other words, the mesocolon of the splenic flexure is shorter- 
 and tauter than that of the hepatic flexure. This indirect 
 means of attachment is therefore stronger on the left than 
 on the right. 
 
 3. The ascending colon does not form a right angle with 
 the transverse colon as the descending colon does, but an obtuse 
 angle, or even forms a dependent loop before passing into the 
 transverse colon. 
 
 The reason for this peculiar behaviour of the ascending 
 colon, which I have seen a few times in children, and many 
 times in adults, and which Sappey has described as normal,, 
 appears to me to be the upward movement of the fa)ces in 
 
 ^ [This sentence, which is somewhat obscure, seems to mean that the colon 
 (which by means of its attachments to the posterior abdominal wall on the 
 one side and to the kidney on the other, is one of the defences of the kidney 
 against do\ATiward displacement) is itself attached to the posterior abdominnJ 
 wall higher and more extensively on the left side than on the right. — 
 Tbanslatoe.]
 
 MOVEABLE KIDNEY IN WOMEN. 279 
 
 the ascending colon contrary to the action of gravity, and 
 only effected by the peristaltic movements of tlie bowel. By 
 this means the spot where the ascending becomes the trans- 
 verse colon is gradually dragged downwards so much as to 
 form in extreme cases a fairly long loop, though it usually 
 passes obliquely or with a curve into the transverse colon. 
 
 But during the passage of the fasces from the transverse 
 into the descending colon, the weight of the column of fasces 
 and peristaltic action work in the same direction, no stagna- 
 tion takes place in the splenic flexure, which maintains its 
 original form. This difference between the hepatic and 
 splenic flexures explains also in its turn how the right kidney 
 has more room to descend than the left.^ 
 
 4. The descent of the left kidney is opposed by the iJosUion 
 of its vessels above the inferior or horizontal 'part of the duode- 
 num. Moreover, the position of the aorta on the left side 
 of the spinal column makes the left renal artery shorter than 
 the right ; this shorter attachment by means of the renal 
 artery (w'hich is natui'ally considered in this capacity before 
 
 1 [This explanation seems highly questionable. In the first place it 
 belongs to the category of " ftecal theories " which arc pressed into service 
 on very small provocation, and have, generally speaking, no positive evidence 
 in tlieir favour. Among the unsymmetrical conditions which they have been 
 called in to explain may be mentioned varicocele (left), iiterine obliquity and 
 torsion (to the right), and torsion of ovarian tumours, which this is no place 
 to discuss ; but with regard to the question now before us the following 
 objections may be urged : 
 
 a. It is probable that the ciuestion of ascent or descent of the frecal 
 column has very little to do with it. Take a familiar instance — a monkey 
 climbing up a rope and then down it, the rope being connected with a spring 
 weighing machine; how much difference in tension will there be.? The 
 only point of difference, addition or deduction, in the case of the colon will 
 be the rate of movement of tlic ficcal column. How fast is that ? 
 
 6. If this explanation were correct we ought constantly to find the 
 ascending loops of intestine full, and the descending empty, or at least one 
 fuller than the other. Where is this evidence ? 
 
 c. This explanation assumes a permanently perpendicular position. This 
 ceases for about one third of each day at least. Again, here we ought to 
 have evidence of a difference between the position of faeces in bed-ridden and 
 other people. Where is this evidence ? Is it not, on the contrarj^ rather, 
 these very bed-ridden people who are predisposed to moveable kidney ? 
 
 In the absence of direct proof, and in the face of the above considerations, 
 we think this explanation ought not to be entertained. — Teanslatoe.]
 
 280 MOVEABLE KIDNEY IN WOMEN. 
 
 the thin-walled vein) renders the mobility of the left Iddney 
 the more restricted. Less stress must be laid on the circum- 
 stance pointed out by Oerum-Uowifz, that the left suprarenal 
 vein opens into the renal vein, while the right suprarenal 
 vein opens directly into the vena cava, the left kidney (as 
 opposed to the right) having thus an additional indirect 
 connection with its suprarenal body (see Figs, i and 2). 
 
 5. The left renal vessels are closely connected by cellular 
 tissue with the head and neck of the pancreas, which thus 
 furnishes an additional attachment to the left kidney, of which 
 the right is destitute ; for the right renal vessels lie bare, 
 except for their peritoneal covering (see Figs. I and 2).^ 
 
 These reasons seem to me to explain sufficiently why 
 descent of the left kidney, though not impossible, is consid- 
 erably rarer, other things being equal, than that of the right. 
 
 The direction in which the kidney is permitted to move is 
 prescribed by the normal attachments and normal position 
 of the kidney, and is nearly constant. Since the insertion of 
 its vessels {i.e. the aorta and vena cava at the level of the 
 first lumbar vertebra) is a fixed point, it follows (presuming 
 the most favourable conditions for mobility, namely the 
 complete separation of the renal vessels from the posterior 
 abdominal wall) that the right kidney is capable of moving 
 
 ' Conf. E. Znclcerlcandl, " Beiträge zur Anatomie des menschlichen 
 Korpers." 'Wienei*. med. Jahrb.,' 1883,8.58; ' Centi'alblatt med. Wiss.,' 
 25Aug., 1883, S. 611. 
 
 If, after removal of the Capsula adiposa, the right kidney is raised from 
 the posterior abdominal wall, a membrane composed of connective tissue and 
 varying in thickness is seen, which passes into the parietal peritoneum at 
 the borders of the kidney and suprarenal body. This fascia is entirely 
 unconnected with the a])oneurosis which covers the anterior surface of the 
 quadratus lumborum. Tims, the right kidney is enclosed in a capsule 
 (besides the Capsula adiposa and fibrosa), the anterior wall of which is formed 
 by the peritoneum, and the posterior wall by this post-renal fascia. In the 
 case of the left kidney the colon runs along its side and not in front of it, 
 as it does on the right side. Thus, the front of the Capsula adiposa of the 
 left kidney is covered not only by the parietal peritoneum, but also by the 
 descending mesocolon, and these are joined together. This, however, applies 
 only to the portion of the left kidney which lies beneath the transverse 
 mesocolon, while above this the pancreas lies. The left kidney thus appears 
 decidedly more firmly fixed than the right, and this is perhaps the reason 
 why the right kidney is oftener moveable than the left. — [Tbanslatoe.]
 
 MOVEABLE KIDNEY IN WOMEN. 281 
 
 witliin the segment of a sphere of wliicli tlie centre will be 
 the entrance of the right renal vein into the vena cava infe- 
 rior, and the left within the segment of a sphere of which 
 the centre will be the origin of the left renal artery from 
 the aorta. Hence, it follows that the presumption of some 
 authors, among whom is Sappey, that a moveable kidney 
 moves vertically downwards towards the corresponding iliac 
 fossa, is not correct. It is mucli nearer the fact that it can 
 only move downwards, forwards, and inwards ; its move- 
 ment upwards and outwards being impossible on account of 
 the presence of the spleen, liver and diaphragm, not to 
 mention other reasons. 
 
 The degree of its mobility depends not only on that of the 
 relaxation of its capsule and vessels from the posterior ab- 
 dominal wall, but also from the resistance of the organs 
 lying below it, the amount of the pressure of the abdominal 
 walls, and the weight of the kidneys. 
 
 Again, the kidney, as it descends, never maintains its orig- 
 inal relation to external dimensions (wird sicli . . niemals 
 sich selbst parallel nach unten bewegen), but is compelled 
 to rotate, as it descends, on one or more of its axes, by virtue 
 of the obliquity of the planes over which it glides, as well 
 as by changes in the attitude of the body. The more it 
 descends, the more transversely will rotation round its 
 centre cause its long axis to lie ; the farther forward it ad- 
 vances, the more will its outer border and its upper end look 
 forwards. 
 
 The deepest possible i')osition of the kidney is determined 
 by the length of its vessels, which, together witli the ureter, 
 suffer manifold torsions and kinks during the displacement 
 of the kidney, varying according to its depression and rota- 
 tion round its axes, as indeed might have been assumed 
 a priori. 
 
 VII. Symptoms. 
 
 The opinions of authors as to the clinical consequences of 
 moveable kidney are very various. Rosenstein observes : 
 *^ More important than congenitally displaced kidney is
 
 282 MOVEABLE KIDNET IN WOMEN. 
 
 moveable kidney, altliough it properly possesses ratlier a 
 negative than a posltiuc interest, so that a knowledge of the 
 facts in point is more important as a moans of avoiding- 
 errors in diagnosis than on its own account, since the affection 
 itself causes no great inconvenience, and treatment is power- 
 less to relieve it.'' 
 
 This view is adopted by most of the handbooks and text- 
 books, while Kcppler, on the contrary, regards even uncom- 
 plicated moveable kidney as a deadly disease, which should 
 be extirpated whenever it gives rise to symptoms. 
 
 It is therefore most important, considering such opposite 
 opinions, to obtain clear views of the symptoms and conse- 
 quences of moveable kidney. 
 
 . It is evident from the study of its pathogenesis that ac- 
 quired moveable kidney is but very rarely to be described as 
 the primary lesion. We often find with it maladies, which 
 have either arisen from similar canscs to those which pro- 
 duced the moveable kidney itself, or have themselves produced 
 the moveable kidney. Moreovc:*, the degree of mobility 
 and the anatomical consequences of moveable kidney, as well 
 as individual susceptibility, are different in different persons, 
 so that moveable kidney calls up no idea of a typical disease 
 but rather the idea of a disease of many various forms. It 
 is, therefore, more necessary to individualise with regard to 
 this than with regard to almost any other complaint. 
 
 It is rare for a moveable kidney to leave the patient quite 
 unaware of its presence. This is most likely to happen in 
 the case of persons who are otherwise very healthy, and who, 
 as we know, sometimes feel no inconvenience from other 
 displacements, such as those of the womb, or from ruptures ; 
 or it may happen in those who are very ill, as for instance in 
 consumptive patients, in whom the symptoms of moveable- 
 kidney arc obliterated by the principal complaint. 
 
 Generally, however, moveable kidney exercises an injurious 
 moral and physical effect on the patient in its capacity as a 
 foreign body, by dragging and compression of nerve-trunks,, 
 vessels and viscera, and by functional disturbances.
 
 MOVEABLE KIDNEY IN WOJMEN. 283- 
 
 Symjitoms arising from the Nervous System. 
 
 Patie&ts who are the subjects of moveable kidney are- 
 usually affected with hypochondriasis, especially if they dis- 
 cover a tumour in their abdomen by accident, and this frame- 
 of mind increases if the malady is diagnosed as a malignant 
 growth by the doctor, or if, in spite of a contrary opinion on 
 his part, the patient takes it for one. This unfortunate 
 humour finds tangible pabulum if the patient feels pains in 
 the abdomen, whether due to the tumour or other causes, 
 and often grows so much on her that she readily decides of 
 her oAvn accord to have the moveable kidney removed. This 
 condition, which is seldom found even in the case of malig- 
 nant tumours, can easily be explained when one considers 
 that these patients are reminded by a moveable kidney 
 more than by any other tumour — at every step, on dressing 
 and undi'essing, even on turning in bed — of the presence of 
 an apparently serious malady ; and in this view they are often 
 confirmed by doctors. 
 
 Some patients complain of a feeling of pressure and weight,, 
 of dragging and drawing in the lower abdomen, they feel' 
 " as if something had been unhooked in their belly." Others 
 feel beating, or a more circumscribed gnawing griping pain 
 in the region of the navel. These unpleasant sensations are 
 compared bj^ women who have had children to foetal move- 
 ments, and they sometimes thiuk themselves pregnant, espe- 
 cially if they wish to be so. Among other characteristic- 
 expressions may be mentioned the feeling as if one of their sides 
 was dropping off, or as if something was turning round in their 
 belly. Often, but wrongly, these complaints are regarded as 
 hysterical. No doubt among the Avomen who have moveable 
 kidney some are hysterical, but wo should not agree with 
 Ghrohach (who in nineteen cases saw hysteria eight times) or 
 with Lancereaux (who saw it ia cases of moveable kidney 
 four times), in considering the moveable kidney as the cause 
 of the hysteria. It is intelligible that the imagination of an 
 hysterical patient will be unusually excited by the presence 
 of a moveable tumour in the abdomen, but the painful and 
 unpleasant sensations caused by moveable kidney ought not
 
 284 MOVEABLE KIDNEY IN WOMEN. 
 
 to be regarded as hysterical, inasmucli as we find tliem o£ 
 the same kind and intensity in women who are not hysterical, 
 and in men. One sign that these painful sensations are not 
 hysterical is that they are increased by sudden movements or 
 great bodily exertions, but in the recumbent position and 
 during rest they disappear. 
 
 Besides these vague, insufficiently localised sensations of 
 pain, one not uncommonly observes circumscribed neuralgias 
 in remote spots, arising reflexly through dragging on the 
 nervous plexuses and ganglia which plentifully surround the 
 kidney. Now the capsule of the kidney normally lies upon 
 the two last branches of the lumbar plexus, and is surrounded 
 by a rich network of sympathetic ganglia. Thus we often 
 find pains down the fi'ont of the leg as far as the knee, between 
 the ribs, in the loin, and in the abdomen. Sometimes these 
 radiate as they do in liver affections to the scapula, some- 
 times along the ureter as far as the labia majora. These 
 neuralgias are usually confined to the affected side, more 
 rarely they are transferred to the opposite side. Gueneau 
 de Mussij observed intercostal neuralgia of the left side in a 
 moveable kidney of the right side ; and among my observa- 
 tions are two in which there was lumbar and intercostal 
 neuralgia on the left side, the right kidney being moveable. 
 On pressing firmly against the kidney, which is easily mani- 
 pulated, both patients alike complain of circumscribed pain in 
 the region of the opposite kidney.^ 
 
 Menstruation produces increase of pain and impairment of 
 the general comfort. We then observe the same phenomena 
 as those described by Matthews Duncan under the name of 
 aching kidney, these complaints consisting essentially of dull 
 pain in the region of the kidney radiating thence into the 
 bladder and sacrum. As a matter of fact this pain can 
 almost constantly be found in women with moveable kidney 
 at the menstrual period, even when they arc free from it 
 betwcenwhiles. Whether it is induced more by menstrua- 
 tion or by the moveable kidney cannot now be decided. The 
 fact, however, that it sometimes quite ceases after menstrua- 
 tion and after the menopause, proves the existence of a 
 * [The same transference is sometimes observed in the case of tlie ovary. — 
 
 TßANSLATOE.]
 
 MOVEABLE KIDNEY IN WOMEN. 285 
 
 vasomotor connection between the generative organs and the 
 kidney, that is between the ovarian and renal plexuses, as was 
 supposed by Lancereaux and Fourrier. 
 
 It is rare for the pain in the renal region to cease during 
 menstruation, as it did in some observations by Grout and 
 Le Ray. 
 
 The recumbent position alleviates the diffuse pains as well 
 as the circumscribed neuralgias, as set forth by Müller (io6) 
 with regard to the lumbar neuralgia which frequently occurs 
 with moveable kidney. 
 
 Symjptoms arising from tha Great Vessels. 
 
 Although the above symptoms arise principally from pres- 
 sure and traction of the great nerve-trunks and small nerve- 
 fibres, we sometimes meet with symptoms of 'pressure hy the 
 Icidney on the great vessels, especially the easily compressible 
 vena cava, with subsequent thrombosis from pressure and 
 oedema of the corresponding lower limb. A very instructive 
 case is communicated by Girard (see above. Case 3), only it 
 is doubtful whether in this case the intestines distended with 
 gas, or perhaps some adhesions had not pressed the kidney 
 against the vein. I have observed one case of moveable 
 kidney on the right side with subsequent oedema of the right 
 lower leg, for which no reason could be found except the 
 pressure of the kidney on the vein. The oedema began to 
 disappear as a pregnancy, which had supervened, advanced. 
 
 Symptoms arising from the Digestive Tract. 
 
 Very many persons affected with moveable kidney suffer 
 from gastric disturbances, varying from slight epigastric 
 pains and nausea, to phenomena which sometimes amount to 
 the well-marked signs of chronic gastric and intestinal 
 catarrh, jaundice, or even attacks of peritonitis. 
 
 These gastric disturbances depend on complaints which 
 happen to coincide, or they are consequences of causes similar 
 to those which produce moveable kidney. When, therefore, 
 diseases accompanied by rapid emaciation, such as enteric or 
 severe intermittent fever, or rapidly succeeding labours,.
 
 1^86 MOVEABLE KIDNEY IN WOMEN. 
 
 prolonged sucklings or genei'ative affections o£ all sorts liave 
 preceded or still persist, we are hardly justified in calling 
 moveable kidney the cause o£ tlie gastric disturbances. A 
 jprimary chronic gasti'o-intestinal catarrh or a gastric ulcer 
 may, however, so impair nutrition that these affections may 
 be justly regarded as furnishing a cause for the mobility of 
 the kidney, rather than as being themselves caused thereby. 
 When, therefore, Kej)pler attributes the disturbances of 
 nutrition, emaciation, even death to a moveable kidney, it is 
 necessary for us to be emphatically warned against these 
 practically injurious exaggerations, as has been done by 
 Oerum-Howitz with reference to the cases described by 
 Keppler. The real ill-consequences of moveable kidney, 
 ■^even in its bearings on the digestive tract, are only obscured 
 hj such performances. 
 
 As a matter of fact moveable kidney may contribute to 
 gastric disturbances, as might bo assumed beforehand from 
 the nervous and vascular connections between the renal and 
 •other abdominal organs. This connection is completely con- 
 firmed by clinical observation, inasmuch as persons with 
 moveable kidney experience epigastric pains and digestive 
 disturbances Avhich are otherwise inexplicable. It is often 
 possible by pressing on the prolapsed kidney to produce 
 »epigastric pain, nausea, and retching, in these patients, to 
 I'eproduce in short exactly the same condition which they 
 will tell you unasked is that from which they are suffering. 
 
 A very plausible theory has lately been suggested by 
 Bartels, of Kiel, to explain the frequent coincidence of dila- 
 tation of the stomach and subsequent gastric and intestinal 
 catarrh with moveable kidney on the right side. According 
 to this, the right kidney displaced forwards and inwards by 
 the pressure of tight lacing (as descrihed hy MüUer-Warneclc 
 (107) ) compresses the fixed descending portion of the duo- 
 denum which lies between the hilum of the right kidney and 
 the vertebral column, and thus produces a mechanical 
 obstacle to the escape of the chyme from the pylorus, and 
 dilatation of the stomach with its well known consequences. 
 
 Oser (108) has rightly opposed this hypothesis, and espe- 
 cially on clinical grounds. He thinks it is self-evident that 
 -a moveable tumour which has a tendency to sink either
 
 MOVEABLE KIDNEY IN WOMEN. 287 
 
 dovviiwards oi* backwards as the patient stands or lies, can 
 luirdly exercise such a pressure on the bowel as to produce 
 obstruction while the abdominal walls are lax. In spite of 
 the opportunity of observing very many cases of moveable 
 kidney, lie never once found hypertrophied stomach, which 
 is usually found in cases of stenosis of the pylorus. Finally, 
 he proved the complete competence of the pylorus by directly 
 distending the stomach with air, in cases of moveable kidney 
 in which another method had seemed to prove its incom- 
 petence, and, therefore, the truth of Bartels' hypothesis. 
 
 On the whole Oser considers the causal connection between 
 displacement of the kidney and distention of the stomach as 
 not proven, and only allows the possibility of this connec- 
 tion in cases in which the displaced kidney is so firmly fixed 
 in its new position that it is able to compress the duodenum. 
 
 The principal objection, however, to Bartels' assumption is 
 its inadmissibility on anatomical grounds. The right kidney 
 even when in its normal position lies with only its upper half 
 parallel to the descending poi'tion of the duodenum, as Fig. 1 
 shows, and, when moveal)le, lieS' with its upper eud below 
 the inferior horizontal part of the duodenum, so that the two 
 organs are actually not in contact. Besides, the specific 
 gravity of the kidney, which alone can be considered as con- 
 tributing to real compression (the intra-abdominal pressure 
 being probably somewhat the same as that of water), is far 
 too low to exorcise such compression, so that a force is still 
 needed to press the kidney against the gut, and this force is 
 wanting. 
 
 Moreover, since chronic catarrh of the stomach is found 
 even when the moveable kidney is on the left side, in women 
 who do not lace, and in men who have moveable kidney, it 
 is evident that another explanation of general application 
 must be sought for the connection between gastric disturb- 
 ances and moveable kidney. Such an explanation seems to 
 me to be easily found in the fact that the posterior parietal 
 layer of the peritoneum covers at once the anterior layer of 
 the capsule and vessels of the kidney and passes over the 
 duodenum, so that if the kidney becomes displaced forwards, 
 inwards and downwards, a tendency to dragging and kinking 
 of the limbs of the duodenum both on the right and left side
 
 288 MOVEABLE KIDNEY IN WOMEN. 
 
 must Le produced, especially as tliese limbs, but particularly 
 the flexure between the duodenum and jejunum, are fixed by 
 somewhat firm connective tissue to the vertebral column, and 
 are comparatively unyielding (see Fig. 1). Of course this 
 kinking- should not be represented as permanent, as the 
 kidney changes its place with various movements of the 
 body, and in the recumbent position generally returns to its 
 normal position, thus instantly relieving the dragging pro- 
 duced through the peritoneum. When, however, this drag- 
 ging and the consequent obstruction to the calibre of the gut 
 are frequently repeated as the erect position is assumed, and 
 when other influences, such as pendulous belly, which acts in 
 a similar manner, supervene, distention of the stomach and 
 chronic catarrh of the stomach will not fail to appear. 
 
 With respect again to the jaundice which occurs in move- 
 able kidney, direct compression of the common bile duct by 
 the right kidney has been cited as the cause of the jaundice 
 by Litten (109), who observed in Frerichs' clinique (in the 
 case of a woman, thirty-seven years of age, suffering from 
 frequent attacks of pain in the right hypochondrium induced 
 by a moveable kidney on the right side) a jaundice recui-ring 
 twice within two weeks and only lasting a few days. Litten, 
 who was unable to find a similar observation on record, put 
 aside the idea of gastro-duodenal catarrh and of gall-stones 
 as a cause for the jaundice, and assumes a temporary com- 
 pression of the common bile duct. 
 
 Stiller (no) had already alluded to the possibility of this 
 connection, when he replied to the assumption by Bartels of 
 compression of the duodenum by the moveable kidney, that, 
 if the descending portion of the duodenum were really com- 
 pressed by the kidney, this same pressure must produce 
 jaundice by pressing on the diverticulum Vateri (the common 
 gall and pancreatic duct) in this situation. This objection, 
 however, according to Stiller is enfeebled by the anatomical 
 consideration that the right kidney in becoming moveable 
 must sink down along the right or outer surface of the duo- 
 denum, and the compression can hardly be so complete as to 
 close the orifice of the common bile duct which lies on the 
 opposite or left surface. Besides (says Stiller) the subject 
 is at present too novel for us necessarily to accept the
 
 MOVEALLE KIDNEY IN WOMEN. 289 
 
 assumption that as cases in point arc collected we sliall have 
 to recognise this as an additional cause of jaundice. 
 
 Although I have seen jaundice supervene on three occa- 
 sions in women affected with moveable kidney (in one of 
 them four times within a short space, lasting on each occasion 
 a few days), I cannot regard these cases as a clinical proof 
 of temporary compression of the common bile duct, as this is 
 impossible for the same reasons as the direct compression of 
 the duodenum. How, moreover, can we explain an isolated 
 compression of the common bile duct which opens on the left 
 side of the duodenum by a moveable and not fixed kidney 
 on the rierht side ! I am much more inclined to refer the 
 frequent appearance and disappearance of the jaundice, 
 which I also saw in my case, to a temporary occlusion of the 
 duct by mucus or a gall stone, particularly as this peculiar 
 appearance and disappearance of jaundice is not a very rare 
 occurrence even among women who are not the subjects of 
 moveable kidney, as I have often had occasion to observe. 
 
 It is, hoAvever, certain that women who have moveable 
 kidney are more prone than others to jaundice, but only 
 because they more frequently suffer from gastro-duodenal 
 catarrh, for the reasons above enumerated, and because a move- 
 able kidney not infrequently contracts adhesions to the gall- 
 bladder. Thus, in a case observed by me (see below), in 
 which there was jaundice which persisted several weeks, the 
 cause for the jaundice appeared to be connected with a firm 
 adhesion between the moveable kidney and the lower 
 surface of the liver and gall-bladder (mit dem unteren Leber- 
 lappen und der Gallenblase). 
 
 Still more serious disturbances arc said to be produced by 
 moveable kidney through compression and consequent 
 obstruction of the colon. Rollet relates a case in Oppolzer^s 
 clinique of a woman, twenty- six years of age, and apparently 
 consumptive, who had a moveable kidney, and who had 
 suffered many years previously from small-pox, later from 
 enteric fever, and in early years had been in the habit of 
 masturbating. Inasmuch as she in the meantime, up to six 
 months previously, had suffered (especially after bodily exer- 
 tion such as dancing) from, violent colic, and since her 
 admission into the hospital had frequently suffered .from 
 
 19
 
 290 MOVEABLE KIDNEY TN WOMEN. 
 
 obstinate, constipation often lasting six or seven days, from 
 frequent colic, swelling* of tlie alxlomen, retching, desire to 
 vomit, and sensitiveness of tlie abdomen, tlie following diag- 
 nosis was made : Intestinal obstruction, caused by pressure 
 exercised by tlie kidney on tlie ascending colon. This case, 
 however, is so far from proving obstruction of the colon by 
 the kidney that it ought not to bo lot loose on literature 
 without a query, until it is proved by an appropriate autopsy 
 that the improbable assumption is true, viz. that the colon 
 can be permanently couipressed by a moveable kidney. The 
 origin of such a compression in adhesions formed by the 
 moveable kidney is not unlikely. Certain it is, however, 
 that a moveable kidney is competent to produce (by mechan- 
 ical injury and dragging on the bowels) colics and dull boring 
 pains in the abdomen, which are not otherwise easily explic- 
 able, and which we not infrequently find in patients with 
 moveable kidney, ^vithout any other discoverable cause. 
 
 The Symptoms of Renal Inearcerntion so-called. 
 
 Patients with moveable kidney are subject, generally after 
 violent exertion or rapid movement, to a sudden piercing 
 pain in the abdomen, which forces them to lie down. Soon 
 the whole abdomen becomes sensitive and distended, and the 
 side (especially in the region of the prolapsed kidney) 
 becomes painful on jialpation. A profound feeling of general 
 discomfort follows. The patient is weak, giddy, palpation 
 of the renal region easily makes her faint, a cold sweat 
 covers the brow, the pulse is small, the respiration superficial. 
 Sometimes there is a desire to vomit, actual vomiting often 
 supervenes. The urine is dai-k and scanty, often coloured 
 red from the admixture of blood. The attack is not always 
 ushered in by a rigor, in fact the pyrexia is slight throughout. 
 The observer detects (as far as the tension, resistance, and 
 tenderness of the abdominal walls allow him) in the region 
 of the prolapsed kidney a large tumour, confined to the 
 corresponding side, over which percussion is impaired, and 
 which is hardly moveable. 
 
 In the course of one or two weeks, however, this tumour
 
 MOVEABLE KIDNEY IN WOMEN. 291 
 
 entirely disappears, as all observations agree in stating, the 
 threatening symptoms having reached their acme on the 
 fourth to the sixth day. One of the first signs of recovery 
 is the copious excretion of clear urine of low specific gravity. 
 Dietl, who first directed attention to this hitherto unknown 
 train of s^^mptoms and gave it the name of renal incarceration, 
 considers its essence to consist (as in the case of ruptures) in 
 incarceration of the kidney in the surrounding connective 
 tissue and peritoneum, with subsequent circumscribed peri- 
 tonitis with effusion. He is followed by nearly every Avriter. 
 Thus Rollet gives the following explanation : " In order to 
 understand the symptoms of renal incai'ceration we need only 
 consider the physical processes which must take place when 
 the kidney (under bodih' exertion, violent straining, shock, 
 or congestive swelling at the menstrual period, &c.) changes 
 its place and is displaced from its normal position with more 
 or less force. Apparently it must first make its way within 
 the connective tissue surrounding it, and in which no vacant 
 space exists. It is inevitable during this that parts of the 
 sui'rounding connective tissue, and even the peritoneum 
 passing over it, should be dragged and pressed, and the 
 vascular arrangements disturbed in some manner. In con- 
 sequence of the irritation and vascular disturbance in the 
 surrounding connective tissue, produced by changes in the 
 position of the kidney, the connective tissue becomes the seat 
 of inflammatory swelling'. The kidney is all the more likely 
 to stick in the narrow meshes of the sub-peritoneal cellular 
 tissne and to become really incarcerated there, as its retreat 
 into the normal situation is in a moment cut off. The sym- 
 l^toms caused by the incarceration of a moveable kidney tally 
 with this representation of facts. If the incarceration of the 
 kidney is not reduced early enough, either spontaneously 
 (by the recumbent posture, observation of strict diet, and 
 softening fomentations), or artificially by gentle or, if the 
 diagnosis is quite certain, even powerful pressure on the 
 kidney in the contrary direction, not only does the cellular 
 tissue surrounding the kidney become inflamed, but the 
 inflammation easily spreads to the peritoneum and a more or 
 less violent circumscribed peritonitis supervenes, with inflam- 
 mation of the capsule and parenchyma of the kidney."
 
 292 MOVEABLE KIDNEY IN WOMEN. 
 
 Ebstein accepts this view, and considers the clinical sym- 
 ptoms as prodnced by the pi^odnction of a more or less con- 
 siderable peritoneal effusion. 
 
 According to Oilewsld the incarceration of the kidney is 
 produced by the wedging- of the kidney between the last rib 
 and vcrteln-al column, and by its being held there by the 
 morbid contractions of the abdominal muscles. In a case 
 observed by him this mode of incarceration is said to have 
 been favoured by a curvature of the spine. The kidney thus 
 incarcerated pressed the nreter against the vertebral column, 
 produced pyelitis, acute hydronephrosis, and the symptoms 
 above described. 
 
 Oeritm-Howitz accept this explanation only in part. 
 
 To me, neither the character of the acute attacks described 
 (pointing to the incarceration of the kidney), nor the clinical 
 symptoms themselves (referred to the supervention of cir- 
 cumscribed peritonitis, or, according to Gilewslci, to acute 
 hydronephrosis) appear to be correctly explained. 
 
 It is a ])riori unlikely that the kidney should become incar- 
 cerated in the cellular tissue which is everywhere so yielding, 
 and especially in the neighboitrhood of parts so soft as the 
 intestines. But granting that it could become wedged for 
 a moment between W\g vertebral column and ribs ; the force 
 to hold it fast in this position would fail, for one cannot 
 possibly assume with GiZews/^i a contraction of the abdominal 
 muscles lasting for days. A wedging of the kidney between 
 the vertebral column and the anterior surface of the arch of 
 the rib in the healthy skeleton is, however, impossible, 
 because its longest diameter is less than the distance between 
 the parts mentioned. On the supposition of an incarceration 
 it would bo most remarkable that the train of symptoms 
 under discussion should, so far as at present observed, in- 
 variably end in recovery without any active treatment, and it 
 is not apparent how an incarcerated kidney could free itself 
 from its incarceration without external interference. Finally, 
 the incarceration of a kidney would certainly be a far more- 
 frequent occurrence than it actually is, considering that drag- 
 ging of the cellular tissue and peritoneum takes plnce in. 
 every case of moveable kidney.
 
 MOVEABLE KlDJS'Er IN WOMEN. 293 
 
 Taking tlio analogy of a strangulated^ lieruia the symptoms 
 consequent on incarceration of tlie kidney have been explained 
 in this bearing also by the supposition of a circumscribed 
 peritonitis. This idea has been strengthened by the resem- 
 blance of the clinical symptoms to those of circumscribed 
 peritonitis due to other causes, such as perimetritis and peri- 
 typliilitis, by the supervention of great distention, which was 
 taken for effusion, and finally by the fact now and then 
 observed that during and after an attack the mobility of the 
 kidney is restricted. 
 
 The invai'iably favourable course, however, of this supposed 
 peritonitis with effusion, as well as the cii'cumstance that the 
 effusion, w^hicli is sometimes " enormous," disappears in from 
 six to eight days, cannot fail to throw doubt on the correct- 
 ness of this explanation. Besides, the peculiar outline of 
 impaired resonance which is found diffused around the move- 
 able kidney, does not admit of easy explanation on the assump- 
 tion of circuniscn'hcil peritonitis. 
 
 The opinion of ixlleioshl that acute hydronephrosis produced 
 by incarceration of the kidney constitutes the essence of the 
 process under discussion, appears again unlikely, inasmuch 
 as the weight of a normal kidney is far too small to be able 
 to overcome by its pressure the pressure under which the 
 urine is secreted into the ureter ; besides an acute hydrone- 
 phrosis is not competent to distend the pelvis of the kidney 
 to the size found in those cases, and, moreover, it does not, 
 as we know from numerous experiiuents, produce the sym- 
 ptoms we have named. A dog whose ureter has been tied, 
 secretes, as Coliulicim (in) says (when the operation is not 
 followed by inflammation, the general health remains unim- 
 paired and the same food is taken), the same quantity of 
 urine and that of the same specific gravity as before. And 
 this not only in the first days and weeks after the operation, 
 but also later, when the occluded kidney is attacked by 
 ^ [Great difficulty has been felt in deciding between " strangulation " 
 and " incarceration " as the equivalent o£ "Einklemmung;" but the latter 
 word has been chosen, as tallying best with the facts, as a word used synony- 
 mously witli Einklemmung frequently in tlio text, especially in connection 
 with the name of Dictl, the author of the term. But, in the present passage, 
 the reference is obviously to tlic general class of Strangulated Hernia. — 
 
 Tl{A>'SLATOE.]
 
 294 MOVEABLE KIDNEY IN WOMEN. 
 
 hydronephrotic atrophy, becomes ansßmic and ceases to secrete. 
 But in the case of moveable kidney we see from the com- 
 mencement disturbances in the secretion of the urine, 
 amounting oven to haematuria. In a woman, the subject of 
 an uretero- vaginal fistula {112), moreover, I produced an 
 unilateral hydronephrosis by the use of the probe, but this 
 was not followed by the symptoms enumerated above. In 
 unilateral hydronephrosis again produced unintentionally by 
 sewing up the ureter in the course of the operation for vesico- 
 vaginal fistula, I have seen symptoms develope which were 
 essentially different from those under discussion. 
 
 We must, therefore, look out for another explanation of 
 the production and of the clinical symptoms accompanying 
 so-called renal incarceration, and this I find in an intense 
 local disturbance of circulation in the movcahlc hidney, caused 
 hy twisting or Icinhiny or acute angular insertion of the renal 
 vessels, esijecially the vein, in conseqiience of the change of 
 position and rotation of the Icidney. 
 
 Although the authority of Cohnheiw, (113) (who thinks that 
 renal obstructions due to local obstacles to the return of blood 
 in the renal veins play hardly any part in pathology) is 
 opposed to this supposition, its correctness seems to me to be 
 supported by a series of important reasons. 
 
 We have already discussed the relation of the renal vessels 
 and ureter during descent and rotation of the kidney, a rela- 
 tion which is of great importance for the train of symptoms 
 before us. We have also already found the acute angular 
 course and torsion of the renal vessels established by some 
 autopsies. In order, however, to bring these relations more 
 prominently into view I have got some preparations of 
 kidneys made artificially moveable in the dead subject drawn, 
 these preparations showing some kinds of twisting and kink- 
 ing of the vessels (see Figs. 4 and 5^). 
 
 But my hypothesis is supported by experiment and by 
 observation of the clinical changes even more strongly than 
 by these drawings. 
 
 ' I have to thank Dr. Guttmann, Director of the State Hospital at Moabit 
 for furnishing me with a subject, and Dr. Smidt for lielp in preparing the 
 dissections. Figures 4 to 8 are drawn after nature by Herr Ch'ohmann. — 
 
 AUTHOB.
 
 MOVEABLE KIDNEY IN WOMEN. 
 Fia. 4. 
 
 29^ 
 
 1. Left l«clney. 
 
 2. Itight kidiifjy. 
 
 3. Lett renal veiu kiuked and twisted. 
 
 4. Right reniil vein compressed. 
 
 5. Ureter. 
 
 6. Abdominal aorta. 
 
 7. Vena cava inferior. 
 
 There are, perhaps^ few patliological processes whicli have 
 been so accurately investigated as the coarser disturbances 
 of circulation in the renal vein. Max Hermann and Ludioig 
 (114) found that after tying the renal vein the tubuli uriniferi 
 became completely closed in consequence of the obstruction 
 to the return of the blood, so that the secretion of urine 
 ceased. If the renal vein became pervious again, the secre- 
 tion of urine became quickly reestablished. Litten and 
 Buchivald (115) who completely tied the renal vein, saw the 
 kidney very quickly swell up, as the following example shows. 
 Even within four hours of the ligature of the vein, the weight
 
 296 MOVEABLE KIDNEY IN WOxMEN. 
 
 ¥lG. 5. 
 
 Lc'fb kidney. 
 IMy:lit kidnoy. 
 liC'I't renal voiii. 
 Loft renal artery. 
 Left ureter. 
 Uijjlit renal arterj'. 
 
 7. lliglit renal vein twisted and 
 
 kinked. 
 
 8. Tiie ureter bent round and 
 
 wrou'^ly inserted. 
 
 9. Abdominal aorta. 
 10. \'ena cava interior. 
 
 tiiid iiicasurcmcuts of tlic two kidii03-s bore the lollowing' pro- 
 portion« to cacli other : 
 
 lidhhii's KIdiici/. 
 
 Side not ligatured. Side ligatured. 
 
 Weight . . 4'7 grammes. b'j grammes. 
 
 Length . . 2'9 centimetres 
 
 Breadtli . • i'4 ,, 
 
 Thickness • i'5 }} 
 
 2'2 centimetres. 
 i"0 
 
 JJreadth of cortex 0*25 
 
 0-3
 
 MOVEABLE KIDNEY IN WOMEN. 297 
 
 No inflammatory processes were remarked. The ligatured, 
 kiduey usually became rapidly smaller after the sixth day, 
 and very soon returned to its former size. In some cases 
 the ligatured kiduey became atrophied after some weeks. 
 
 Gohnheim (ii6) observes that when the renal vein is tied, 
 the kidney swells up so rapidly from obstruction to the 
 return of blood and from the supervention of ODdema, that 
 in less than an hour it may be twice as heavy and big as the 
 other. 
 
 Just as in the experiment, we find clinically in human 
 beings a sudden onset of the symptoms of incarceration so- 
 called ; in them also there developes in a very short time a 
 tumour sometimes twice as large as the kidney itself, undis- 
 tinguishable by the most accurate palpation from the kidney, 
 and generally disappearing without leaving a trace in six or 
 eight days. 
 
 Again, the symptoms furnished by the secretion of urine 
 tally with those in the experiment ; in men as well as in 
 animals under experiment at the beginning of the attack a 
 •dark urine, sometimes containing blood, and scanty for the 
 first few days, is secreted, which does not become replaced 
 by a profuse clear watery urine till recovery has set in. 
 Inasmuch as the function of the affected kidney is naturally 
 impaired when the renal vein is obstructed, or even as soon 
 as its calibre is narrowed (as Rohinson (117), Perls and 
 WeissgerJjer (118) found), the quantity of urine of course 
 diminishes at once. The subjective symptoms are likewise 
 very easily explained by this hypothesis, since, when one 
 kidney suddenly ceases to act the other does not at once 
 .supply its function, so that for a short time slight symptoms 
 of urasmia are produced. 
 
 The favourable issue lastly tells in favour of my hypothesis ; 
 for in animals, even after complete ligature of the renal vein, 
 we see the kiduey recover its function completely by means 
 of the establishment of a collateral circulation, to which the 
 vasa aberrantia which are often present, and the veins of 
 the capsule of the kiduey and of the supra-renal bodies con- 
 tribute. 
 
 It is difficult in an individual case to decide from the 
 gTavity of the symptoms, whether we have to deal with
 
 2Ö8 MOVEABLE KIDNEY IN WOMEN. 
 
 complete obstruction of the vein witli subsequent thrombosis, 
 or kinking, or only considerable narrowing by twisting. 
 If the patient immediately assumes a quiet horizontal posture, 
 we have at once the most favourable conditions for the 
 organisation of a thrombus, or the untwisting of a twist, or 
 the straightening of a kink in the vein. 
 
 Finally, my hypothesis explains certain processes, the 
 causes of which have been hitherto obscure. Among these 
 I count the atrophy of the moveable kidney comparatively 
 often found post-mortem, which has been observed by Litten 
 and Buchwald after ligature of the renal vein in animals, 
 especially when a delay or impei'fectiou in the reestablishment 
 of the collateral circulation has suspended the function of the 
 whole or of certain parts of the kidney. Similarly it is probable 
 that the colloid degeneration of the epithelium, observed by 
 these authors, and due to the same causes, stands in intimate 
 relation to the discovery of colloid material in the cyst of a 
 hydronephrosis, in which, also through pressure, the function 
 of the kidney has been considerably impaired. 
 
 But it is certain that the yerinciihritic and iDaraneiiliritic 
 abscesses of moveable kidneys mentioned by lliolan himself, 
 and finally the so-called putrefaction or formation of abscesses 
 in the kidney itself, are best explained by thrombosis of the 
 renal vein. A thrombus in a larger or smaller branch of 
 the renal vein remains of course harmless provided it is not 
 infectious and the kidney is healthy. But if these conditions 
 necessary for the harmlessness of a thrombus are absent, 
 especially if there is pyelitis, or if the collateral circulation 
 leading to recovery does not become properly established, 
 abscesses in or near the kidney, or even '/'(^ritoiiitis and 
 jpycemia easily supervene. 
 
 We cannot be surprised that obstruction of the renal vein, 
 joroducing oedema of the kidney, &c., will cause dragging ou 
 the peritoneal investment of the capsule, and secondarily pro- 
 duce pain like that of peritonitis, as in twisted ovarian pedicle. 
 In the next place slight adhesions between the kidney and 
 neighbouring organs may form ; but the essential part of the 
 process is produced neither by incarceration of the kidney 
 nor by circumscribed peritonitis. Moreover, these adhesions 
 arc often produced by the same chronic process as affects
 
 MOVEABLE KIDNEY IN WOMEN. 299 
 
 tumours of the ovaries and uterus, and witliout symptoms 
 of inflammation ; the process consisting in friction of the 
 peritoneal surfaces, abrasion of the epithelium, and subsequent 
 adhesion of the abraded surfaces, so that the presence of the 
 adhesions does not always indicate previous inflammatory 
 changes. 
 
 It would perhaps seem strange, on the above hypothesis 
 explaining the origin of the symptoms of incarceration, that 
 these symptoms are not more frequently observed. This would 
 certainly happen often, if there were not other causes to 
 prevent the danger of frequently occurring complete or long 
 persistent occlusion or narrowing of the renal vein. These 
 causes receive additional support from the fortunate circum- 
 stance, that the renal artery and vein are not equally long, 
 owing to the difference between the course of the aorta and 
 vena cava inferior, so that spiral twisting of both vessels in 
 their whole extent (like that for instance in the umbilical 
 cord) is here rendered impossible. 
 
 We must further remember that the i^art of the right renal 
 artery between the aorta and the right border of the vena 
 cava inferior, and the part of the left renal vein between the 
 vena cava and the left border of the aorta (see Fig. 2) are 
 very firmly fixed by connective tissue to the main trunks, 
 i.e. to the vertebral column, and are therefore jjrotected 
 against kinks in part of their course, though a comparatively 
 small part. But it is just here that a series of small veins 
 from the capsule of the kidney, and on the left side from 
 the suprarenal body open, and these effect a collateral cir- 
 culation easily and quickly, if the circulation in the renal 
 veins becomes obstructed. This end is favoured by the 
 double renal vein found especially on the right side, the 
 frequency of which was pointed out even by liiolan and Ilaller 
 (119). It must also be remembered that if the renal vein 
 is kinked or twisted, the renal artery, although provided 
 with very thick walls and a large calibre, will be narrowed 
 at the same time, so that the diminished supply of blood will 
 slightly alleviate the excessive engorgement of the renal 
 vein. 
 
 Finally, however, quiet horizontal decubitus, and a return 
 of the kidney to its normal position will very often relieve
 
 300 MOVEABLE KIDNEY IN WOMEN. 
 
 the clisturbauco of tlio reual circulation under discussion, 
 before the supervention of thrombosis or long persistent 
 kinking of the renal vein. 
 
 All these causes explain the reason why, in spite of the 
 probability that kinks and twists often occur in the vessels 
 of a moveable kidney, it is rare for disturbances of the cir- 
 culation to persist long and produce the symptoms of incar- 
 ceration so-called, and it is also rare for narrowing or occlu- 
 sion of the renal vein to arise. Decisive post-mortem proofs 
 are hardly to be expected, since even the ligature of a renal 
 vein never of itself causes death, and on the other hand if 
 fatal complications occur, the vascular changes will be 
 obliterated. 
 
 Syiiijjtoius arising from the Secretion and Excretion of the 
 
 Urine. 
 
 It is denied by almost all writers that moveable kidney 
 produces any effect on the secretion and excretion of the 
 urine, liosenstciii (120) especially insists on the absence of 
 all symptoms of diuresis. Henoch (121) lays stress on the 
 healthy nature of the urinary secretion established by 
 Oppolzcr himself, only one of whose patients complained of 
 frequent desire to pass water when in the erect position, 
 which Henoch thought might have depended on other causes. 
 Trousseau (122) observes : " Quant ü la secretion uriuaire, eile 
 n^est en aucuue fa9on influencee, il en est ainsi de la miction." 
 On the other hand I have frequently observed disturb- 
 ances in the secretion and excretion of the urine in patients 
 with moveable kidney, and believe that they play an essen- 
 tial part in the pathology of this disease. These disturb- 
 ances are shown not so much in colicky pains radiating from 
 the renal region along to the bladder, as in alterations in the 
 ([uality tmd (juantity of the urine, which is sometimes scanty, 
 high coloured and depositing a copious sediment, at other 
 times becoming more copious and profuse than normal. 
 Ha)maturia is also seen in cases of moveable kidney, a 
 phenomenon which in the absence of every other cause must 
 be considered to depend on the moveable kidney. A par- 
 ticularly striking case of this kind has been recorded by
 
 MOVEABLE KIDNEY IN WOMRN. 301- 
 
 Wirle (123) in Niemeycr's clinique_, wlio_, without any cogent 
 reason, assumed a stone in the kidney as the cause of the 
 ha3maturia. In the same way Rollet (124) mentions a case 
 of left-sided displacement of the kidney in Oppolzers cliniquc, 
 in which the urine was passed with pain and contained blood. 
 I myself have frequently been able to prove the presence of 
 blood in the urine, especially when the patients complained 
 of considerable pain in the region of the kidney. But we 
 have already become acquainted with the most intense form 
 of disturbance in the secretion of urine, in the form of sup- 
 pression caused by venous engorgement, when considering 
 the symptoms of renal incarceration so-called. 
 
 If we recall the kinks and twists of the renal vessels, 
 especially the vein, which inevitably follow disjDlacemcnt and 
 rotation of the moveable kidney, we shall be compelled to 
 regard the symptoms described as also dependent on local 
 disturbances of circulation, and to a certain extent as the 
 first, and certainly often very transitory, stage of renal in- 
 carceration so-called. It will depend on the duration and 
 degree of interruption to the circulation in the renal vein, 
 whether in any individual case we have to deal with a sup- 
 pression of urine of short duration, or a more or less copious- 
 discharge of red-blood corpuscles, or finally with regular 
 ha3maturia or epithelial denudation, and subsequent pyelitis. 
 The instructive experiments of Perls and Weissrjerher and of 
 JRohinson^ already mentioned, who found exactly the same 
 changes as those above-named in the secretion and excretion 
 of urine in the animals under experiment, point in the same 
 direction, namely, that here an obstruction to the circulation 
 in the renal vein takes place. In the same way frequent 
 impediment as well as total obstruction to the circulation in 
 the renal vein is capable of producing atrophy of the kidney. 
 Whether such local disturbances in the circulation may also 
 lead to parenchymatous nephritis, as Frerichs (125) and Leudet 
 (126) imagine, must remain an open question. 
 
 By far the most important disturbances however take 
 
 place with reference to the excretion of the urine. We have 
 
 already seen that this is disordered even by local disturbance 
 
 of circulation in the vessels, and this is confirmed by 
 
 ' [" Robertson " in the text. But see p. 297. — Teanslatoe.]
 
 502 
 
 MOVEABLE KIDNEY IN WOMEN. 
 Fia. 6. 
 
 Right kidney, twisted on its hori- 
 zontal axis, and with its ontcr 
 border looking downwards. 
 
 Right renal artery. 
 
 Right renal vein. 
 
 4. Right ureter, kinked and twisted. 
 
 5. Abdominal aorta. 
 (). Vena cava inferior. 
 
 7. Left kidney in its normal situa- 
 tion. 
 
 numerous cxpeinmcnts involviuf^ tLo ligature and artificial 
 narrowing of the renal vein. In this relation however the 
 disturbance of the circulation, even when it occurs more or 
 less contemporaneously with the disturbance of the circulation, 
 is secondary, and caused by the alteration in the secretion. 
 But I must affirm, contrary to the general opinion, that the 
 secretion of the urine especially, may be primarily suppressed 
 by narrowing or occlusion of the ureter. 
 
 As soon as the kidney descends, the origin of the ureter, 
 which is normally placed at the lowest point of the renal 
 pelvis, and therefore at the point most favourable for the
 
 MOVEABLE KIDNEY IN WOMEN. 
 Fig. 7. 
 
 303 
 
 The last dissection (Fig. 6) seen in profile. References the same as to Fig. 6. 
 
 escape of the urine, moves to a liiglier position, and, if the 
 kidney is very low down, to the very highest point of the 
 pelvis. But as the kidney rotates (as it usually does) the 
 ureter will also become twisted on its axis. In the former 
 case kinking of the ureter results, in the latter torsion, in 
 either case obstruction to the flow of urine must result. 
 
 Here, as in the case of the renal vessels, I have endeavoured 
 to render the torsion, kinking and bending of the ureter 
 intelligible by the help of drawings. Figs. 6 and 7, in which 
 the ureter is bent and twisted, represent the same dissection 
 from two different views ; Fig. 6 from the front. Fig. 7 in 
 profile. The very perceptible upward bend of the ureter, 
 which we have already seen in Fig. 5, is repeated in Fig. 8 
 below. If this is compared with Mosler's post-mortem account, 
 (see above p. 258) the resemblance between the course of the 
 ureter as there described and as here drawn, cannot fail to 
 be seen. 
 
 It is in fact probable that the colicky pains often observed in 
 patients with moveable kidney depend on temporary obstruc- 
 tions and occlusions of the ureter, and the simultaneous local 
 disturbances in the circulation. The suppression of urine is 
 however usually soon relieved, inasmuch as the loosening of 
 the capsule of the kidney from the posterior abdominal wall.
 
 304 MOVEABLE KIDNEY IN AVOMEN. 
 
 Avhich we find in cases of moveable kidney, allows the pelvis 
 of tlie kidney and upper part of tlie ureter to gi^adually 
 separate itself from the posterior abdominal wall also, and 
 follow the kidney in its movements. In this way an obstacle 
 to the escape of the urine arising from the abnormal course 
 of the ureter is more easily overcome by the pressure of the 
 retained urine than when the ureter remains kinked and not 
 moveable. To this must also be added that the pain caused 
 by the retention soon obliges a patient to lie flat down, and 
 that in this position the kidney returns to its normal "position 
 find the kinked or twisted ureter at once rights and untwists 
 itself. 
 
 If however, under the influence of severe or prolonged 
 bodily labour, especially in the erect posture, or in con- 
 sequence of extreme descent and rotation of the kidney, the 
 obstruction to the escape of urine becomes more frequently 
 repeated, and increases in intensity, the continual change 
 between tense repletion and complete evacuation of the 
 pelvis of the kidney must result by degrees in its diminished 
 elasticity and increased distension, and finally in the condition 
 described by Colinheim as the consequence of so-called kink- 
 ing and improper insertion (and, I would add, torsion) of the 
 ureter — that is, in hydronephrosis. According to his clear 
 description, when, for instance, the ureter is inserted into 
 the kidney opposite the upper part of the pelvis, in the erect 
 posture the urine cannot overflow into (? out of) the pelvis of 
 the kidney until the pelvis o£ the kidney is full to that point. 
 " The pelvis of the kidney is enclosed by a yielding and 
 expansible wall, which gradually dilates under the pressure 
 of the urine collecting within it, until the sac reaches such a 
 size as to be capable, on its part, Avhen full, of completely 
 compressing the urctci', which lies immediately in contact 
 with it. But only in the erect position ! For as soon as 
 the owner of this kidney lies down, as for instance during 
 sleep, the urine Hows away continuously, and without any 
 obstacle, out of the sac into the bladder. In the case of 
 kinks, on the other hand, the change is produced by the 
 segment of the ureter situated above the kink, rising some- 
 what as the distension becomes greater, in such a way that 
 the point of bending comes rather to resemble the point
 
 MOVEABLE KIDNEY IN WOMEN. 
 Fig. 8. 
 
 305 
 
 1. Right Ifidney. 
 
 2. Iligbt renal artery kinked. 
 
 3. Right renal vein. 
 
 4. Right ureter hent, and inserted into the highest 
 
 point of the pelvis of the kidney. 
 
 5. Ahdominal aorta. 
 
 6. Vena cava inferior. 
 
 7. Li'ft kidney in its normal situation. 
 
 wliere a funnel passes into its neck. But as soon as tlie 
 greater part of tlie urine has escaped, tlie ureter becomes 
 kinked again at the old spot. But even in the case of 
 simple narrowing, however little the obstacle itself changes, 
 thei'e is by no means always the same impediment to the 
 secretion of urine. Suppose a case in which a considerable 
 obstacle arises suddenly during a period of plentiful secretion, 
 a moment will be reached (not, indeed, so rapidly as in 
 complete obstruction, but in a relatively short time) in which 
 the disorder of relation between secretion and escape will 
 
 20
 
 306 MOVEABLE KIDNEY IN WOMEN. 
 
 result in so great a repletion and distension of the pelvis 
 of tlie kidney and proximal segment of the ureter^ that 
 absolutely no urine will be able to issue from the kidney 
 into the pelvis. But the pelvis of the kidney soon relieves 
 itself of its excessive contents, which escape through the 
 narrowed spot, partly by simple gravitation, partly by the 
 powerful aid of the peristaltic movements of tbe ureter,, 
 which are abnormally excited by the obstacle, and then the 
 process may begin again/' 
 
 The reason why the largest sj^ecimens of hydronephrosis 
 are produced by an obstruction in the ureter, which is not 
 permanent but alternates with periods of patency, is to be 
 found, according to Gohnheim (127), in the state of the urine 
 after removal of the unusual resistance. " No sooner is the 
 obstacle which prevents the escape of the urine secreted 
 removed, no sooner are the glomeruli relieved of the pressure- 
 upon them, than a cojnous secretion of limpid urine of low- 
 specific gravity begins. It is just for this reason that, in the 
 case of men with abnormal insertion of the ureter, as long 
 as they are recumbent, so great a quantity of urine is secreted 
 into the bladder, and is then excreted therefrom ; when 
 however the passage to the bladder is not completely patent 
 (as happens in the same persons when they stand or walk, 
 and as happens in narrowing of the ureter) the profiase 
 secretion fills and over-distends the pelvis of the kidney and 
 the ureter with greater and greater quantities of urine. And 
 because the secretion of urine never ceases as long as any 
 escape from the distended renal pelvis is possible, years and 
 tens of years may pass in the same process, though of course 
 not without a very considerable expansion of the parts^ 
 affected." ^ 
 
 * The same kind of " hysterical " urine is secreted under a variety of cir- 
 cnmstances, including any retention in the bUidder sufficient to raise the 
 pressure in the ureters. A familiar instance is furnislied by the fi-equently- 
 observed phenomena of Retroversion of the Gravid Womb, the prominent 
 symptom of which is retention of urine. The urinary symptoms do not 
 cease witli the evacuation of the bladder, nor with the simultaneous reduction 
 of the incarcerated uterus, but a " copious secretion of limpid urine of low- 
 specific gravity " continues for some time, and often for some days, the 
 quantity being enormous. The same set of facts is discussed in a paper 
 alluded to in a previous note (Champneys, ' St. Bartholomew's Hospital
 
 MOVEABLE KIDNEY IN WOMEN. 307 
 
 Although however, no further demonstration is needed 
 to prove the impossibility of so marked an alternation between 
 tense repletion and complete evacuation of tho pelvis of the 
 kidney as Cohnhevm has assumed in the above exposition ; 
 the origin of hydronephrosis by means of mobility of the 
 kidney as assumed by me contradicts this assei'tiou. 
 
 So little attention has hitherto been paid to the production 
 of hydronephrosis by moveable kidney, that Lanccreaux, 
 Trousseau and others describe it only by the way as an 
 occasional cause of moveable kidney, and Gilewslci only 
 mentions acute hydronephrosis, and that in an erroneous 
 connection with the symptoms of incarceration so-called. 
 The reason of this is that the formation of the hydrone- 
 phrosis entirely obliterates the primary causes, not only in 
 their clinical relation, but also in their anatomical appearances 
 on dissection. 
 
 In order therefore to establish my hypothesis, (that 
 moveable kidney furnishes one of the chief causes of hydro- 
 nephrosis, and that very many cases whose causes are con- 
 sidered obscure are nothing else than hydronephroses in 
 moveable kidneys) not merely upon the above somewhat 
 theoretical arguments, I shall here give additional proofs 
 from the pathogenesis of hydronephrosis founded on patho- 
 logical conditions, experiment, and clinical symptoms. 
 
 (i) Proofs deo-ived from the Patliogencsis of Hydronephrosis. 
 
 That form of hydronephrosis, in which no cause of com- 
 pression or obstruction of the ureter is found after death, 
 was known even to ancient writers. 
 
 Schönlein (128) disagrees with the assertion of P. Franli 
 
 Eeports,' vol. xvi), treating of the dilatation of the ureters in Extroversion 
 of the Bladder, the author's theory heing that of obstruction to the flow of 
 TU'ine hy spasm of the vesical orifices of the ureters caused by irritation of 
 the extroverted bladder. Similar urine is often secreted by children suffer- 
 ing from incontinence, and is probably due to the same cause. In all these 
 cases dilatation of the ureters and renal pelves is produced by the same 
 cause, viz. a considerable but not absolute obstacle to the escape of urine. — 
 
 TEANSL.iTOE.
 
 308 MOVEABLE KIDNEY IN WOMEN. 
 
 (that tbo dropsical kidney arises from mecliauical causes, 
 one of the ureters being compressed and preventing the 
 escape of the urine, which is retained in the kidney and 
 gradually distends it), and expressly remarks that cases are 
 met with, and indeed are the majority, in which the ureters 
 are quite patent. " But the conditions of the malady arc 
 still unknown.'^ 
 
 Cruveilhier propounded the following explanation for these 
 cases, which has also been accepted by Englisch (12g) : ^^ If 
 an organic sac or tube has once been expanded and its 
 tissues overdistended so as to lose some of their elasticity, the 
 distention of the walls^ remains, and the collection becomes 
 permanent." In the foetus an obstruction of this kind 
 may be produced by the adhesion of the contiguous epithelial 
 layers. 
 
 According to Rosenstein the cause of hydronephrosis in the 
 absence of any discoverable impediment, is in many cases 
 obscure. 
 
 Virchow (130) observes that those cases are the strangest 
 ©f all in which extreme hydronephrosis is present, in spite 
 ©f patency of the ureter. Virchoiv has frequently examined 
 such cases, and has each time found a valvular obstruction 
 caused by a folding of the wall due to an oblique origin of 
 the ureter out of the pelvis of the kidney. 
 
 Simon (131) has also observed this sort of hydi'oncphrosis, 
 which according to him most frequently gives occasion to 
 operative proceedings, and to which, although practically 
 the most important, but little attention has hitherto been 
 paid. In two cases examined by him the completely pervious 
 ureter arose not only at an acute angle from the pelvis of the 
 kidney, but its upper part even lay in the wall of the pelvis 
 for a length of seven to ten centimetres, yet not in the proper 
 wall of the renal pelvis, but between this and its peritoneal 
 investment. The valvular closure at the renal orifice of the 
 ureter (ostium pelvicum) was so complete, in spite of the 
 perviousness of the ureter, that, even when the sac was filled 
 with water at a considerable pressure, not a drop escaped 
 from the ureter. 
 
 Cohnheim (132) alludes to the abnormal insertion of the 
 ' Wunde, a misprint for Wände. — Tkanslatoe.
 
 MOVEABLE KIDNEY IN WOMEN. o09 
 
 ureter as an important cause of hydronephrosis, when he 
 says he considers it to be a conr/enital malformation. The 
 ureter^ instead of risings as usual, from the lowest point of 
 the pelvis, rises higher up, so that in the erect position the 
 urine cannot escape until the pelvis is full up to the level 
 mentioned. The idea that these were cases in which the 
 ureters had originally been double, and that one of them had 
 subsequently become degenerated and disappeared, is excluded 
 by the fact that where there are two ureters there are also 
 two pelves, and that these are very rarely amalgamated. 
 " The reason for the occasional ahnormal condition of the 
 transitio)tal spot hettueeu the pelvis and ureter is in fact un- 
 known, and moreover in a dissection nothing can usually be 
 ascertained with accuracy, as the distension of the pelvis, 
 which is never absent under these conditions, and is often 
 quite enormous, has already completely changed the original 
 conditions. Moreover, we sometimes meet with quite sharp 
 kinks in the course of one of the ureters, which must pro- 
 perly be considered congenital, in the complete absence of 
 bands of connective tissue caused by adhesions and cicatrices.^' 
 Although however all writers regard the angular insertion 
 and valvular closure of the ureter as the cause of the hydro- 
 nephrosis, which view appears to me to be confirmed by the 
 examination of the new-born infant, Simon considers hydro- 
 nephrosis to be the cause of the morbid changes in the course 
 of the ureter. Owing to some impediment or other, as even 
 Cruveilhier assumed for the case of the foetus, a hydrone- 
 phrosis forms, and the ureter, which vms not enlarged above 
 the impediment, becomes displaced at an acute angle at its 
 pelvic orifice (ostium pelvicum) as the tumour grows larger. 
 This causes a valvular closure, by which the lower half of 
 the distended renal pelvis compresses the upper part of the 
 ureter. Here, therefore, the same mechanism is in operation 
 as that by which, in the case of diverticula of the alimentary 
 canal, the part immediately below the diverticulum is kinked 
 and occluded with a valvular closure. As the distension of 
 the pelvis of the kidney increases (which can only proceed 
 horizontally forwards and outwards, the vertebral column 
 oifering an obstacle on the inner side), the substance of the 
 kidney becomes pressed outwards and backwards together
 
 310 MOVEABLE KIDNEY IN WOMEN. 
 
 witli its calice.s. Tlirougli these changes in position^ the 
 upper portion of the ureter, which normally lies on the inner 
 side, comes to point more forwards and outwai'ds, and comes 
 to be placed between the anterior internal wall of the dis- 
 tended renal sac and the peritoneum which invests it. 
 
 Englisch similarly gives his opinion against the assumption 
 of a primary abnormal course of the ureter as a cause of 
 hydronephrosis. 
 
 When, however, Simon, starting from this explanation, goes 
 on to assert that the ureter, occluded by a stone, or com- 
 pressed by a parametric cicatrix, or hindered in its evacuation 
 of urine by the distension of the bladder, collapses above the 
 impediment, this In^pothesis is actually impossible, for the 
 result of urinary obstruction is to produce distension above 
 the point of compression. Thus, the conclusions drawn from 
 this explanation appear unjustifiable. The origin of hydro- 
 nephroses of this kind is therefore inexplicable, either from 
 the artificial explanations of Gruveilhier and Simon, or from 
 the general hypothesis of the congenital character of the 
 morbid insertion and valvular occlusion of the ureter. 
 
 Moveable kidney, however, appears from the above con- 
 siderations calculated to produce urinary obstruction and 
 consequently hydronephrosis, by frequently repeated dis- 
 placement and twisting and kinking of the ureter. This 
 view is confirmed by the fact that the majority of hydrone- 
 phroses of obscure origin are seen in women of considerable 
 age_, and on the right side. 
 
 (2) Proofs derived from Anatomical conditions. 
 
 When dealing with the post-mortem appearance in move- 
 able kidney (see above), we mentioned some cases in which 
 an abnormal position of the hilum (which sometimes pointed 
 upwards and sometimes forwards), and of the ureter (which 
 sometimes ran upwards in a curve above the pelvis of the 
 kidney) were actually shown. Although hydronephrosis was 
 not simultaneously present in all these cases, wo cannot con- 
 clude from this circumstance, as Hosier has done, that it 
 cannot be caused by these abnormalities^ but only that it
 
 MOVEABLl!] KIÜiNEY IN WOMliN. 311 
 
 does not always necessarily result therefrom. In addition 
 to those given above I have found the following pathologico- 
 anatomical I'eports which confirm my lijqDothesis. 
 
 Sandifort (133) reports a case of hydronephrosis in which 
 the ureter, which was pervious, was twisted on its axis : 
 *' Ren dexter sanus ; sinister morbosus. Hie quippe, ex- 
 pansus insigniter, ultra quinque pollices longas, tres cum 
 dimidio latus, et pressioni cedeus, singularem et pelvis et 
 totius corporis monstrabat expansiouem, vcre hydropicam . . 
 . Ureter . . suporiori in loco quidem parum prominulus, 
 sed dein contractus et quasi coutortus erat, ad vesicam sanam 
 descendens, et toto hoc in tractu minime expansus, verum 
 potius contractuSj non tamen tantopere, quam superiori in 
 loco, ubi haec constrictio tanta erat, ut, compresso maxime 
 rene, nou nisi pauca3 liquoris flavi urinosi prodireut guttulae. 
 Fisso uretero contractus maxime ureter et ferme occlusus 
 iipparuit, ubi ex pelvi originem trahit." The ureter was 
 therefore pervious.^ 
 
 Haller (134) reports: "In a woman who had died of 
 dropsy, a tumour Lad grown some years since below the 
 navel, and was regarded by the sui'geon as a rupture. After 
 death it was found that this lay beneath the peritoneum and 
 omentum, it was membranous, white, and filled with water, 
 an ureter arose from it, and traces of renal papilla3 were found 
 in it. A remarhahle instance of alteration in the iiosition and 
 atrncture of the Icidney. The other kidney was quite healthy 
 and lay on the right side.^' 
 
 The two following cases are still more striking : 
 
 Hare (135) found double hydronephrosis in the body of 
 ti woman, 38 years of age, in whom a largo tumour 
 in the left as well as in the right side had occasionally 
 appeared and disappeared. That on the right side was still 
 full, the left nearly empty. The only impediment to be 
 found was that both ureters were twisted on their own accis. 
 As soon as the ureter was separated from the surrounding 
 tissues and untwisted, the urine collected on the right side 
 flowed freely away. Hare regarded the cause of the twisting 
 as congenital. 
 
 P. [Vilse (136) saw in a woman aged 39 (who had had 
 ' Incorrectfy quoted by tlie author. — Te^u^slatok.
 
 312 MOVEABLE KIDNEY TN WOMEN. 
 
 eleven children and had suffered at times from violent 
 gastric disturbances), a tumour in the left side of the abdo- 
 men which sometimes disappeared. After death, hydro- 
 nephrosis of the left kidney was found. The left ureter was 
 neither obliterated nor occluded by a stone ; on the other 
 hand it was curved upwards at the point where it "sprang 
 from the pelvis, and thus formed a valve which closed the 
 orifice of the ureter as soon as a certain collection of urine 
 took place, but if the accumulation became greater, was 
 unable to maintain the occlusion. A temporary hydro- 
 nephrosis was thus produced, which explained the attacks. 
 
 The analogy between this and the condition of the ureter 
 in cases of moveable kidney strikes one at once (see Figs. 5 
 and 8), but in neither case was it thought of . Besides these, 
 we find in pictures of hydronephroses the ureter twisted on 
 its own axis. 
 
 (3) Proofs derived from clinical ohservations. Intermittent 
 Hydronephrosis. 
 
 Cases of Hydronephrosis associated with and caused by 
 moveable kidney certainly occur oftener than has been 
 hitherto imagined. Even Simon (137) in 1875 was acquainted 
 with not a single example of hydronephrotic moveable kidneys, 
 although his own explanation of the origin of hydronephrosis 
 from temporary disturbances frequently repeated ought cer- 
 tainly to have led him to regard moveable kidney as the 
 cause in doubtful cases. Since then hydronephroses in 
 wandering kidneys have bceu observed with certainty 
 (namely by operation), by Fcrnico (138), Ahlfeld (139), 
 Czerny (140) (two cases), Wagner (141), and Landau (142). 
 All these observations concerned women and the right kidney. 
 
 The connection between moveable kidney and hydro- 
 nephrosis is recognised most unmistakeably by a symptom 
 which must be regarded as quite pathognomonic in the pro- 
 duction of hydronephrosis by moveable kidney, namely, the 
 periodical filling and emptying of the sac of the hydro- 
 nephrosis. This phenomenon, which attracts our notice
 
 MOVEABLE KIDNEY IN WOMEN. 313 
 
 by the frequent appearance and disappearance o£ a tumour, 
 and Avliich can be called (as Gole (143) and Mori'is (144) have 
 done), intermitting, or temporary, or relapsing hydro- 
 nephrosis, has been described in moveable kidney by no one 
 but Eger (145), so far as I can see. I myself have also seen 
 a case in point (146), The refilling and disappearance of 
 the hydronephrotic sac could be repeatedly proved. In the 
 woman especially on whom I operated, the torsion or valvular 
 closure of the ureter was relieved by changes in posture and 
 by diminution of the pressure of the hydronephrotic fluid 
 following moderate aspiration, the escape of the urine be- 
 coming re-established. Both observations are appended 
 below. 
 
 The reason why intermittent hydronephrosis is so seldom 
 observed may be that, as long as the alternation between 
 repletion and evacuation goes on, the hydronephrotic sac has 
 still a small volume and therefore easily escajjes recognition. 
 But as soon as it becomes larger and more easily palpable, 
 the valvular closure or the abnormal insertion of the ureter 
 is generally so firmly established that the hydronephrosis 
 remains permanent. Thus it happens that intermittent 
 hydronephrosis in moveable kidney is often overlooked or 
 otherwise interpreted. 
 
 Tulpms (147) is the first to report on this peculiar form 
 of " ischuria," which he observed in a patient each time at 
 full moon. It lasted in his case five days on each occasion, 
 and only yielded to a venesection. He was unable to explain 
 this peculiar condition during the life of the patient •} " Sola 
 anatome, post obitum instituta, emit illic feliciter veritatem 
 in profundum demersam ; et ostendit distincte, qui angusta, 
 renis sinistri, pelvis, excrevisset in earn amplitudinem, ut 
 suppleret commode vicem, vesicae urinariae.^ Quae propterea 
 tarn fuit vacua, quam, ren repletus." 
 
 Sauvages (148) described this form of retention of urine, 
 connecting it also with the moon, i.e. with the '' Ischuria 
 lunatica Tulpii.'^ 
 
 Johnson (149) observed in a Avoman pregnant for the 
 eighth time a remarkably changeable condition of the urine, 
 
 * The case is reported under the heading "Ischnria lunatica" and the 
 original contains " uniariae " — a misprint for " urinariae." — Teakslatoe.
 
 ■314 MOVEABLE KIDNEY IN WOMEN. 
 
 wliicli was either scanty and dark or plentiful and milk- 
 white ; in the first case its " excretion was accompanied by 
 great pain, in the last case it was easily passed. After 
 delivery a large tumour was noticed on the left side, pro- 
 jecting four inches above the surface of the abdomen, and 
 measuring seven or eight inches in diameter. The tumour was 
 tense and smooth over its whole surface ; on gentle palpation 
 there was distinct fluctuation ; pressure on it caused pain. 
 The diagnosis of an ovarian tumour was made. Soon after 
 the patient died ; the autopsy showed bilateral hydro- 
 nephrosis. 
 
 Schönlein (150) distinguishes two varieties of renal dropsy 
 (Hydrops renalis). In the first, in which the ureters are per- 
 vious, the patients pass an enormous quantity of pale greenish 
 urine, four to six quarts^ or more in the twenty-four hours. 
 In the second variety, in wliich the ureter is closed, the urine 
 passed is scanty, dark, and reddish ; the tumour in the 
 renal region and the sympathetic symptoms arc much more 
 plainly marked in the second than in the first. " The dia- 
 gnosis is veiy difficult. The disease has not hitherto been 
 recognised till after death, in several cases it has been taken 
 for ovarian dropsy .^^ 
 
 Rosenstein (151) quotes a case of supposed hydronephrosis 
 which, in consequence of the sudden disappearance of the 
 tumour, he erroneously considers to have been an ovarian 
 tumour, as he remarks : " In cases where the develojDment of 
 the tumour is not observed, there will always be sources of error 
 in diagnosis. The statement of the patient also, of occasional 
 spontaneous evacuation through the bladder, is well worthy 
 of consideration, as this is more likely to happen when 
 an ovarian tumour is adherent to the ureter than in hydro- 
 nephrosis, where the mechanical occlusion occasioned by the 
 hydronephrosis is hard to overcome.^' 
 
 Itillier (152) relates the case of a woman who showed a 
 tumour in the right side, which occasionally disappeared and 
 then reappeared. As long as the tumour remained she had 
 violent pain and the urine was scant}^, as soon as it dis- 
 
 ^ A " Maass " is a German measure for l)oer, dilTerent in different States. 
 It seems to be about a pint on an average, but in this plaec must mean a 
 larger quantity. — Teanslatoh.
 
 MOVEABLE KIDNEY IN WOMEN. 315 
 
 appeared tlie pain weut away aud tbe uriue became profuse 
 and turbid. 
 
 Tlie similar observations of Uare and Wilse have been 
 already mentioned above. In the discussion wliicli followed 
 the relation of a case of intermittent hydronephrosis caused 
 by cancer of the bladder, by Morris (153), altogether three 
 or four cases of intermittent hydronephrosis were mentioned 
 by Hare and Smyth, of which I believe, as I also do of 
 those mentioned before, that they were caused by the same 
 mechanism as the hydronephroses observed by Eger and me. 
 
 (4) Confirmation hy experiment. 
 
 If the moveable kidney, pelvis, and ureter are represented 
 by an india-rubber elastic ball loosely fastened on a firm board, 
 with a thin afferent and efferent tube (154), intermittent 
 hydronephrosis is easily reproduced under exactly the same 
 conditions as in the living subject. 
 
 (i) If the bag filled with water is lifted up vertically 
 and bent so that the efferent tube occupies the highest point, 
 evacuation will not take place until the pressure of the water 
 overcomes the elasticity of the india-rubber bag. Analogue : 
 Moveable kidney with the ureter inserted into the highest 
 point of the pelvis. 
 
 (2) If the bag is laid horizontally, evacuation will spon- 
 taneously take place if the efferent tube is intact. 
 
 (3) If the bag is tilled in a horizontal position and placed 
 so that the efferent tube forms an angle with the bag, and 
 the tube is then twisted ; as the pressure of water increases 
 in this position, the bag will become more and more elevated 
 and distended, and no evacuation will take place until the 
 board on which it lies is considerably tilted to the side, 
 which will cause the bag to turn on its side and thus untwist 
 the efferent duct. 
 
 (4) If on the contrary the board is made vertical, the 
 bag if moderately filled in this position will bend towards 
 the efferent duct and form a kink in it. It will depend on 
 the size of the angle and the downward resistance occasioned
 
 316 MOVEABLE KIDNEY IN WOMEN. 
 
 by the further influx of water into the expanding bag^ 
 whether the bag can rise so as to diminish the angle between 
 it and the efferent tube. Analogue : Intermittent hydro- 
 nephrosis caused by the descent of the kidney and axial 
 rotation of the ureter. 
 
 (5) The effect of increased and diminished pressure can 
 also be easily imitated with this apparatus. As in the 
 patient, when the bag is filled, evacuation will at one time be 
 rendered possible by increase, at another by diminution of 
 pressure, according to the position of the bag. 
 
 (6) The causation of hydronephrosis by prolapsus uteri 
 is illustrated by hanging a weight on the efferent duct. As 
 the weight is increased the walls of the efferent duct to a 
 greater or less height above the weight are seen to become 
 firmly pressed together and to close the duct. 
 
 Phenomena of Moveable Kidney during Pregnancy and 
 Labour. 
 
 According to the scanty observations hitherto available, 
 the troubles caused by moveable kidney appear to be rather 
 diminished than increased. 
 
 {a) The growing womb pushes the intestines gradually 
 up, and with them indirectly the kidney, as I have observed 
 in two cases ; and by this means the evil effects of dragging 
 and kinking of the vessels and ureter are usually alleviated, 
 just as is the case when pregnancy supervenes in a case of 
 descent of the generative organs. 
 
 [b) To this is to be added the circumstance, that during 
 pregnancy there is usually a copious deposit of fat in the 
 panniculus adiposus and in the subperitoneal cellular tissue, 
 which gives additional firmness to the attachments of the 
 kidney. 
 
 (c) Moreover the circumstance that menstruation (which 
 exercises an untoward influence on the capsule of the kidney 
 both anatomically and also symptoniatically in its effect on 
 
 1 i.e. On the action of gravity as against the tendency of the elastic^bag 
 to erect itself as it becomes tense ? — Tkanslatoe.
 
 MOVEABLE KIDNEY IN WOMEN. 317 
 
 the general liealtli) ceases during pregnancy, contributes 
 essentially to the relief of the disturbances caused by moveable 
 kidney. Some observers, as Mare and Oppolzer, have indeed 
 observed cures of moveable kidney during pregnancy, which 
 cannot bo doubted when the same experiences are remem- 
 bered in the case of prolapse of the vagina and uterus. 
 Whether moveable kidney exercises an injurious influence on 
 the other hand on the pregnant uterus, is as yet unknown. 
 It is however not unlikely that where it has descended very 
 low, or in case of complications such as interruption of the 
 circulation in the renal vein (in the former case mechanically, 
 in the latter by the great disorder of the circulation), it is 
 capable of inducing abortion, as indeed happened in the case 
 related by Eger. That this is not inevitable in cases of 
 intermittent hydronephrosis is proved by the observations of 
 Johnson and Bger, in whose cases also the growing uterus 
 appeared to undo the kinking and twisting of the ureter, and 
 to make it pervious for the urine. 
 
 Dearth of observations prevents us from stating a iniori 
 the exact mutual relations between labour and acquired 
 moveable kidney. The cases of Ghambon de Montaux (155) 
 (in which a kidney was found incarcerated behind the grow- 
 ing uterus), Boinet (156) (who observed a deviation of the 
 uterus, caused by a kidney lying behind the bladder), and 
 Hohl (157) (in which a displaced kidney is said to have 
 formed an obstruction to labour), one and all concern cases 
 of congenital malformation and probably of displacement with 
 subsequent fixation. Moreover the case of Ilohl is so inac- 
 curately and unscientifically described that it cannot be 
 utilised to prove anything. 
 
 It is however obvious, as well as established by many 
 cases, that the pressure which occurs in labour is capable of 
 acting injuriously on the kidney. Women therefore who 
 have a moveable kidney must be cautioned against bearing 
 down too strongly during labour.
 
 318 MOVEABLE KIDNEY IN WOMEN. 
 
 VIII. Objective Signs of Moveable Kidney. 
 
 Moveable kidney is capable of attracting attention botli 
 by its absence from its normal position and by its appearance 
 in an abnormal situation. It will therefore be necessary to 
 examine the question what physical signs, both in the anterior 
 and posterior lumbar region are due to it. 
 
 Inspection. — In thin subjects with a moderate amount of 
 pendulous belly, the moveable kidney may occasionally be 
 found against the anterior abdominal wall in the erect posture. 
 Its outline can in some cases be also made out when the 
 patient lies flat on the back or on the side opposite to that of 
 the moveable kidney. Sometimes the kidney can be seen to 
 map itself out by a sulcus parallel to itself which moves down- 
 wards on deep inspiration along the anterior abdominal wall. 
 
 The condition of flattening or depression of the corre- 
 sponding lumbar region, especially plain in the knee-elbow 
 position, described by the majority of writers (158) as constant, 
 is an unti'ustworthy and exceptional sign. Its small value is 
 best seen by the fact that in a patient» whose right kidney 
 had been removed, and whose great emaciation also furnished 
 the most favourable conditions for its production, I was 
 unable to see this flattening. Keppler also failed to find 
 this depression. The fact that in certain positions, especially 
 when the legs are adductcd, the so-called lateral lumbar 
 sulcus corresponding to the lateral border of the sacrospinalis 
 muscle normally comes out pretty plainly in thin subjects, 
 has in my opinion given rise to many mistakes of this kind. 
 
 Percussion. — The resonance over a moveable kidney in the 
 abdomen is generally dully tympanitic. It is only when the 
 kidney has a long mesentery, and relaxation of the subperi- 
 toneal cellular tissue allows the ureter to detach itself far 
 from the posterior wall of the abdomen, that the resonance is 
 absolutely dull (and then of course only on superficial 
 percussion), because in this case no intestines separate the 
 kidney from the abdominal wall. On the left side the 
 resonance is also but seldom quite dull, because the 
 voluminous stomach and intestine filled with air always lie in
 
 MOVEABLE KIDNEY IN WOMEN. 319 
 
 front of the kidney, unless tliis is very low down ; and 
 altliough purgatives may evacuate tlie air wliicli masks tlie 
 true percussion sound from tlie intestine, they cannot do so 
 from the stomach. A special value has been laid on the 
 percussion signs in kidney diseases, caused by the relations 
 of the kidney to the colon. Whereas in the case of tumours 
 of the kidney the colon almost invariably lies on their inner 
 side, and the percussion sound on their outer side is dull (as 
 Avould naturally be supposed in the case of extraperitoneal 
 tumours), moveable kidney has had the percussion signs of 
 an intraperitoneal tumour assigned to it {8imo7i, Ahlfeld), and 
 it has been believed always to lie on the inner side of the 
 colon, and always to be bounded on the outer side by 
 tympanitic resonance. This relation however is only found 
 where the kidney has a long mesentery, and where in addition 
 the flexure of the colon is very long or the kidney has 
 migrated between the folds of the mesocolon. But when the 
 mesocolon is taut and short, even if the kidney is moveabh^ 
 the colon is usually pressed inwards, and the percussion note 
 on the outer side of the kidney remains dull, as in the case 
 of a subperitoneal tumour. A moveable kidney therefore 
 behaves with regard to percussion, at one time as an intra- 
 peritoneal and at another as an extraperitoneal tumour. 
 
 Here also it is generally believed that the absence of the 
 kidney from its usual position in the lumbar and posterior 
 abdominal region furnishes important percussion signs. 
 According to Bollet, Trousseau and others, the note over the 
 side corresponding to the displaced kidney is clearer and 
 fuller than on the other side. 
 
 The majority of the textbooks and handbooks on 
 percussion say the same. Fiorry (159), the founder of renal 
 percussion, claims to have percussed out even the slightest 
 changes of size in the kidney. 
 
 According to Outtmann (160) the diagnosis of a moveable 
 kidney (whenever at least a proof is needed), rests on the 
 circumstance that percussion shows the absence of the kidney 
 from the normal place, by the diminished dulness. " If a 
 kidney is displaced the lumbar region of that side is more 
 resonant than the other side." 
 
 Numerous investigations however hf\ve convinced me of
 
 320 MOV R ABLE KIDNEY IN WOMEN. 
 
 tlio untrustwortliiness of this sign. Even strong percussion 
 hai'dly detects any difference between the two sides in move- 
 able kidney. When one considers that one percusses a thick 
 layer composed of the muscles of the back, the ribs, and the 
 quadratus lumborum muscle, it is not to be exjDOcted that 
 the dulness will bo changed into resonance by the absence 
 of the kidney. If the kidney is displaced on the right side, 
 which is generally the side in point, its place is at once taken 
 by the posterior surface of the liver, which of course in no 
 way changes the original dulness. Thus neither Weil (i6i), 
 who examined a patient whose kidney had been removed by 
 Gzcrny, nor I under similar circumstances found any differ- 
 ence in resonance. Moreover Kepj^ler (162) justly denies, on 
 the ground of careful examination, the so-called physiological 
 kidney dulness. 
 
 Pansch (163) again has pointed out, from minute topo- 
 graphico-anatomical investigations, the errors of the clinical 
 observers like Gerhardt, according to whose account of the 
 kidney dulness the kidney normally reached as far as the 
 crest of the ilium, whereas it does not reach so far by three 
 to five centimetres. PanscJi moreover correctly observes 
 that even an area of dulness reaching to the crest of the 
 ilium is not necessarily identical witli the pi'oper kidney dul- 
 ness, since the Capsula adiposa lying* below the kidney 
 is often as thick as the kidney itself which causes the 
 dulness. 
 
 After all we shall therefore be obliged to agree with 
 Shoda's ( 1 64) statement already mentioned : " The size of 
 the kidney has very little to do with the state of the reso- 
 nance in the lumbar region. This may bo quite dull wlien the 
 kidneys are very small, and tympanitic although the kidneys 
 are very large. We must therefore when possible press the 
 Plessimeter down until we get complete dulness and the 
 resistance of a solid organ. By repeating this process at 
 several spots we can judge where the kidney shows a striking 
 enlargement.^' 
 
 As a matter of fact even in the case of moveable kidney 
 the most unmistakeable signs are furnished by palpation. 
 
 Palpation.' — A moveable kidney is generally to be per- 
 ceived beneath the free edge of the ribs, rather towards the
 
 MOVEABLE KIDNEY IN WOMEN. 321 
 
 middle lino and tlie navel, as a smootli, oval, solid sensitive 
 body. Now and then wc succeed in feeling tlie shape of the 
 kidney, but rarely (as happened in Frerichs' cliuique) in 
 feeling the pulsation of the renal artery. The right kidney 
 is easier to feel than the left, because the left is surrounded 
 by softer and more yielding parts than the right, aud can 
 therefore more easily slip away. The extreme mobility of 
 the kidney is remarkable, for a slight touch or the contrac- 
 tion of the abdominal walls is sometimes alone sufficient to 
 make it change its position, and in the horizontal posture it 
 easily slips back into its normal place. The mobility of the 
 kidney is often so great that one has actually to surprise it 
 in order to catch it for palpation. Once back in its normal 
 position it is sometimes hard to render it apparent again. 
 Some patients can press it into the flanks and bring it 
 forward again by peculiar sidelong movements of the trunk. 
 This however does not always succeed, and so, after making 
 a diagnosis one is often subsequently at a loss. This habit 
 that the kidney has of retreating into its normal position and 
 staying there is so characteristic that in two cases in which 
 a moveable kidney was certainly present and a long incision 
 had been made in the linea alba with the view of removing it, 
 it could not be brought forward into the wound in the abdo- 
 men without shaking and changing the position of the 
 whole body (see Kejtpler (165) and Lauenstehi (166)). On 
 a third occasion even the shaking was in vain, and King 
 (167) (whose case it was) was obliged to abandon the 
 operation . 
 
 Palpation must be practised with the patient in different 
 postures and always himanually (168). The knee-elbow 
 position which was formerly recommended is least suitable for 
 this purpose, because in this position the kidney tends to 
 fall towards the diaphragm, that is, into its normal position ; 
 the most convenient is the horizontal posture with the upper 
 part of the body moderately raised and the legs moderately 
 bent, a position which is usual in gynaecological examinations 
 on account of the diminution in the intra-abdominal pressure 
 which it causes. It appears useful to place the patient on 
 the left side to feel the right kidney, to press the right hand 
 firmly against the lumbar region and to press the kidney 
 
 21
 
 322 MOVEABLE KIDNEY IN WOMEN. 
 
 witli tlie right hand, against tlie left liand resting on tlio 
 abdomen. In the case of the left kidney vice versa. 
 
 By these manipulations it is sui-prisingly easy in favourable 
 cases to feel the lower end even of the normally placed 
 kidney, and. when it is moveable to move it to and. fro 
 between the hands. At the same time an impression is 
 gained by practice whether one or other lumbar region is 
 more easily indented than usual or than the other. This 
 condition, constantly to be observed in moveable kidney and 
 important for diagnosis, depends upon the fact that when 
 the kidney is absent from its normal position, the soft parts 
 situated in the flank, the muscles and intestines, are more 
 easily pressed, under the arch of the ribs ; but is not, as has 
 been erroneously supposed, explained by imagining that the 
 kidney which is normally situated, beneath the arch of the 
 ribs betrays its absence directly by this diminished resist- 
 ance. 
 
 Palpation itself is generally painful. Sometimes violent 
 pressure makes a patient vomit. Trousseau (169) made use 
 of the tenderness caused by pressure on the kidney for dia- 
 gnosis, comparing it with the tenderness produced by pressure 
 over the other kidney. 
 
 Auscultation has not hitherto been utilised for diagnosis 
 in the case of moveable kidney. It is not however to bo 
 doubted in this case also a whistling murmur will be 
 audible when twists and narrowing of the vessels occur,^ 
 
 IX, Diagnosis. 
 
 The recognition of a moveable kidney depends on the 
 physical signs, especially those derived from jDalpation, and 
 
 ^ The auscultation of abdominal tumours is in so unsatisfactory a state 
 that little can be said about it. A murmur is said to be occasionally heard 
 in ovarian tumours, but what these tumours are, or what are the circum- 
 stances under which murmurs occur in them is not stated. It would be a 
 picturesque circumstance for a murmur to develop in an ovarian tumour 
 during twisting of the pedicle ; but where is such a case recorded ? The uterine 
 murmur in some fibrous tumours is well known. The wisest course in the 
 present chaotic state of knowledge is to follow the advice of the American 
 ambassador, and " Never prophesy unless you know." — Thanslatoe.
 
 MOVEABLE KIDNEY IN WOMEN. 323 
 
 tlie knowledge of the numerous symptoms caused by it. The 
 fact that they are so very often overlooked or wrongly 
 interpreted depends not only on want of acquaintance with 
 their subjective and objective symptoms, and on the usual 
 supposition that the patients are hysterical or hypochondriacal, 
 but also on real difficulties standing in the way of their 
 recognition. 
 
 When indeed one succeeds in seizing a solid body situated 
 in the abdominal cavity in such a way that one can move it 
 more or less backwards and forwards between the lumbar and 
 umbilical regions, in finding the pulsation of the renal artery 
 aud the hilum, tlicre is no difficulty in making a diagnosis. 
 But if a kidney possesses only moderate mobility or is 
 situated within a patient with strong and fat abdominal walls, 
 the physical symptoms aiford but an uncertain conclusion, and 
 the subjective symptoms are generally of such a nature as to 
 be capable of other equally justifiable interpretations. 
 Finally, if one even succeeds in feeling a solid round body in 
 the abdomen without recognising the shape of the kidney, 
 there are a large number of other pathological conditions 
 (tumours and so forth) which can easily be mistaken for it on 
 account of the similai-ity of their subjective and objective 
 symptoms. On examining the statistics of moveable kidney, 
 we find in fact that the same may be said of them as Simon 
 (170) asserted for hydronephrosis: ^'^ That they consist of a 
 long series of errors of diagnosis followed by an equal 
 nuu]ber of inappropriate interferences." Now since moveable 
 kidney has no pathognomonic symptoms, it is quite necessary 
 to ascertain the differential sigus between it and many 
 pathological conditions which give similar manifestations. 
 Eveu then it will often be impossible to make a correct 
 diagnosis except by exclusion. An enumeration of all 
 possible sources of mistake would amount to a treatise on the 
 diagnosis of abdominal tumours. Only the most important 
 and frequent will therefore be given here. 
 
 Partial contractions of the Recti, Tx-ansversi and Obliqui 
 Abdominis muscles frequently give the impression of a smooth 
 oval tumour, which after a certain time disappears on pressure 
 by the palpating hand, just like a moveable kidney. If these 
 patients are put under chloroform, it is true that the influence
 
 324 MOYEAELE KIDNEY IN WOMEN. 
 
 of tension of. the abdominal walls is eliminated^ hut the- 
 differential diagnosis cannot always be made, because a 
 moveable kidney also usually retreats into its place during 
 narcosis. A conclusion is however arrived at by frequent 
 examination, and especially by carefully conducted strong- 
 percussion over the supposed tumour. 
 
 It may be very hard to decide whether the tumour is a 
 tumour of the liver, a liver deformed hy tight lacing, 
 hypertropliy of the liver, a liver developed in lajpi^ets- 
 (Zipfelbildung^) ; or a moveable Icldney without comiüications , 
 or adherent to the loiver border of the liver ; because the same- 
 signs on percussion and palpation hold good under both 
 conditions, and the symptoms in both cases may consist of 
 gastric disturbances, jaundice, and vague pains in the lower 
 abdomen. It has already been mentioned that the physical 
 signs deduced from the absence of the kidney from its normal 
 situation are not decisive. 
 
 I have observed a patient (see below) who frequently 
 suffers from jaundice, and in whom a diagnosis of moveable- 
 kidney adherent to the lower border of the liver would be 
 impossible but for the fact that the moveable kidney could 
 be felt before the formation of adhesions. 
 
 Lastly, a conclusion may frequently be arrived at by the 
 presence of some a3tiologicar element, or by the course and 
 consequences of treatment. In this way it took me severa) 
 months of observation in the case of three patients to diagnose- 
 a moveable kidney and exclude an affection of the liver ; in 
 two cases a tumour finally declared itself as a hypertrophic 
 cirrhosis of the liver of obscure origin. 
 
 Trousseau (171) relates a case of moveable kidney in which 
 ten physicians had made the diagnosis of a tumour of the 
 liver, an instance to which I could add many others. When 
 le Ray (172), referring to the differential diagnosis between 
 affections of the liver and moveable kidney, remarks that a 
 sulcus must intervene between the moveable kidney and tho 
 liver, it must be remembered that palpation just at the border 
 of the arch of the ribs is much hampered, and that a similar 
 
 * There is no English word equivakMit toZipfelbiklung. The Lippets are 
 generally more or less isolated and nioveahle over tlie right lobe. Man}- of 
 them represent conditions found in the lower animals. — Tuanslatoe.
 
 MOVEABLE KIDNEY IN WOMEN. 325 
 
 sulcus may be easily felt ou palpating lappets of tlie liver 
 (Leberzipfelu) and livers deformed by tight lacing. 
 
 The most decisive sign is that furnished by the observation 
 of the further course of the affection, and a conclusion is of 
 course quickly arrived at when malignant tumours are 
 present. 
 
 A mistake between 7)ioveahle Jcidncy and cystic tumour of 
 the liver (Echinococcus) or of the gall-hladder (Hydrops 
 vesicas fellea)) or solid tumours of the gall-hladder, is very 
 likely. The former is ascertained by tapping, the latter only 
 by the course of the disease. How little the statements of 
 textbooks can be trusted (173) when they say that tumours 
 of the gall-bladder are firndy fixed, are situated ou the outer 
 border of the rectus muscle, are pear-shaped and give rise to 
 colic, can be seen from the following observation. 
 
 Ou the 24th of February, 1S80, I saw Frau E. E — , thirty- 
 .six years of age, a patient of Herr Geh. San.-Rath Dr. J. 
 Meyer, complaining of a swelling in the abdomen and 
 violent epigastric pain. She was fairly well nourished, of 
 healthy appearance, she had had five children quickly and 
 had been till lately free from all discomfort. 
 
 Her present ailment is said to have been caused by hard 
 work. 
 
 Present condition : — Thoracic organs, &c., healthy ; well 
 marked pendulous belly. Beneath the right lobe of the liver 
 is a firm tumour of the shape and size of a kidney, remark- 
 able for its extraordinai'y mobility, aud which can bo easily 
 pushed downwards, outwards and inwards away from the liver 
 without causing the patient much pain, but (as in Urag's case 
 described above) when the pressure is relaxed, returns to its 
 original position nearly in the parasternal line. The tumour 
 itself was painless on pressure, but pressure caused a circum- 
 scribed pain in the epigastrium. The functions were normal 
 except that lately the patient had lost her appetite. 
 
 The most obvious supposition founded on the above con- 
 -dition Avas that of a moveable kidney adherent to the liver, 
 which, in spite of its great mobility^ was pulled back to the 
 liver by its adhesions as in Urag's case. On the other hand 
 it had been pronounced to be a tumour of the omentum. 
 
 Meanwhile, after some time an increase in the tumour and
 
 326 MOVEABLE KIDNEY IN WOMEN. 
 
 deterioration of the general health were observed, so that 
 thoughts were naturally entertained of a malignant growth. 
 But even then it was impossible to interpret the signs except 
 on the hypothesis that a moveable kidney had become can- 
 cerous, especially as the mobility of the tumour remained 
 very considerable. The appearances did not change till June, 
 when pain persisted even during the horizontal position, 
 jaundice appeared, and emaciation advanced so rapidly that 
 it became possible on deep bimanual palpation to feel plainly 
 the lower end of the right kidney in its normal situation. 
 Although the tumour was neither fixed, nor situated at the 
 outer border of the Rectus, nor pear-shaped, nothing but 
 cancer of the gall-bladder could now be diagnosed. 
 
 The autopsy, held in the Elizabeth Hospital, Berlin 
 (where the patient attended at last), confirmed this dia- 
 gnosis. 
 
 The instances in which, vice versa, a moveable kidney is 
 taken for an affection of the liver (as has already been men- 
 tioned), are still more frequent. It should also be remem- 
 bered that both affections may occur together. In the case 
 of Aherle mentioned above, gall-stones coexisted with move- 
 able kidney ; moreover I have seen a similar case myself (see 
 below). If well-marked gall-stone colic, yielding to large 
 doses of morphia, and the passage of gall-stones had not 
 been ascertained, the jaundice which occurred in this case 
 would very likely have been referred to the moveable kidney. 
 
 The presence of pain occurring even during quiet decubitus 
 ought to prevent us from mistaking cancers of the stomach or 
 pancreas for moveable kidney, even apart from the relative 
 immobility of these tumours. 
 
 Such a mistake however is more likely to be made in 
 cancers of the asccndiny and desccndlny colon, which frequently 
 cause nothing for a long time but digestive distui'bances 
 (Stenosis), and present to the examining hand a moveable 
 tumour lying beneath the abdominal walls in the region of 
 one or other flexure (I examined such a tumour in the Jewish 
 Hospital of Berlin, which had been wrongly considered to be 
 a moveable kidney). Then again the difi'erential diagnosis is 
 decided by the circumstance that the i^ercussion note over a 
 small cancerous growth in the colon lying immediately
 
 MOVEACLE KIDNEY IN WOMEN. 327 
 
 bcneatli tlio abdominal walls is alwaj^s tympaultic ; in the 
 case of sucli tumours when largci' and more diffuse^ there arc 
 so many signs of local and general disturbance that a move- 
 able kidney would hardly be thought of. 
 
 In like manuer/a?cftZ inasses Joiu/ retained in a loop of colon 
 with a long mesentery may sinmlate a moveable kidney, for 
 the hepatic flexure is a favourite place for faecal accumulation. 
 A long-continued constipation indeed suggests this complaint, 
 which is at once ascertained with certainty as soon as we 
 succeed in pushing the supposed tumour down into another 
 portion of gut. This however is only rarely possible, and 
 besides, defa3cation can proceed almost normally past a ffocal 
 tumour lying in a diverticulum. This condition, viz. that 
 the ingesta lying in proximal portions of the alimentary canal 
 take precedence of those lying in distal portions must bo 
 remembered, in order to avoid the mistake of excluding the 
 idea of a fa3cal tumour on account of regular' dcf location. 
 This can sometimes be easily recognised by the shape of 
 the tumour and its retreat after passive movements into a 
 situation in which moveable tumours ai'e not met with. 
 
 A moveable kidney on the left side may bo mistaken for 
 a moveable spleen. The spleen however during spontaneous 
 and passive movements always lies immediately beneath the 
 abdominal walls, while a moveable kidney when moved 
 upwards retreats from the abdominal wall and slips under the 
 intestines. The note over the spleen is therefore always dull, 
 over the kidney at one time dully tympanitic, at another 
 tympanitic. This sign appears much more trustworthy than 
 the assertion that the spleen must be recognised by its more 
 elongated shape. 
 
 It is otherwise in the case of tumours of the spleen {Ague, 
 Lvulccemia, Amyloid 82deeii,) , tho size of which indeed forbids 
 their being mistaken for anything but "Diovcablc tumours of 
 the Iddncy, but which also, when of a certain size lie close 
 beneath the abdominal walls. In this case however the pre- 
 sence of splenic dulness in the normal situation is decisive, 
 but still more the circumstance that in leukaemia, &c., there 
 
 ^ I once saw a woiiian wlio had swallowed a small coin, and who, in spito 
 ot' purgatives and consequent copious daily motions, did not pass it for ten 
 days. — AuTHOE.
 
 328 MOVEADLE KIDNEY^ IX WOMEN. 
 
 are other distinct signs arising with certainty from disease 
 of the spleen. 
 
 lu the case of the freqnently occurring doubt whether we 
 have before us a tiirnour of fJtc woiiih or ovary or a moveable 
 kidney^ the direction of the mobility should be tested before 
 all things. If a tumour can be moved towards the lumbar 
 region without causing much pain, a tumour of the generative 
 organs seems excluded. On the other hand a moveable 
 kidney cannot be excluded on the score of slight mobility of 
 the tumour towards the pelvis, for such a tumour can 
 sometimes be moved in that direction. Moreover even tym- 
 panitic resonance over the true pelvis does not absolutely 
 disprove the presence of tumours of the generative organs, 
 as the following case observed by me in the gyneecological 
 cliuique of Breslau shows. 
 
 In a woman who had been confined some months previously, 
 a tumour of the shape and size of the kidney was observed 
 at the level of the splenic flexure of the colon. Examination 
 of the generative organs threw no light on its nature. There 
 was tympanitic resonance above the pubes. The autopsy 
 showed the tumour to be an ovarian tumour with a thin 
 pedicle about 20 centimetres long. The tumour owed its 
 unusually high situation, to the recently pregnant uterus, 
 and had during the course of pregnancy contracted adhesions 
 with the mesentery and posterior abdominal wall, which held 
 it fast in its abnormal situation in spite of the diminution 
 and descent of the uterus into the true pelvis. As the 
 pedicle which was very likely originally long and thin had 
 been much drawn out, coils of small intestine had naturally 
 taken up their position between the generative organs and 
 ovarian tumour, and thus the tumour, though really intra- 
 peritoneal, had given the physical signs of a sub-peritoneal 
 (retro-peritonealen) body. 
 
 On the other hand moveable kidneys have frequently been 
 taken for ovarian tumours, as Spic(jclhcr(j (174) and others 
 point out. I saw how hard their differential diagnosis from 
 fibrous tumours with long pedicles can be, from two cases, in 
 which it was only in the course of the operation that I Avas 
 able to make out the connection of the kidney-shaped fibrous 
 tumour with the uterus. In both cases the mobility of the
 
 MOVEABLE KIDNEY IN WOMEN. 329 
 
 tumour was extreme^ and a certain diagnosis could only be 
 made from the circumstance that in spite of the superiicial 
 situation of the tumour and the possibility of grasping it 
 completely, the pulsations of the renal artery could not be 
 felt. 
 
 The stock signs given for the diagnosis of tumours of the 
 kidney (175) are useless under the circumstances under dis- 
 cussion. 
 
 In making a diagnosis therefore it is recommended to 
 proceed by first disregarding entirely the doubtful tumour 
 itselfj and looking to see if the other organs claiming attention 
 are to be found and are of normal shape. With a view to 
 this, bimanual palpation of the kidneys should be attempted, 
 the result of which is however seldom trustworthy. But 
 before all things the diagnosis of the presence of the normal 
 uterus and both normal ovaries should be attempted by the 
 usual bimanual examination or Siiiion^'? rectal exploration 
 with the entire hand, which is only of value in this case (176) ; 
 and these facts can nearly always be ascertained. In making 
 a differential diagnosis between tumours of the kidney and 
 generative organs therefore, the presence of the normal ovaries 
 and of the normal uterus will confirm the diagnosis of a 
 moveable kidney ; the presence of only a single normal ovary, 
 that of a tumour of the other ovary. 
 
 Lastly, there is still a condition under Avhich the wroug 
 diagnosis of a moveable kidney is likely to be made, namely, 
 that of so-called phantom tumour, whose symptoms consist 
 of a permanent and extreme distention of the abdomen with 
 unusually tense abdominal walls, and the aätiology of which 
 is still obscure. Women affected by this complaint generally 
 feel themselves pregnant, say they feel the movements of 
 the child, and so on. The thickness and firmness of the 
 abdominal walls and their contraction on the slightest touch 
 renders palpation useless without anaesthesia, then indeed it 
 is usually possible to I'ecognise the nature of the apparent 
 tumour and to exclude moveable kidney. It is still more 
 frequent for moveable kidney to simulate so-called spurious 
 pregnancy, which will however hardly be mistaken after a 
 careful examination of the generative organs. Other possibili- 
 ties of error, such as isolated collections of fat in the omentum
 
 330 MOVEABLE KIDNEY IN WOMEN. 
 
 and tumours in the abdominal walls need only be borne in 
 mind to avoid mistakes. 
 
 TJie Diagnosis of the GompUcations of Moveable Kiduei/. 
 
 A moveable kidney may be supposed to be adlicrent when 
 the kiduey lies more or less immoveable in an abnormal 
 situation, but still within an area not much farther removed 
 from the first lumbar vertebra than the length of the renal 
 vessels. It is however extremely rare for a displaced kidney 
 to become fixed in an abnormal position -, the statements of 
 some writers that the kidney contracts adhesions now and 
 again with the neighbouring parts and becomes surrounded 
 with deposit_, like an ovary embedded in a parametric^ deposit, 
 are entirely unproven. The adhesions are usually very 
 delicate and loose, permit movements of the kidney to 
 continue, and by no means prevent it from being replaced in 
 its normal position. It is true that the kidney I'eturus to the 
 place to which it adheres, which is generally the lower surface 
 of the liver (untere Leberlappen), gall-bladder or transverse 
 colon, so that its return is a test for the diagnosis of the 
 adhesions. No further symptoms are caused by the adhesions, 
 as would be expected from their usual non-inflammatory origin. 
 
 The recognition of the symptoms of incarceration so-called 
 is only specially difficult when the existence of a moveable 
 kidney is unknown or overlooked. Under these circum- 
 stances the extreme sensitiveness of the abdomen and the 
 fixation of the kidney iu a high state of oedematous swelling 
 and infiltration forbids careful palpation, so that this condition 
 is frequently mistaken for perityphlitis or perimetritis, on 
 account of the resemblance between the symptoms of these 
 diseases. The sudden appearance of violent symptoms, the 
 conditions of the seci'etion and excretion of the urine, the 
 suddenly commencing and rapidly proceeding disappearance 
 of tlic apparently large deposit, however, establish the dia- 
 gnosis even in these cases. 
 
 The liydrone-pJirims of moveable kidneys affords only a 
 sinrjJc sign which distinguishes it from hydronephroses due 
 * ? Perimetric. — Translatoe.
 
 MOVEABLE KIDNEY IN WOMEN. 331 
 
 to other causes, namely, its frequently intermitting appearance 
 attracting even clinical attention. These intermissions are 
 of course observed under other circumstances, as for instance, 
 in cancer of the bladder in the region of the trigone, or iu 
 the case of the repeated passage of stones from the kidney, 
 but other symptoms characteristic of these disorders render 
 it almost impossible to mistake them for hydronephrosis iu 
 a moveable kidney. It should not be expected that, after the 
 disappearance of the tumour, remains of kidney tissue iu the 
 hydronephrotic sac will be palpable through the abdominal 
 walls; the sac is far too thin for accurate palpation and when 
 empty siuks back against the vertebral column. Even after 
 complete evacuation of unilocular ovarian tumours, the most 
 searching bimanual palpation sometimes fails to make out 
 their walls, as I have repeatedly ascertained. 
 
 Besides this, hydronephroses of üioveable kidney have 
 nothing at all special about them ; indeed, as their origin 
 implies, when they become larger they completely resemble 
 the hydronephroses of fixed kidneys. Both grow in the 
 direction of least resistance, the fixed variety downwards, 
 the moveable upwards, so that it is only when they are of 
 a certain moderate size, i.e. repletion, that their I'elations to 
 neighbouring organs, especially the colon, are different. The 
 assertions of 8iino7i (177) that in the case of the hydrone- 
 phrotic sacs of moveable kidneys, the ascending or descending 
 colon remains in its normal situation ; and of Ahlfeld (178) — 
 that hydronephrosis in a moveable kidney dcvelopes in front 
 of the intestines like an ovarian tumour, caunot therefore be 
 regarded as correct. Again, the hydronephroses o£ moveable 
 kidneys gradually grow into the lumbar region, so that when 
 of a certain size they cannot be distinguished from the 
 hydronephroses of fixed kidneys. I will not here dwell 
 further upon the remaining diagnostic points, especially upon 
 the value of exploratory tapping and the differential diagnosis 
 between hydronephroses and other tumoui's.
 
 -332 MOVEALLE KIDNEY IN WOMEN. 
 
 X. Peognosis. 
 
 Tlio prognosis of uncomplicated moveable kidney is 
 favourable as far as life is concerned. No case has been 
 hitherto recorded in the literature of the subject in which 
 death could be even probably attributed to it. The fatal 
 case quoted by Ke^ypler (17g) can hardly be regarded as a 
 proof that an uncomplicated moveable kidney can cause 
 death. Still more must the assertion of Kepplcr (iSo) — that 
 " Moveable kidney, even without any complications at all, 
 gives rise to slow but continually developing disturbances of 
 nutrition, whicb, as time goes on, infallibly undermine the 
 health and even life '' — be rejected as quite unproven ; and 
 we can only agree with Trousseau (181) who — referring to the 
 treatment of moveable kidney by leeches, venesection, and 
 stili more questionable measures — expressed his opinion as 
 follows : " Le pronostic du rein deplace n'a vraiment pas de 
 gravite ; il ne devient grave que par les erreurs aux quellcs il 
 pent donner naissance, ct le traitement errone qui en ducoule 
 est ordinairement d'autant plus actif que le medecin est nioins 
 convaincu." 
 
 The prognosis of uncomplicated moveable kidney has 
 however grown decidedly worse since men have begun to 
 I'emove healthy moveable kidneys, basing their practice on 
 the view set forth by Kcpplcr. Of course some of the patients 
 (who otherwise would not have been killed by the moveable 
 kidney which gave occasion to the operation) now pay for 
 this with their lives. 
 
 Spontaneous cures of moveable kidneys are commoner, 
 especially in cases of acute traumatic dislocation, and they 
 have been observed in cases in which emaciation following 
 acute febrile aifections occasioned the mobility of the 
 kidney. 
 
 Ilollct (182) gave a correct explanation of this when he 
 said that when the kidney is put back into its normal position 
 and ke})t there by suitable means such as quiet decubitus, 
 the stretched subperitoneal cellular tissue around the kidney 
 iind against the posterior wall of the abdomen, as well as the 
 peritoneum itself, gains time to contract more firmly by
 
 MOVEABLE KIDNEY IN WOMEN. 333 
 
 virtue of its elasticity, and thus to afford a powerful obstacle 
 to the displacement of the kidney. Oirpolzer, Rayer, and 
 Hare have proved the ocurrence of cui^es after the superven- 
 tion of pregnancy. In like manner many observers have seen 
 considerable relief to all the troubles (amounting to cure) 
 follow the menopause and the proper treatment of symptoms 
 by drugs, diet, and mechanical appliances. A cure is some- 
 times effected by nothing more than a correct diagnosis, and 
 an explanation to the patient of the benign character of her 
 complaint ; after which her hypochondriacal frame of mind 
 and numerous imaginary maladies disappear suddenly. 
 
 Even with regard to the complications of moveable kidney 
 a good prognosis as far as concerns life is on the whole to be 
 given. Thus, even the menacing symptoms of incarceration, 
 have never yet been described as the cause of a fatal termi- 
 nation. 
 
 The prognosis after the establishment of hydronephrosis 
 and perinephritic and paranephritic abscesses is less favour- 
 able, but even then only in case of imjiroper treatment. 
 
 XI. Tkeatment. 
 
 Moveable kidney does not require treatment corresponding- 
 to the ludicatio morbi, unless it is the ruling cause of the 
 morbid symptoms. To direct one's treatment against a 
 moveable kidney in a case of general disease due to consump- 
 tion or cancer, would be just as much beside the mark as to- 
 treat a moveable sarcomatous kidney on account of its 
 mobility. Attention must before all things be paid to the 
 causes of the moveable kidney. If they are of such a 
 nature as to act continually on the mobility of the kidney 
 (such as pendulous belly, or prolapse of the generative 
 organs), it will be useless to treat the moveable kidney alone. 
 Fortunately the ludicatio morbi often coincides with the 
 Indicatio causalis ; but in debating different methods it is 
 important to be clear from the first about the object to be 
 aimed at in each individual case, and about the end which it 
 is possible as well as desirable to attain by one method or
 
 3ot MOVEABLE KIDNEY IN WOMEN. 
 
 anotliei'; the more so as moveable kiduey gives rise to 
 different symptoms iu individual cases, oven under the same 
 aetiological and anatomical conditions. 
 
 As in displacements of the uterus and hernia), it must 
 here he our task to restore the kidney to its normal situation 
 and keep it there.^ 
 
 Ecj)osition is very easily affected in the horizontal decubitus 
 by moderate pressure after removing all tight articles of 
 clothing. In recent cases, especially such as have arisen 
 after acute injuries, horizontal decubitus persisted infer some 
 time, during which the kidney remains in its normal situation, 
 may be sufficient to produce a cure. 
 
 The maintenance of a moveable kidney in its normal posi- 
 tion is however extremely difficult. To effect this object a 
 number of the most complicated orthopaedic appliances, 
 bandages, renal trusses, &c., have been pi'oposed and tried. 
 The most inconvenient are those which depend for their 
 support on the soft abdominal walls alone, for they are 
 constantly shifting, and, to start with, do not admit of a 
 mode o£ fixation similar to the ordinary trusses for keeping 
 up the bowels. Better than these are the bandages to fasten 
 on the thorax and provided with a pad, Avhich exert leverage 
 for the most part on the spot occupied by the kidney in the 
 erect position. Gueneau de Mussij has described an angular 
 pad for this purpose, the lower and horizontal arm of which 
 is intended to support the displaced kidney, and the perpen- 
 dicular arm to prevent its moving in an inward direction. 
 All these pains however to maintain the replaced kidney in 
 its position must remain fruitless, for the kidney is covered 
 by the bowels, and is exposed to no pressure from the pad 
 when the pressure is moderately strong, while an increase of 
 pressure will drive it away from the pad. These appliances 
 therefore, being useless and much more apt to cause pain 
 and discomfort than their relief, are soon discarded by the 
 patients of their own accord. 
 
 On account of the incompetence of mechanical appliances 
 to fix a moveable kidney in its position, it has been quite 
 recently proposed to fasten the kidney hy operation, namely 
 
 ' This association between moveable kidney, hernia, and descent of the 
 uterus will be mentioned further on, see p. 357. — Teanslatoh.
 
 MOVEABLE KIDNEY IN WOMEN. 335 
 
 by sewing it to the abdominal walls (1S3). Favourable 
 results however from this proceeding, based as it is on 
 incorrect anatomical and pathological ideas, is not to be 
 expected. If an attempt were made (as by Hahn) to make 
 an incision in the lumbar region and get the kidney to heal 
 in it, this proceeding would displace the kidney, whose normal 
 situation is higher and more lateral than the lumbar incision. 
 But if an attempt is made to sew the kidney into its normal 
 situation, it would be necessary to resect one or two ribs, or 
 insei't sutures at random into the last intercostal space 
 through the muscles and the kidney. In either case one 
 would expect to open the pleural cavity and to puncture 
 important vessels and nerves. But even after the sewing 
 has been safely accomplished, a cure of the moveable kidney 
 is not to be expected, for we have not two serous surfaces, 
 capable of mutual adhesion, to deal with, and the causes of 
 the mobility of the kidney are of course not removed by 
 sewing. 
 
 All these experiments, unpromising and dangerous as they 
 would seem a priori, can however be abandoned, as it is not 
 necessary, in order to remove the discomforts caused by 
 moveable kidney, to fix it in its normal situation ; but just 
 as in the case of retroflexion of the uterus it is generally 
 sufficient to keep it as immoveable as possible. With this 
 view we must act indirectly on the kidney by fixation of the 
 abdominal walls and viscera, since it is impossible to act 
 directly upon it. This is best accomplished by a comfortable 
 and firm binder encircling the whole abdomen. If the 
 kidneys are only prevented from constant movements down- 
 wards and inwards, and from rotation on their axes, the 
 discomforts caused by di'agging of the nerves and vessels as 
 well as by pressure, cease. It is of course difficult to produce 
 general immobility of the abdominal contents and walls by a 
 binder, because the size and shape of the abdomen vary not 
 only in different individuals, but even in the same person, 
 during breathing, and with different postures, movements, &c. 
 Even binders accurately made to the measures of the abdomen 
 do not therefore fulfil the desired end, for they ride up as 
 the patient walks, and leave the lower half of the abdomen 
 free for the descent of the abdominal contents, or they exert
 
 336 MOVEABLE KIDNEY IN WOMEN. 
 
 an unbearable pressure over the region of tlie stomach bj 
 their upper circuit. 
 
 The material and shape of the binder must therefore be 
 varied in the most manifold ways according to the condition 
 and occupation of the individual. Elastic binders of india- 
 rubber are least of all to be commended, as they produce the 
 greatest pressure and also retain the perspiration. Ticking 
 is better in summer, flannel in winter, with lengths of some 
 elastic material let in. Further, it may be convenient to 
 prevent the abdominal binder from riding up by means of a 
 T bandage or perineal bands (Schenkelbändei'), and to fix it 
 by braces to the shoulders. I have never seen any special 
 good from padding the binder over the situation of the dis- 
 placed kidney. It is preferable to let in a thin concave tin 
 shield over this spot, as I have often tried Avith success. 
 
 All these binders are however uncomfortable for many 
 reasons, and I have therefore tried to find a material which is 
 more or less capable of forming an artificial abdominal %vall 
 by itself. My experiments with poroplastic felt, thin tin and 
 whalebones let into the front surface of the binder have not 
 however been very successful, but I have been led by these 
 experiments to an appliance, w^hich, modified to suit our 
 purpose, is capable of almost completely fixing the abdominal 
 walls and with them the moveable kidney — namely, the 
 much abused stays, the use of Avhich is at once shown by the 
 support it gives to the breasts and the defence it afl^ords to 
 the abdomen from the pressure of the strings of the garments. 
 I have obviated the disadvantage of the usual short stays 
 reaching about to the navel, which compress the upper part of 
 the abdomen and allow the lower part to bulge, by having 
 the longer stays lately come into fashion lengthened as far 
 as the pubes and both Poupart's ligaments. Shaped thus, 
 they cover the whole abdomen, they exercise an equable 
 pressure on the abdominal contents, without being tightly 
 laced, and (unlike all forms of abdominal binders) taking 
 their support from the bony thorax, they are not displace- 
 able. 
 
 There are few women, mostly those whose bellies are very 
 pendulous, or who suffer from violent epigastric pains, who 
 cannot bear these stays. Women again who have sedentary
 
 MOVEABLE KIDNEY IN WOMEN. 337 
 
 occupations cannot wear them unless the lower end of the 
 middle piece^ the so-called busk (Blanchette) is well padded, 
 or, as I have tried, arranged to fold up. But in most cases 
 these long stays act extremely well. The favourable effect 
 of this artificial abdominal wall consists not only in 
 rendering the abdominal contents immoveable, but at the 
 same time in the temporary removal of one of the fundamental 
 causes of moveable kidney, pendulous belly, for the radical 
 treatment of which we possess no method.^ 
 
 The abdominal muscles, which are generally loose in cases 
 of moveable kidney and pendulous belly, must however be 
 also directly strengthened. To this end the use of cold in 
 the form of cold compresses and douches, or sensible 
 hydropathic treatment or sea bathing, or lastly electrical 
 treatment of the abdominal muscles by the induced current, 
 are to be recommended. 
 
 Methodical shampooing of the abdomen again appears benefi- 
 cial in many ways in the treatment of moveable kidney ; in the 
 first place it strengthens the abdominal muscles, in the second 
 place it is capable of removing constipation with its peculiai'ly 
 evil consequences, by exciting the peristaltic movements of 
 the intestines, and in certain cases by direct mechanical de- 
 pression of the fasces (184). 
 
 By the combined use of the above methods remarkably 
 good results are often obtained. A stay of several weeks at 
 
 ' The above considerations on the very important subject of stays lead us 
 back to the question of the intra-abdominal pressure. Moveable kidney 
 seems to be a member of the Hernial Group (including Hernia, Pendulous 
 Belly, and Descent of the Pelvic Organs, including, probably backward dis- 
 placements of the womb even where descent is not well-marked. Prolapsus 
 Ani, &c.), one of the characteristics of which is the relative increase of the 
 intra-abdominal pressure (relative that is to the resistance afforded by the 
 supports). We need not again discuss the question of increased buoyancy 
 of the kidney by increase of the intra-abdominal pressure, which seems not 
 to be the main question. But increase of pressure by stays will increase 
 the intra-abdominal pressure, and will almost certainly tend to increase the 
 descent of a hernia, of the pelvic organs, or of the rectum, all of which 
 must be considered together. It is quite likely that the stays will tend to 
 fix the viscera, but they ai-e at best only palliative appliances, and it must 
 not be forgotten that by increasing the intra-abdominal pressure they come 
 under the class of palliatives which increase the original morbid state. — 
 TEANSIiATOB. 
 
 22
 
 338 MOVEABLE KIDNEY IN WOMEN. 
 
 sea-bathing places or hydi'opathic establislimeuts, in wliicli 
 sliampooing and electricity can be applied by skilled hands 
 is therefore advisable for patients afflicted with moveable 
 kidney and pendulous belly. 
 
 It is obvious that associated maladies^ such as chlorosis^ 
 angemia, chronic catarrh of the stomach and intestines, as 
 well as descent and flexions of the uterus require special 
 treatment, and that in the case of serious general diseases 
 treatment which gives exclusive attention to the moveable 
 kidney is inadmissible. 
 
 An entirely different method has been lately recommended 
 for the treatment of moveable kidney ; this will be discussed 
 in the following section. 
 
 On the removal of JJncom])licatcd Moveable Kidney. 
 
 After Kep'pler's (185) assertion, that "Moveable kidney as 
 such, even without any complications at all, should be removed 
 by excision through the abdomen, as soon as it causes any 
 disturbances in the system, ''and in accordance with this advice, 
 — up to the end of 1880 six healthy moveable kidneys have 
 been removed, four of them by Martin (186), with two deaths, 
 once by Smyth (187), and once by MerJcel, in whose case the 
 result was fatal. Thus of six persons three died. 
 
 The excision of a healthy moveable kidney, however, is in 
 every sense unjustifiable. We possess milder mechanical 
 and therapeutical means of alleviating the discomforts of a 
 patient with moveable kidney, nay even of removing them 
 entirely, as is shown by numerous observations of the most 
 trustworthy writers. Reasons again for the extirpation of 
 an organ so important for the human economy as the healthy 
 kidney have neither been produced, nor indeed do they exist. 
 There neither exists an accepted case in which death has 
 been caused by moveable kidney, nor are the cases brought 
 forward by Kcp2^ler as proof of its injurious influence un- 
 equivocal or conclusive. The fact that patients whose 
 healthy moveable kidneys have been removed felt well im- 
 mediately after the operation, and suffered no inconvenience 
 from the moveable kidney, can only astonish and enlist on
 
 MOVEAELB KIDNEY IN WOMEN. 339 
 
 the side of tlie operation a man who would think it remark- 
 able that a woman, whose healthy ovaries and hoaltLy uterus 
 have been removed, ceases to suffer from uterine ha)mor- 
 rliages. 
 
 It requires no demonstration that an operation, however 
 brilliant, does not seem to be indicated for its own sake, but 
 only when it restores the patient to health. From this point 
 of view the amputation of a normal cervix uteri or the removal 
 of normal ovaries, which perhaps give rise to tlysmenorrhoea 
 or other slight ailments, is not to be endorsed ; how much 
 more blameworthy does the extirpation of an organ, so im- 
 portant to life as the kidney seem to be ! 
 
 What should we say of the recommendation to amputate 
 a log for sciatica or varicose ulcers, a recommendation which 
 stands on the same footing as that here given — to I'emove 
 the kidney ? 
 
 Besides it is certain that if the operation is undertaken 
 on the above indications, some of the patients will die from 
 the operation itself (septicsemia, haamorrhage, &c.). More- 
 over, putting these accidents aside, a fatal issue is certain 
 if (as in Merker's case), after the moveable kidney has been 
 removed, the other, in a state of fatty degeneration, is no 
 longer capable of vicariously supplying the function of the one 
 removed ; or if (as in a case of Lange' s) the other kidney is 
 hydronephrotic and so the occurrence of urcemia is inevitable. 
 It ought also not to be forgotten, in considering the recom- 
 mendation to remove healthy moveable kidneys, that cases 
 in which there is only one kidney are by no means rare. 
 Even Willis (i88) collected thirty-six such cases out of the 
 literature of the subject, Beumer (i8g) forty-eight. There 
 is however no means of diagnosing the absence of one 
 kidney without opening the abdomen. Thus in many cases 
 the operation in question will be the direct cause of death. 
 
 But the life even of those patients who survive the 
 operation will be shortened if the other kidney, although 
 present, is attacked by certain diseases, such as stone, hydro- 
 nephrosis, Bright's disease, — complaints which, in the presence 
 of a second kidney to supply vicariously the fuiiction of the 
 first, are by no means fatal. It is no accident that calculous 
 affections are especially frequent in cases in which only one
 
 340 MOVEABLE KIDNEY IN WOMEN. 
 
 kidney is functionally active. Lastly, it is not a matter of 
 indifference — even in the case of other diseases which (apart 
 from the weakness of old age) finally befall every human 
 being — whether one or two kidneys provide for the secretion 
 and excretion of the urine. Although under physiological 
 conditions one kidney takes up the function of the other, 
 hypertrophies, and so on, it appears very doubtful whether 
 in case of affections of the heart, lungs and liver, one kidney 
 is enough to discharge the renal functions in the presence 
 of the disorders of elimination present under these conditions 
 and to replace the other. Certainly the chances of the main- 
 tenance of life are less in persons with one kidney than with 
 two ; how much more when the second kidney also is or 
 becomes moveable. 
 
 All these dangers must be faced by the physician who 
 advises so serious an operation, even although the chances, as 
 far as the operation is concerned, are of the most favourable 
 kind in the present state of surgery. The rage for operation 
 is far more dangerous in its consequences when it concerns 
 the kidneys than when it concerns the cervix uteri and 
 ovaries which are not necessary for the maintenance of life. 
 The hypochondriacal frame of mind and the Avisli of the 
 patients to get thoroughly rid of a malady which they 
 regard as malignant, ought not to decide the physician to 
 undertake, for the sake of an exploit which imposes on the 
 laity, an operation which endangers and shortens life. Un- 
 fortunately, nephrectomy which frequently saves life in cases 
 of abscess, stone in the kidney, &c., is only discredited by 
 such proceedings. 
 
 Treatment of the Gomjilications. 
 
 Special consideration is required with regard to the 
 treatment of the symptoms of incarceration so-called. 
 The importance of a correct estimation of the pathogenesis 
 of this train of symptoms is here very plain. If these 
 symptoms were due to the actual incarceration of tlie 
 kidney, it would be our duly to try and replace the
 
 MOVEABLE KIDXKV IN WOMEN, 341 
 
 Iciduey l^y every possiljlc means, at any stage of tlie com- 
 plaint. As in tlie case of strangulated hernia, the in- 
 flammatory and other concomitant symptoms would dis- 
 appear after reduction. But experience shows us that 
 forcible attempts at reduction are useless, and that the 
 complaint usually ends favourably without them. We should 
 therefore lay well to heart the advice of Rollet (190), which 
 is contrary to the ordinary views of the nature of this affection. 
 Rollet says we should pu.t off the reduction of the kidney 
 '^ until the inflammatory symptoms have yielded to anti- 
 phlogistic measures, which, as experience shows us, generally 
 happens in a few days." Indeed reduction is usually contra- 
 indicated by the condition of the kidney itself, which swells 
 in a very short time, and in some cases in a few hours, to 
 double its size, and therefore is too big for its old situation. 
 But when, some days later, the inflammatory symptoms have 
 subsided, all attempts to replace the kidney become at once 
 superfluous. For the cure of the kink, twist and subsequent 
 thrombosis of the renal vein proceeds spontaneously, either 
 by the establishment of a collateral circulation, or by organi- 
 sation of the clot, or by the undoing of the kink or twist in 
 the vein, without any interference, if the patient is kept on 
 her back. 
 
 If it is however decided to attempt reduction, the attempt 
 should be made in the first few hours of the attack, with the 
 greatest precautions, if possible, in a wai^m bath and under 
 chloroform, especially as we can never know whether the 
 renal vein is already thrombosed, and, if so, how far. Finally, 
 a purely expectative treatment and the avoidance of further 
 injurious influences are advisable. It is proper to assuage 
 pain by opium and warm baths according to the symptoms ; 
 if inflammatory symptoms become prominent, it is sufiicient 
 to apply an ice-bag over the prolapsed kidney. It is also 
 advisable — not so much with a view to mitigating the inflam- 
 matory symptoms as to relieving the engorged kidney — 
 if the swelling becomes intense, to apjoly several (six to ten) 
 leeches to the renal region. 
 
 This expectative treatment must however be at once 
 abandoned, as soon as symptoms of a perinejyhritic or para- 
 nejoltritic abscess manifest themselves ; but this will be seldom..
 
 342 MOVEABLE KIDNEY IN WOJTEN. 
 
 Free incisions in the region of tlie abscess, and even tlie- 
 removal of the kidney are in this case, and this case alone 
 indicated. This event is happily so rare, that I have not 
 succeeded in finding a single case in point in recent litera- 
 ture. 
 
 Treatment of HydroncpJirosis in a Moveable Kidney. 
 
 Although Hydronephrosis in a moveable kidney shows its- 
 characteristic intermissions from a clinical jDoint of view, we 
 can wait quietly till it has become stationary. But even then 
 nothing but the general treatment of hydronephrosis is 
 appi'opriate ; and indeed only two methods deserve considera- 
 tion, namely, total extirpatum of the sac, and estallishmoit of 
 an ahdominal fstnla from the 2^Gh"i^'< of the Iddney. 
 
 Kroner's {191) list shows that the whole sac has heen 
 extirpated eight times up to the present date ; of these 
 operations four were performed unintentionally by mistake 
 for an ovarian tumour; four were fatal. I wnll not discuss 
 the performance of the 02:)eration, nor the special question 
 whether the entire sac should be removed through an 
 abdominal or lumbar incision, especially as the last interesting 
 question has been exhaustively discussed by Barlcer (192) 
 and Czerny (193). We should be particularly careful in 
 dealing Avith the pedicle, on account of the frequent abnor- 
 malities of the renal vessels, especially the vein, and on 
 account of an eventual thrombosis of the renal vein. As 
 in the case of tying the navel-string in new-born children a 
 clot may be pressed through the ductus venosus (Arantii) 
 (194), so here the same cause may force a clot in the renal 
 vein also into the vena cava. Thus, in a case of Barlcer's,. 
 embolism of the pulmonary artery was found after the' 
 unfortunate removal of a sarcomatous moveable kidney- 
 The renal vein was found cut across close by the vena cava; it 
 was not observed either on dissection or during the operation ;. 
 there had been haematuria during life, so that it does not 
 seem to me impossible that death Avas caused in this case by 
 a clot in the renal vein, as described above. 
 
 The prognosis of the second method of cui-c now under
 
 MOVEABLE KIDNEY IN WOMEN. 343 
 
 consideration, namely, tlio cstahlü-hment of an ah dominal fistula 
 from the 'pelvis of the Icidney, as recommended by Simon, 
 is far more favourable. All the cases liitlierto treated in 
 tliis way, by Ahlfeld, Pernice, and Landau ended favourably. 
 The evacuation of the urine through the fistula in no way 
 interfered with the occupations of the patients, and the site 
 of the fistula, as my case (see Fig. 9) shows, was situated 
 most favourably for the escape of the urine. 
 
 With regard to the mode of operating, it is advisable to 
 operate at one sitting, as has already been often done after a 
 wrong diagnosis has been made^ and as I have done inten- 
 tionally. In this case, as in that of abdominal hydatids (195) 
 and of extra-uterine pregnancy (196), I consider that my 
 plan of stitching the sac of the hydronephrosis (to the 
 abdominal wall) before opening it (as against Kroner's plan) 
 offers decided advantages ; for the contents of the sac, which 
 may be mixed with pus, the products of decomposition, and 
 colloid masses, are not harmless to the peritoneal cavity. It 
 appears however highly disadvantageous to operate at two 
 or more sittings ; of such methods, Simon's method by 
 puncture is certainly the best. 
 
 The question whether, after an abdominal fistula has been 
 successfully established in connection Avith the pelvis of the 
 kidney, Simon's proposal of passing a probe along the ureter 
 from the bladder or from the wound, in order to make it 
 pervious again, and then closing the abdominal woiind 
 should be adopted, has still to be discussed. But attempts 
 to effect this offer little prospect of success, as dissections of 
 hydronephroses show ; and even if they were to succeed, the 
 reappearance of the old hydronephrotic condition might be 
 anticipated, so that it seems better to put this opei'ation 
 entirely aside. 
 
 An attempt might also be made to destroy the remains of 
 the kidney which still secreted urine, by caustics, the actual 
 cautery, &c ; but this is painful, and (as Simon's attempts, 
 in such a case which lasted for months, show) it is hardly 
 possible. In this case we should still have to perform 
 extirpation of the remains of the kidney by a subsequent 
 operation, which could have been done in the course of the 
 first operation. But this also seems to me unjustifiable, for
 
 344 MOVEABLE KIDNEY IN WOMEN. 
 
 extirpation is a dangerous operation, and tlie presence o£ 
 kidney tissue wliicli is still licaltliy;, able to discharge its 
 functions, and cannot be replaced, is licre of the greater 
 value, since the risk of the affection of the other kidney (as 
 autopsies on cases of uioveablo kidney show) is increased. 
 
 In debating the question whether one should decide once 
 for all to extirpate the whole sac, or to establish a fistula, 
 «part from the above considerations, individual circumstances 
 must be considered, such as the ago and occupation of the 
 patient, the presence of still active kidney tissue, and the 
 state of the other kidney. Other things being equal, I 
 would not myself decide on extirpation, even if it were no 
 more dangerous than the establishment of a fistula. Experi- 
 ence shows that after the establishment of a fistula, the 
 flattened renal papilla), now freed from pressure, recover 
 themselves and secrete urine nearly normal in quantity and 
 quality, so that by this operation the patient regains at once 
 the use of a kidney which had been rendered useless. 
 
 XII. Original Observations. 
 
 (i) Moveable Kidney on the right side, Pendtdoics Belly, 
 urinary troiihlcs. 
 
 CI. St — , 44 years of ago, has had ii children in 12 years, 
 the last seven years previously. She complains of violent pain 
 and a swelling in the right side, the removal of which had 
 been advised on the ground of its malignant nature. She 
 suffers from frequent calls to pass water, pains in the loin, 
 &c. After using a long pair of stays the patient feels quite 
 well, for the tumour is nothing but a moveable kidney. 
 
 (2) Movcahlc Kidney on the rigJii side, Pendulous Belly. 
 
 D. Kr — , 32 years of age, has had 7 children and 2 mis- 
 carriages. She is to undergo an operation for an abdominal 
 tumour. She is a strong buxom woman with very little dis-
 
 MOVEABLE KIDNEY IN WOMEN. 345 
 
 coiufortj and notliiiig- amiss except a moveable kidney on tlie 
 right side and a lai'ge pendulous belly. She gets on very 
 well with an abdominal belt and witliout an operation. 
 
 (3) Movoahlc Kidney on the rujht side, Pendulous Belly after 
 
 ovariotomy. 
 
 N. S — , 47 years of age, no children, observed an abdominal 
 tumour when only 19 years old; this has constantly increased 
 for the following 24 years. When taken in to my clinique 
 tlie cii'cumference of tlie abdomen was 108 centimetres. 
 After the removal of a multilocular ovarian tumour the 
 patient at first felt very well, but a ventral hernia formed, 
 and, together with lax shrivelled abdominal walls, contributed 
 to form a pendulous belly. Since then she has complained 
 of feeling as if she had something alive in her abdomen. 
 Examination shows a moveable kidney on the right side. 
 
 (4) Moveable Kidney on tlie rigid side. Sensation of a foreign 
 body in the abdomen, increased inconvenience during men- 
 struation. 
 
 Fran A. H — , 34 years of age, has had several children in a 
 short time. Since her last confinement (two years ago) she 
 says she has worked very hard and in doing so has strained 
 herself. She has never worn stays. Whenever she stands 
 she suffers violent dragging pain in the abdomen. Her 
 feelings, according to her own account, are " as if something 
 had been unhooked in her abdomen, or as if all her inside were 
 falling out. Now and then as if a heavy body turned round in 
 her belly." If she lifts her right arm up she has a peculiarly 
 unpleasant sensation, '' as if all her side was falling away.'^ 
 All her troubles are worse during her menstruation (which is 
 regular) and during work. Also she has frequent calls to pass 
 water, and has not been able to lie on the side for two years. 
 
 I found an unusually moveable kidney on the right side. 
 On moving this to and fro the same unpleasant sensations
 
 346 , MOVEABLE KIDNEY IN WOMEN. 
 
 were produced as tliose wliicli the woman complained of. 
 The generative organs were normal except that the uterus 
 was low down. 
 
 The account of this woman, who was considered hysterical, 
 is all the more valuable from the fact that neither she her- 
 self nor the doctors who had treated her had detected an 
 abdominal tumour. 
 
 (5) Moveable Kidney on the right side, symptoms of incar- 
 ceration, adhesions to the liver, jaundice. 
 
 J. W — , 55 years of age, has had 4 children, last menstrua- 
 tion nine years ago. After the last confinement, sixteen years 
 ago, the patient observed a lump in the right hypochondriuui, 
 which was at first very moveable. For some years she has 
 suffered from a peculiar boring and pinching pain deep down 
 in the abdomen. Two days ago she was suddenly seized 
 with retching and a darting pain in the abdomen especially 
 on the right side, and became much collapsed. The abdomen 
 is much distended and painful even on the slightest touch. 
 Percussion is dull from just below the liver to the level of the 
 iliac crest. Palpation is impossible ou account of abdominal 
 tenderness. Improvement soon followed the use of opiates 
 and ice poultices. It was some weeks before the kidney 
 could be felt, easily displaccable into the lumbar region. 
 On pressing this kidney the patient complains of a circum- 
 scribed pain in the^ left side of the epigastrium and the left 
 loin. The dulness below the liver has quite disappeared. 
 A year later, examination showed the right kidney no longer 
 so moveable as before ; on pressure it can be replaced into 
 the lumbar region, but on relaxing the pressure it soon 
 reappears, even in the horizontal posture, below the right 
 lobe of the liver. 
 
 Two years after the first acute attack Frau W — had a fresh 
 attack of violent pain in the abdomen, which again became 
 very tender and distended, the tumour below the liver 
 
 • The fact of pain on the opj)Osite side to the kidney affected (see Cases 5 
 and 7) must be remarked. A similar ti-ansference of sensation is not very 
 rare in the case of the ovaries. — Tkanslatoe.
 
 MOVEABI.E KIDXET IN WOMEN. 347 
 
 considerably increased, but little moveable, the kidney sliape 
 recognisable. After some days distinct jaundice appeai'ed, 
 and lasted some three Aveeks, accompanied by symptoms of 
 high fever which showed a distinctly intermittent type ; the 
 spleen was very large. The fever only yielded to large 
 doses of quinine, so that I do not hesitate to consider this 
 an intercurrent attack of ague. How far the adhesion of the 
 kidney to the right lobe of the livei", which had meanwhile 
 taken place, contributed to the janndice, I will not decide. 
 At the present time the patient is quite well. 
 
 (6) Moveable Kidney on hotli sides, especially fJic left. 
 
 CI. V. S — , 30 years of age, has had no children, she has 
 menstruated regularly, and has lately lost much flesh, which 
 circumstance alone induces her to seek medical aid. On 
 examination on April 23, 1881, I discovered both kidneys 
 very moveable, especially the left, the uterus retroflexed ; 
 nothing else. There was no discoverable cause for the 
 moveable kidney except the extreme and apparently rapid 
 emaciation. 
 
 (7) Moveable Kidney on both sides, right more than left. 
 
 M. St — , 25 years of age, had a child five years ago. 
 Complains of violent pain, especially in the left side of the 
 abdomen, in the last left intercostal space, and in both loins. 
 The urine is now and again scanty and dark, during which 
 time the patient feels worse. She also complains of an 
 increase in all her symptoms at every monthly period. Both, 
 kidneys moveable, the right more than the left. Pressure 
 on the right kidney causes pain in the left side. Moderate 
 pendulous belly, moderate amount of subcutaneous fat. No 
 other cause than the habit of carrying a heavy coal-box on 
 the hips, as the patient has done for years, can bo found.
 
 34-8 MOVEABLE KIDNEY IN WOMEN. 
 
 (S) InfermUtent Hydroncj^hrof^i s in a Moveable. Kidney on the 
 riciht side. Perinejjliritic abscess, estabUsJi.ment of an 
 abdominal fistula from lite iielvis of the hidiiey at one 
 sitting. Cure. 
 
 C. M — , 60 years of age, lias liad 2 childrcu, born respec- 
 tively forty and tliirty-six years ago. After the last confine- 
 ment the generative organs became prolapsed. For about 
 the last ten years she has suffered from paiu in the sacrum, 
 constant abdominal discomfort, epigastric pain, gastric troubles, 
 dragging and pain in the loins and pressure in the region of 
 the bladder. Eight years ago she observed for the first time a 
 moveable tumour in her abdomen, which however disappeared 
 from time to time, and was variously regarded by the different 
 physicians under whose care she was, as a hydatid of the- 
 omentum, an ovarian tumour, and as a tumour of the liver. 
 On September 14, 187g, the patient came to my out-patient 
 room. 
 
 Present condition. — A pale emaciated woman with prolapse 
 of the anterior vaginal wall and uterus. In the right hypo- 
 chondriac and epigastric regions is a tensely elastic globular 
 tumour, passing almost imperceptibly into the liver above, 
 and reaching internally almost to the linea alba, externally 
 almost to the axillary line, and inferiorly some three centi- 
 metres below the level of the navel. The tumour is freely 
 moveable, especially inwards and downwards. On depressing 
 the tumour downwards, a sulcus is remarked between it and 
 the liver. The percussion note over it is dully tympanitic, 
 and quite dull only on the summit of the convexity ; in the 
 axillary line it is impaired. 
 
 Aspiration with Diculofoy's finest needle (which withdrew 
 about three cubic centimetres) proved the contents of the 
 tumour to be a limpid fluid, white even to transmitted light, 
 clear, destitute of formed elements, non-albuminous, and 
 containing abundance of chlorides.^ 
 
 It could therefore be only a hydatid of the liver or kidney, 
 or a hydronephrosis in a moveable kidney. After repeated 
 examination in different postures on September 20th, 187g, 
 ' Specific gravity? — Tuanslator.
 
 MOVEABLE KIDNEY IN WOMEN. 31D 
 
 and after withdrawing about tliree cubic centimetres of fluid 
 by a second aspiration, the operation was fixed for the fol- 
 lowing* day. On the next day however the tumour had 
 disappeared, and percussion showed the presence of intestine 
 in its place. Deep j^alpation failed to detect any firm body, 
 even on pressing deeply beneath the right arch of the ribs. 
 On inquiry, the patient — who felt comparatively well — declared 
 that after the examination of the previous day she had passed 
 an unusually large quantity o£ limpid and clear urine, an 
 occurrence by no means unusual with her, for the quantity 
 of urine was constantly varying. The urine itself was 
 normal. 
 
 It was still doubtful whether the fluid from the cyst had 
 escaped by the fine puncture of the sac into the peritoueum 
 or had been passed iicr vias naturales. In the former case, 
 the diagnosis would remain doubtful, in the latter it would 
 certainly be hydronephrosis. It was possible that the kinked 
 or twisted ureter might have untwisted itself by rotation of 
 the sac in consequence of examinations in the very various 
 postures which had been adopted ; or it was possible that 
 the diminution of pressure in the sac in consequence of 
 puncture might have removed a valvular impediment. 
 
 For the first few weeks however the diagnosis remained 
 doubtful, for the urticaria characteristic of hydatid did not 
 appear, and the tumour did not return. It was not until 
 February, 1880, that the patient came back complaining of 
 unbearable pressure in the abdomen, and presented much 
 the same appearances as on the first examination. The 
 diagnosis of hydronephrosis was now sure, and was moreover 
 confirmed by a careful chemical examination of the fluid which 
 was now withdrawn in somewhat greater quantity. The 
 report on the result of this examination kindly made by 
 Priv.-Doc. Dr. Leivin is as follows : — " The fluid was slightly 
 turbid and its reaction, as far as could be determined by 
 gaslight, faintly alkaline. The turbidity disappeared on the 
 addition of nitric acid. This circumstance shows the turbidity 
 to be due to the presence of phosphates. No ui'ic acid 
 crystals can be found, and the proof of the presence of uric 
 acid by the murexide test remains doubtful on account of its 
 being conducted by (artificial) light. Urea, on the other
 
 ooO MOVEABLE KIDNEY IN WOMEN. 
 
 hand, is proved to be present ; for after eliminating the 
 phosphates, the addition of nitrate of mercury to the fluid 
 gave a white precipitate of hydrargyrate of urea. The proof 
 of the presence of urea by converting it into nitrate of urea 
 succeeds even better ; for on leaving the fluid treated with 
 nitric acid to spontaneous evaporation, characteristic rhombic 
 crystals of nitrate of urea lying over one another like tiles on 
 a roof, separated out." 
 
 I was able to observe the refilling and emptying of the 
 cyst four times more, each time with the above described 
 symptoms connected with excretion of the urine. At last 
 however the sac did not disappear, the general health visibly 
 declined, a course of Carlsbad failed to improve the gastric 
 symptoms, continued pyrexia ensued, the aspirated fluid, which 
 was formerly clear and destitute of formed elements, contained 
 many pus corpuscles, so that I could no longer delay the 
 operation. Meanwhile the tumour had increased, and had 
 become very tense, and very tender to the slightest touch. 
 
 On June 20th, 1880, I operated, making my incision from 
 the angle of the right costal arch, more or less parallel to the 
 fibres of the internal'^ oblique muscle, towards the navel, and 
 about twelve centimetres long ; a fleshy-looking cyst-wall 
 appeared. As the excessive tension of the tumour prevented 
 its being grasped, it was punctured with a fine needle and 
 some 300 cubic centimetres of very purulent fluid drawn off, 
 the incision was then prolonged for some three centimetres 
 towards the axillary line, after which it became possible to 
 get round the tumour in all directions. It was found to be 
 bounded above by the liver, internally and in part anteriorly 
 by the intestines, externally by a second tumour reaching to 
 the vertebral column, Avhich proved on puncture to be a 
 perinephritic abscess with thicker, more tenacious and more 
 jnirulent contents than those of the hydroncphrotic sac. The 
 idea of the entire removal of the sac was therefore given up 
 on account of this perinephritic abscess, and the cyst-wall 
 was stitched to the abdominal wall on both sides of the 
 
 ' In tlic above soiilcnco the word " internal " appears to be a mistake for 
 '• external." Tlie filires of tlie extornal oblique run downwards and inwards 
 those of the internal oblique in this region downwards and ouhoards. — 
 Tbanslatob.
 
 MOVEABLE KIDNEY IN WOMEN. 351 
 
 wounds beginning from tlie innei* angle of the wound, the 
 sutures thus running at riglit angles to tlie directiou of the 
 incision. The peritoneal cavity was tlius protected from the 
 escape into it of purulent fluid, a circumstance which proved 
 very useful in the sequel, for in an endeavour to lift the 
 tumour a little forward by grasping the posterior surface, 
 the wall of the perinephritic abscess tore, and a copious dis- 
 charge of pus took place. The sac therefore, stitched to 
 the abdominal wall in its entire length, Avas cut through in 
 the direction of the first incision, and united with the peri- 
 nephritic abscess by incision of the partition between them 
 formed of atrophic kidney tissue, in order to establish a 
 single Avound cavity. The part of the hydronepbrotic sac 
 lying in apposition w^ith the anterior abdominal wall does 
 not consist, as usual, of the wall of the pelvis of the kidney, 
 but of genuine kidney substance, flattened by pressure and 
 atrophied. This bled freely on incision and was tied eu masse. 
 The fluid evacuated was highly purulent, its hydronephrotic 
 I'eceptacle larger than a child's head, everywhere studded 
 with flattened and atrophied portions of kidney. The open- 
 ing of the ureter could neither be seen nor found by a probe. 
 
 The sac was now further secui'ed by several (12) sutures 
 and the cavity drained. The subsequent course of the case 
 pi'esented nothing remarkable. On July 19th the whole wound 
 Avas closed with the exception of an opening at its inner angle, 
 as big as a finger. In this an india-rubber tube was left, 
 passing easily some fourteen centimetres into the cavity, and 
 allowing an easy escape to the urine which was at first scanty, 
 but gradually became more and more copious, and also 
 permitting the cavity to be washed out. The fluid, which 
 was at first purulent, became more and more clear and 
 urinous, the sac contracted towards its centre, the renal 
 papillae which Avere flat and atrophic became more and more 
 compact and hypertrophied. The ligatures on the renal 
 substance did not come away for three and a half months. 
 A renal papilla Avas seen to bo slightly everted through the 
 inner angle of the wound. 
 
 A portable urinal was not well borne, and was moreover 
 superfluous, for the patient was by no means impeded from 
 leading her ordinary life and pursuing her ordinary occupa-
 
 352 
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 tions witli a simple linen bandage^ and a simple drainage- 
 tube in the inner angle of the wound. The appended 
 drawing, taken after the expiration of a year_, shows the scar 
 
 Fio. 9. 
 
 Fistulous opening in tlic abdominal wail from the pelvis of tlie kidney. 
 
 to have contracted, but otherwise to have undergone but 
 little change in relation to the wound. The fistulous 
 opening which remains, situated at the inner angle of the 
 wound, is only about one centimetre in diameter. 
 
 (9) Peculiar conoiection between Moveable Kidney and Hydro- 
 nephrosis {Egery. 
 
 Frau M — , 29 years of age, had been deli veiled of a son 
 ten years previously. Nine months later she began to feel a 
 slight gnawing pain in the left lumbar region, which dis- 
 appeared after a short period of recumbency, and during the 
 next few years returned but seldom and then always after 
 mental disturbance. Four years back she became pregnant 
 for the second time ; during the first two months the gnawing- 
 pain returned, and remained till sixteen weeks after her con- 
 finement. At this time she weaned her child on account of 
 
 1 I had the opportunity at Breslau of examinin;^ this case, wliich was 
 under Erjer's treatment, and was described in the ' Berl. klin. AVochenschr.,' 
 1876, No. 28.^AuTnoR.
 
 MOVEABLE KIDNEY IX WOMEN. 353 
 
 ana3mia. Shortly afterwards the pain in the left lumbar 
 region increased aud violent attacks developed, which did 
 not leave the patient for years, defied all treatment, and 
 persisted until Eger saw her for the first time on January 
 13, 1874. 
 
 She is a slender but muscular woman, with normal circula- 
 tory and respiratory organs, normal spleen and liver dulness. 
 The only striking thing about her is the absence of subcu- 
 taneous fat, antemia and the remarkable laxity of the 
 abdominal walls. The attacks alluded to were much alike ; 
 their mode of occurrence was that, independently of phy- 
 sical exertion, imprudent conduct, the monthly period, or 
 psychical disturbance, the patient is attacked while at work 
 by a pain in the left lumbar region, radiating to the inguinal 
 and umbilical regions, which is so violent as at once to 
 render her incapable of work. A rigor then occurs, followed 
 by violent vomiting of bile-stained mucus, with coldness and 
 pallor of the extremities, fainting fits, and deep depression 
 of spirits. The pulse is small, infrequent, no rise o£ tem- 
 perature. Immediately after the commencement of the pain, 
 a smooth, bean-shaped tumour, with its convexity directed 
 outwards and downwards quickly makes its appearance 
 beneath the left arch of the ribs in the umbilical and hypogas- 
 tric region, which at once feels like the kidney. Usually it is 
 closely apposed to the abdominal wall, but is nevertheless 
 overlaid by coils of intestine; it is always separated from 
 the hepatic and splenic dulness by wide areas containing 
 intestines. The tumour maintains the same size throughout 
 the attack, and is immoveable. Any attempt to displace it 
 is extremely painful and always unsuccessful. On one 
 solitary occasion the attempt to displace the tumour upwards 
 succeeded, though with enormous suffering, but the attack 
 ceased some hours earlier than usual. 
 
 Simultaneously with the appearance of the tumour, fre- 
 quent and very annoying desire to pass water set in, during 
 which only a few drops of clear and always non-alb timinoics 
 urine were voided. 
 
 A whole day usually, and often a day and night or longer, 
 elapsed before .the attack ended. The troubles were as 
 severe during the whole night as by day, every morsel of 
 
 23
 
 354 MOVEABLE KIDNEY IN WOMEN. 
 
 food and every drop of water swallowed wei'e vomited. Then 
 tlie pain ceased, usually all at once, and tlie tumour disap- 
 peared as rapidly as it came, witli eructations, vomiting, and 
 the passage of an increased thougli not considerable quantity 
 of urine, whicli was bright yellow, clear, and always non- 
 albuminous, and the health became perfect with the exception 
 of an easily intelligible weakness. 
 
 In this manner the attacks returned at intervals of fourteen to 
 twenty days, once they ceased for six weeks. An attempt to 
 prevent the descent of the kidney (which was the only imag- 
 inable condition) with a padded binder was unsuccessful. 
 Morphia alone afforded the patient constant, though only 
 slight relief. 
 
 Then, in July, 1874, the patient became pregnant again, 
 for the first time for three years. Instead of the relief hoped 
 for from the chance of the mechanical prevention of the 
 prolaj^se of the kidney, a considerable aggravation of the 
 symptoms ensued during the next few months. The attacks 
 became more violent and the intervals were often hardly as 
 long as a week. When at last the attacks seriously threatened 
 the general condition of the patient, they suddenly ceased 
 between the fourth and fifth months of pregnancy. The 
 patient became free from pain for the first time for tlii'ee years, 
 an occasional gnawing in the left inguinal region (which did 
 not amount to real pain) was the only reminiscence of the 
 terrors of the past. Pregnancy, and labour, which ensued 
 on March 12, 1875, ran their course without disturbance. 
 The uterus was however hardly quit of the child and after- 
 birth, before a tumour of the size of a small child's head 
 pushed itself forward without any pain, in the left side of the 
 hypogastrium, beneath the left arch of the ribs. It was 
 tense, elastic, iin*cgularly nodular, not tender on pressure, 
 and absolutely immoveable from its place. Entirely unlike a 
 kidney, it remained hardly half a centimetre from the linea 
 alba and usually had coils of intestine in front of it. The 
 percussion note over it was dull, or more or less tympanitic, 
 according to the position of the coils of intestine over it. It 
 Avas separated from the hepatic and splenic dulness by broad 
 bands of intestinal resonance. The uterus and its appendages 
 proved, on subsequent examination, to be entirely unconnected
 
 MOVEABLE KIDNEY IN WOMEN. 355 
 
 with it, and normal. The tumour, which gave the abdomen 
 a peculiar, irregular appearance, underwent during the time 
 of its persistence not the least diminution in size or consis- 
 tence. There was always an evacuation of a normal quantity 
 of non-albuminous and clear urine. 
 
 With the exception of an uncomfortable feeling of reple- 
 tion, the tumour gave the patient no trouble. On the I5tli 
 of May — eight weeks after her confinement — while the patient 
 was going to bed, she felt the size of the tumour diminish, 
 without any distui'bance of her general comfort. Next 
 moiming it had disappeared. The abdomen now remained 
 quite free from the tumour till May 28, on which day the 
 monthly period reapj^eared for the first time, with some slight 
 indisposition, and a feeling of weight in the lower abdomen, 
 but sleep was not especially disturbed by it. Next morning 
 a small tumour appeared in the old place, and within a few 
 hours reached the size of that which had been there before 
 the confinement. It behaved in all respects like the former 
 tumour, and remained till June 20, without any disturbance 
 of the secretion and excretion of the urine. On that day the 
 patient washed the room and staircase with bare feet. The 
 next night she experienced frequent desire to pass watei-, and 
 passed an enormous quantity of limpid urine. Next morn- 
 ing the tumour had vanished, and has remained invisible till 
 now (August). The patient, who resumed her work in the 
 manufactory soon after her confinement, has never felt so 
 well as now, her appearance is incomparably more healthy. 
 Her urine, which has been frequently examined, is normal 
 in quantity, always bright yellow, clear, free from albumen 
 and morphological constituents. 
 
 In the annexed table I have given a short resume of the 
 cases which I have observed up to April, 1881, and most of 
 which I have demonstrated in my courses for doctors in 
 practice and in my Lectures.
 
 356 
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 I. Moveable Kidney on the rigid side. 
 
 No. 
 
 Age. 
 
 Number of con- 
 finements. 
 
 Otlier ailments. 
 
 I. w. 
 
 36 
 
 9 
 
 Retroflexion of the uterus. 
 
 2. R. 
 
 32 
 
 7 
 
 Pendulous belly. 
 
 3F. 
 
 35 
 
 6 
 
 Pendulous belly. 
 
 4. R. 
 
 33 
 
 ? 
 
 
 5- B. 
 
 49 
 
 7 in 14 years 
 
 Prolapse of the anterior vaginal wall. 
 
 6. H. 
 
 47 
 
 12 
 
 Cancer of the womb. 
 
 7. R. 
 
 48 
 
 5 in 6 years 
 
 Retroflexion of the uterus. 
 
 8. D. 
 
 32 
 
 3 
 
 Pendulous belly. 
 
 9. E. 
 
 44 
 
 7 in 9 years 
 
 Right iuguinal hernia. 
 
 10. H. 
 
 34 
 
 4 
 
 Extremely pendulous belly. 
 
 II. M. 
 
 28 
 
 4 
 
 Penduloiis belly ; prolapsus of the uterus. 
 
 12. T. 
 
 32 
 
 6 in 74 years 
 
 Pendulous belly ; descent of the uterus. 
 
 13. St. 
 
 44 
 
 II in 1 2 years 
 
 Pendulous belly. 
 
 14. c. 
 
 24 
 
 
 
 Acute injury. 
 
 15. s. 
 
 47 
 
 
 
 Ovariotomy. 
 
 1 6. R. 
 
 30 
 
 8 in 7 years 
 
 Retroflexion of the uterus ; jaundice. 
 
 17. J. 
 
 35 
 
 6 in 12 years 
 
 Pregnancy ; ccdema of right leg. 
 
 18. W. 
 
 32 
 
 2 in I year 
 
 Pendulous belly ; symptoms of incarcera- 
 tion. 
 
 19. St. 
 
 34 
 
 4 in 5 years 
 
 Pendulous belly ; jaundice; gall-stones. 
 
 20. S. 
 
 30 
 
 7 
 
 Retroflexion of the uterus. 
 
 21. L. 
 
 58 
 
 8 in 14 years 
 
 Commencing cancer. 
 
 22. H. 
 
 34 
 
 8 
 
 Moi-phia habit. 
 
 23. H. 
 
 39 
 
 10 
 
 
 24. Z. 
 
 41 
 
 5 
 
 Right femoral hernia. 
 
 25. G. 
 
 38 
 
 3 
 
 
 26. G. 
 
 34 
 
 9 
 
 
 27. F. 
 
 41 
 
 2 
 
 
 28. C. 
 
 38 
 
 P 
 
 
 29. L. 
 
 51 
 
 ? 
 
 Retroflexion of the uterus. 
 
 30. L. 
 
 49 
 
 V 
 
 
 31. L. 
 
 52 
 
 ? 
 
 
 32. B. 
 
 60 
 
 ? 
 
 Cancer of the womb. 
 
 33- P- 
 
 44 
 
 P 
 
 
 34. G. 
 
 40 
 
 ? 
 
 
 
 35. R. 
 
 29 
 
 2 
 
 
 36. N. 
 
 68 
 
 P 
 
 
 37. R. 
 
 38 
 
 3 
 
 Descent of the uterus. 
 
 38. N. 
 
 34 
 
 2 
 
 
 39. w. 
 
 55 
 
 4 
 
 Adhesions to the lower border of the liver; 
 symptoms of incarceration; jaundice. 
 
 40. M. 
 
 59 
 
 2 
 
 Prolapsus of the uterus ; hydronephrosis.
 
 MOVEABLE KIDNEY IN WOMEN. 
 
 357 
 
 II. Moveahle Kidncjj on fJir left side. 
 
 No. 
 
 Age. 
 
 41. s. 
 
 42. w. 
 
 40 
 36 
 
 Number of coii- 
 fiiicmeuts. 
 
 Oilier aünicnts. 
 
 Pendulous belly. 
 III. Moveahle Kidney on hath sides. 
 
 4,^- 
 
 St. 
 
 2^ 
 
 44- 
 
 Sch. 
 
 36 
 
 45- 
 
 M. 
 
 60 
 
 Repeated injury. 
 
 Consumption. 
 
 Cancer of both kidneys. 
 
 Note. — In the above tables, under tbe bead " other ailments," the 
 author sometimes uses a dash ( — ), and sometimes a blank. It has been 
 concluded that their meaning is different, and that the dash ( — ) is 
 equivalent to " ditto." — Tkanslatoe. 
 
 Note. — These figures are capable of various summaries ; but one is too 
 important to omit. It will be seen that the following conditions occuiTed as 
 below. 
 
 Pendulous belly . . occurred in 11, or about 25 per cent. 
 
 " Eetroflection " of the uterus „ 7 „ 15 )> 
 
 Descent of uterus or vagina „ 6 „ 13 „ 
 
 Hernia .... ,, 3 >> 7 >> 
 
 Now, " retroflexion " is the only term here used for backward displace- . 
 ments, and no note is taken whether it was accompanied or not by some 
 descent. It becomes increasingly probable tliat backward displacements are 
 indications of descent, which is therefore the main condition. If it were 
 true tliat these 7 cases of " retroflexion " were of this nature, we should 
 liave the remarkable result that descent of the uterus or vagina, with or 
 without backward displacement, occurred thirteen times in 45 cases, or in 
 nearly 30 per cent. 
 
 Family history does not ßnd ^üaee in this memoir, hnt in 
 a,ny subsequent investigation inr^iiiry should be made for 
 riquure, prolapsus ani, descent of the uterus, Sfc, varicose 
 veins, and other "hernial'! conditions. Tliough not always 
 found, family histories are sometimes unexpectedly compre- 
 hensive, as the following family history of a tooman ivho came 
 to 7ne at St. George's Hospital a few days ago will shoio : 
 
 Emma B — , iet. 52, laundress, complains of womh coming.
 
 358 MOVEABLE KIDNEY IN WOMEN. 
 
 dotvn outside for hventy-five years. {It is in fact procident.) 
 Father had a rupture, w.otlier a procidentia. Patient's eldest 
 daughter {wt. 30) lias a procidentia ever since set. 21. All 
 patient's sons [three) had prolapsus ani as children. 
 
 Similar histories could no doubt he midtiplied by observers 
 with such matericd as lies at the disposal, for instance, of the 
 Truss Society. — Translator. 
 
 Eeferencfjs. 
 
 (i) Mesne, Opera omnia, Venetiis, 158 1. Ed. Costaous SnppL, p. 74, F. 2. 
 
 (2) Riolani, Enclioiridium anatomicnin et pathologicmn, Lugd. Batav., 
 
 1649, p. 145. 
 
 (3) Haller, im Göttingischen Anzeiger von gelehrten Sachen, 1777, S. 1194. 
 {4) Baillie, Posthumous Works in London Med. and Phjs. Journ., Dec , 
 
 182.(5. 
 
 (5) Otto, Seltene Boohachtungen, &c., Breslau, 1806. 
 
 (6) Mechel, Pathol. Anat., i, S. 632. 
 
 (7) Portal, Cours d'anat. et pathol., Paris, 1804, vol. v, p. 390. 
 
 (8) Saltzhurger Med.-chir. Zeitung, 1826, Bd. iv, S. 253, and Jahr- 
 
 bücher des ärzlichcn Vereins zu München, Bd. iii, S. 169 ; 
 S. Schviidt's Jahrb., Bd. xxxvii, S. 312. 
 {9) Girard, Oedeme du membre abdominal droit cause par un rein 
 mobile, Gaz. med. de Paris, 1837, p. 89. 
 
 (10) Kinij, Lancet, vol. i, 1836-37, No. 18. 
 
 (11) Rayer, Traitc des maladies des reins, Paris, 1S41 ; and Gazette mcdi- 
 
 cale de Paris, 1846, No. 51. 
 
 (12) Braun, Deutsche Klinik, 1853, S. 299. 
 
 (13) Brochin, Gazette des hopitaux, 1854, No. 87. 
 
 (14) Uray, Interessanter Fall einer bewegliclien Niere, Wiener med. 
 
 Wochenschrift, 1857, No. 3. 
 
 (15) Belters, Bericht v. d. 1. med. Klinik, Präger Vicrteljahi"sschr., 18,56, 
 
 Bd. li. 
 
 (16) Opfolzer, lieber bewegliche Nieren, Wiener med. Woch., 1856, No. 42. 
 
 (17) Hare, Medical Times and Gazette, Jan. 2, 23, 30, 18,158. 
 
 (18) Henoch, Klinik der Unterleibs-Krankheiten, S. 3,56 If. 
 
 (19) Fritz, Archives general., 5, sor. xiv, 1859. 
 
 (20) Dietl, Wandernde Nieren und deren Einklemmung, Wiener med. 
 
 Wochenschrift, 1864, Nos. 36, 37, 38. 
 
 (21) Becquet, Archives generales, 1865, S. 9 ff. 
 
 (22) Chrohack, Ueber bewegliche Niere und H^'sterie, Wiener med. Chi- 
 
 rurg., Rundschau, 1870. 
 
 (23) Rollet, Pathologie und Therapie der beweglichen Niere, Erlangen, 
 
 1866.
 
 EEPEÜENOES. 359 
 
 Diivliam, Giiy'w Hospital Reports, i860, p. 404. 
 
 Ziancercaux, Article Reins du Dictionnaire cneycl. des Sciences 
 
 medicales. 
 Trousseau, Clinique de l'Hotel-Dieu, t. iii, 3 ed., t86,'5, S. 556; and 
 
 rUnion med., 32, 1865. 
 GuSaeau de Mitssy, Legons cllniqnes sur les reins flottants, Union 
 
 niedicale, 1867, 74, and 76; and Cliniques medicales, 1875. 
 Fourricr, Reflexions sur plusieurs cas des veins flottants et sur le 
 
 tvaitement de cette affection. Bullet, general de Therapie, 15 Juin, 
 
 Henderson, Medical Times, iS^tj, No, 19. 
 
 Hospital Tidende, xvi, 14, 1S73, S. Schmidt's Jahrb., 1880, No. 12. 
 
 Gynaekolog og obstetr. Middeser utgine at Prof. Howitz, ii, 3, 
 
 S. 307 bis 388, 1879. (The last two essays were unfortunately 
 
 inaccessible to me except tlirough the report in Canstatt's and 
 
 Schmidt's Jahrbücher.) 
 Keppler, Die Wanderniere und ihre chirurgische Behandlung im 
 
 Archiv für Cliirurgie, Bd. xxiii, 1879, S. 520 ff . 
 Gucterhoclc, S. Rosenstein Nierenlcrankheiten, 2 aufl., S. 477. 
 von Dusch, Bericht über die medic. Poliklinik, &c., 18J7 — 59, im 
 
 Arch, für wiss. Heilk., vi, p. 381, 1861, 
 Kecheis, Entzündung einer bew. Niere, Wien, med., Halle, ii, 34, 
 
 1861. 
 Wilks, Lancet, ii, 6, 1S62. 
 
 Edwin Day, Med. Times and Gazette, July 9, 1864. 
 Gllewslci, Wien, med. Wochcnbl., xxi, 18, 1865. 
 Ehrle, Hämaturie bei beweglicher Niere, Berl. Iclin. Woch., 1866, 
 
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 Idin. Woch., 1866, No. 141. 
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 1869. 
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 rurgie, 1879, Bd. xi, S. 28. 
 
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 (87) Cidlingivortli, Lancet, i, i Jan., 1880. 
 
 (88) Wolcott, Philadelphia Med. and Surg. Reporter, 1861. 
 
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 (90) Jcssop, The Lancet, June 16, 1877. 
 
 (91) Czerny, Archiv für Chirurgie, Bd. xxiv, H. 4, 1878. 
 
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 (99) Stadtfeldt, Mon. f. Geb., 1861. 
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 (104) Virchow, Berl. geb. Verb., 1846, und Ges. wiss. Abhandl. 
 
 (105) Transactions of the Obstetrical Society of London, vol. xi, p. 272, 
 
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 Woch., 1872, No. 37, S. 450. 
 
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 Niere und deren Zusammenhang mit der Magenerweiterung, Berl.. 
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 (109) Litten, Zur Pathogenese des Icterus, Charitc-Annalen, 1880. 
 
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 (112) Landau, lieber Entstehung, Erkenntniss und Behandhing der Hai'n- 
 
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 1876.
 
 362 EEFEEENCES. 
 
 (113) 1. c, Bd. ii, S. 308. 
 
 (114) Sitzungsbcriclite der Wiener Academie, 1861 und 1863. 
 
 (115) Litten und Buchwald, lieber die Structurveränderungen der Niere 
 
 nach Unterbindung ihrer Vene, Virclww's Arcliiv, Bd. 66, S. 145. 
 
 (116) 1. c., Bd. ii, S. 309. 
 
 (117) Robinson, Med.-Chir. Transactions, vol. xxvi, p. 51. 
 
 (118) Weissyerher und Perls, Arch, für Experim. Path., vol. vi, S. 113. 
 
 (119) 1. c, S. 267. "Qui raro in sinistro latere varietateni viderim, facile 
 
 credo Riolano, qui dextram venam renalem frequentius duplicem 
 esse monet." 
 Haller gives in his Opusc. patholog. observ. 24 (see also Stannius, 
 VerSchliessung der grösseren Venenstämme, 1839) an account oE 
 the post-mortem appearances in a woman, i^t. 40, in whom he found 
 the vena cava closed between the renal and iliac veins, and the right 
 spermatic vein extraordinarily dilated, anastomosing with the greatly 
 dilated right ureteric vein (? vena uretica dextra) which rose from 
 the iliac vein. 
 
 (120 
 (121 
 (122 
 
 (123 
 (124 
 
 (125 
 (126 
 
 (127 
 
 (I28i 
 
 (129 
 (130: 
 <i3i 
 (132 
 (133 
 
 (134 
 
 (135 
 (136: 
 
 {137 
 (138 
 (139 
 (140: 
 
 (141 
 (142 
 
 Rosenstein, Nierenkrankheiten, S. 374. 
 
 Henoch, Klinik der Unterleibskrankheiten, Bd. iii, S. 367. 
 
 Trousseau, Clinique medicale de l'Hötel-Dieu de Paris, Bd. iii, p. 
 
 749- 
 I.e. 
 
 1. c, S. 37- , , 
 
 Frerichs, Die Bright' sehe Krankheit., S. 41. 
 
 Leudet, IMemoire de la Societc de Biologie, 1852. 
 
 1. c., S. 391. 
 
 Schönlein, Allgemeine und specielle Pathologie und Therapie, Bd. iii, 
 
 S. 274, Würzburg, 1832. 
 1. c., S. 58. 
 
 Virchow, Geschwülste, Bd. i, S. 268 und 274. 
 Simon, Chirurgie der Nieren, Th. ii, S. iSi ft. 
 1. c, Th. ii, S. 385. 
 Sandifort, Observationes anatomicae pathologicae, Lugduni Bata- 
 
 vorum, 1777, lib. iv, cap. vi, S. 54. 
 Haller, Göttingische anzeigen von gelehrten Sachen, 149 St., S. 11 94, 
 
 1777- 
 Hare, Medical Times and Gazette, 1857. 
 P. Wilse, Tillfälde af " temporär " Hydronephrose, Norsk. Magaz. f. 
 
 Lägevid, R. 3 ,Bd. 3, 5, p. 142, 1874. s. report in Canstatt, 1875, 
 
 Bd. ii, S. 275. 
 1. c, S. 211. 
 
 Pernice, Deutsche medicinische Wochenschrift, 1879, No. 9. 
 Ahlfeld, Archiv für Gynäkologie, 1879, Bd. xv, S. 114. 
 Czerny, Centralbl. für Chirurgie, 1879, No. 45, und Verhandlungen 
 
 der deutschen Gesellschaft für Chirurgie, 1881, S. 122, 9 Congress. 
 Verhandlungen der medic. Gesellschaft in Leipzig, Berl. klin. Wochen - 
 
 sehr., 1881, No. 16. 
 s. below, cap. xii.
 
 EEFEEENCES. 363 
 
 (143) Cole, British Medical Journal, 1874, 26 Sept.; Med.-Chir. Trans., 
 
 vol. xli, p. 221, 1876. 
 
 (144) Morris, On a Case of Intermitting Hydronephrosis, Med.-Chir. Trans- 
 
 actions, vol. lix, p. 227. 
 
 (145) Eger, Ueber eine eigenthiimliche Verbindung von Wanderniere mit 
 
 Hydronephrose, Berl. klin. Wochenschr., 1876, No. 23. 
 
 (146) s. Centralbl. f. Chir., 1881 ; Verhandl. des deutschen Chirurgen- 
 
 Congresscs. 
 
 (147) Tulpii, Novae observationes modicinae, editio nov. Amsteloduni 
 
 Elzevir, 1672, p. 173.* 
 
 (148) Boissiers dc Sauvages, Nosologia methodica, Amstelod., 1773, t. iii, 
 
 S.367. 
 
 (149) Jo /mso?i, Monthly Medico-ChirurgicalJournal, July, 1816; see König, 
 
 Praktische Abhandlungen über die Krankheiten der Nieren, 
 Leipzig, 1820, S. 159 ff. 
 
 (150) 1. c, S. 274. 
 
 (151) 1. c, SS., 360, 361. 
 
 (152) Hillicr, Transactions of the Royal Medical and Chirurgical Society, 
 
 vol. xlviii, 1856. 
 
 (153) 1. c, and British Medical Journal, 1876, April 29. 
 
 {154) see Kralcauer, Ueber Hydronephrose, Inaug.-Diss., Berlin, 1880. 
 
 (155) Montaux, Observat. clinic, Paris, 1789. 
 
 (156) Boinet, Archives gcnerales de mcdecine, 1835, p. 348. 
 
 (157) Meckel's Archiv für Anatomie u. Physiologie, 1828, p. 355. 
 
 (158) Rollet, 1. c, S. 24. 
 
 (159) Piorry und Maillot, Untersuchungen der Niere mit dem Plessimeter. 
 
 Examinateure medicale, 1843, Avril, s. Canstatt, 1843, Bd. iii, 
 S. 464. 
 
 (160) Guttmann, Klinische Untersuchungsmethoden der Brust- und Unter- 
 
 liebs-Krankheiten, S. 351, 3 Aufl., i88o. 
 
 (161) Weil, Handbuch und Atlas der topographischen Percussion, Leipzig, 
 
 1880. 
 U62) 1. c, S. 556 fE. 
 
 (163) 1. c, S. 338 fE. 
 
 (164) Skoda, Abhandlungen über Percussion und Auscultation, iii Aufl., 
 
 1850, S. 222. 
 
 ^ Ancient authors include the condition which we now call Hydronephrosis 
 {Bayer) under the name Ischuria. Even Galen must have known this con- 
 dition, as appears from a passage in lib. 3, de symptom, caus., p. 246 : " Cum 
 urina omnino in vesicam non venit, vocat etiam vulgus mediconim ischuriam, 
 quamquam ischuria non sit, et permittendi sunt profecto ita nominare, cum 
 propriam appellationem non habeant." 
 
 [The original is as follows: (Ed. Chart., vii [98]. Ed. Bas., iii [244]. 
 Ki(p' 7] [98].) " KoXovcri St ovStv rjTTOv 01 TToXXoi Twv iarpüv laxovpiav icq,Keivo 
 TO crvfiTTTio^a, Kairotyt ovk yv i<T\ovpia, liraSfi itr]d6\o)Q tig Tr)v kvotiv <i(l>iKVtiTai 
 TO ovpov, aTToXXv/itvjjc rixiv vt(ppwv ryg tvtpytiaq. Kai avyxiiiprjTtov ye avToTg 
 ovofjidl^iiv ovr<t)s diropoiffi irpoariyopiag ötKttaf."— Teanslatoe.]
 
 364 EEEERENCES. 
 
 (165) 1. c, S. 550. 
 
 (166) Laucnstein, Archiv für Chirurgie, Bd. xxvi. 
 
 (167) I.e., No. 18. 
 
 (168) s. Jenner, British Medical Journal, Jan. 2, 18 ; Feb. 6, 13 ; March 6, 
 
 1869 ; and Freund, Hufeisen-Niere, Beiträge zur Geburtslullfe 
 u. Gynäkologie, iv, 2. 
 
 (169) 1. c, S. 759, 
 
 (170) 1. c, S. 176. 
 
 (171) 1. c, S. 757. 
 
 (172) 1. c, S. 50. 
 
 (173) s. leBay, S. 45. 
 
 ( 1 74) Spiegelher g. Die Diagnose der Eierstockstumoren, besonders der Cysten,, 
 
 in Volhnann's Sammlung Klin. Vortr., Bd. ii, S. 445. 
 
 (175) Spencer Wells, Lancet, 1865, und Eierstocksgeschwülste (? "Diseases 
 
 of the Ovaries"). 
 
 (176) Landau, lieber den Werth der Eectaluntersuchung mit der vollen 
 
 Hand., Arch. für. Gyn., Bd. vii, S. 541, 1875. 
 
 (177) 1. c, S. 217. 
 
 (178) 1. c, S. 120. 
 
 (179) 1. c, S. 527. 
 
 (180) 1. c, S. 521. 
 
 (181) I.e., S. 763. 
 
 (182) 1. 0., S. 28. 
 
 (183) S.Deutsche medicinische Wochenschr., 1881, 4 Juni ; Anm. Referat 
 
 über den Chirurgen Congi-ess, 1881. — In the meantime Hahn has 
 described (in the Centralblatt für Chirurgie, Juli, 1881) two cases 
 treated by him by the operation of sewing. The above considera- 
 tions, however, are not in the least weakened by Hahn's statement 
 that one case was cured, since the jieriod during which they were 
 observed is far too short. Moreover (with a view to estimate such 
 isolated cases of alleged cure properly) it should be remembered 
 that King saw improvement follow an abortive attempt to remove 
 a moveable kidney. 
 [The name " Nephrorrluqthy " has been lately given to this operation. 
 For an account of its first performance in England by Dr. David 
 Newman, see Lancet, April 28, 1883, p. 749. Relief is said to have 
 resulted. — Teanslatoe.] 
 
 (184) Btich, Ueber die Behandlung des Ileus mit Massage, Berl. klin. 
 
 Woch., 1880, No. 41, S. 584. 
 
 (185) 1. c, S.522. 
 
 (186) Ibid, and Barker, Med.-Chir. Transact., Ixiii, 1880, p. 588. 
 
 (187) Schmidt's Jahrb., 1881, i Heft. 
 
 (188) Willis, Die Krankheiten des Harnsystems und ihre Behandlung. 
 
 Uebersetzt von Heusinger, Eisenach, 1841, S. 462 fE. 
 
 (189) Virchow's Archiv, Bd. xxii, 1878; Fall; ibid., 1881, Bd. Ixxx. 
 
 (190) 1. c, S. 31. 
 
 (191) Kroner, Rechtsseitige Hydronephrose, &c., Archiv für Gyiiäkol.,. 
 
 Bd. xvii, S. 102, 1881.
 
 REFEliENCES. 3G5 
 
 (192) JJarher, Nephrectomy by Abdominal Section, Med.-Cbir. Transact., 
 
 vol. Ixiii, S. 182 ft". 
 
 (193) Czerny, Archiv für klin. Chir., Bd. xxv. Heft 4, und xxvi, Heft 4. 
 
 (194) Landau, lieber Melaena Neugeborener, nebst Bemerkunge.n über die 
 
 Obliteration der fötalen Wege, Breslau, 1874. 
 
 (195) Landau, Zur operation der Echinococcen in der Bauchhöhle, Berl. 
 
 klin. Woch., 1885, Nos. 7 and 8. 
 
 (196) Landau, Zur Lehre der Eierstocks-schwangerschaft, Archiv für Gynäk., 
 
 1880, Bd. xvi, S. 436. 
 [See also D. Newman, Glasgow Med. Jour., Aug., 1S83. — Translator.]
 
 INDEX, 
 
 PAGE 
 Abdominal bandages in the treat- 
 ment of moveable kidney . 335 
 
 — organs, relation of kidneys to 238 
 
 — pain in typhus and typhoid . 183 
 Abscesses iu connection with 
 
 moveable kidney 
 Absorption of surrounding fat as 
 
 a cause of moveable kidney 
 Affections of the abdominal walls 
 
 as a cause of moveable kidney . 
 Albumen, forms in which excreted 
 
 — in normal urine 
 
 — in transudations . 
 
 — in urine after digestion 
 
 — — of animals 
 
 — losses of, in albuminuria 
 
 — modifications of, in urine 
 
 — morbid conditions of, as a 
 
 cause of albuminuria 
 
 — urinary, source of . 
 
 — — tests for .... 
 Albuminuria, after division of the 
 
 renal nerves 
 
 — after ingestion of egg-albumen 100 
 
 — after ligature of the renal 
 
 artery .... 
 
 of the renal vein 
 
 of the ureter . 
 
 — alcoholic beverages and 
 
 — as a result of increased tem- 
 
 perature .... 
 
 — as a result of muscular exer- 
 
 cise .... 51, 151 
 
 — as a result of the condition of 
 
 the blood .... 
 
 — as depending on altered blood- 
 
 pressure .... 
 
 — diet most suitable for . 
 
 — drugs used in treatment of . 
 
 — factors of . 
 
 — from degeneration of the 
 
 renal epithelium 
 
 — hygienic treatment of . 
 
 — in amyloid degeneration of 
 
 the kidneys 
 
 298 
 
 265 
 
 267 
 3 
 
 15, 138 
 24, 140 
 19, 44 
 , 20 
 . 141 
 . 8 
 
 95 
 
 4 
 14 
 
 46 
 
 61 
 
 57 
 
 63 
 
 147 
 
 47 
 
 94 
 
 39 
 
 145 
 
 144 
 
 1 
 
 78 
 141 
 
 121 
 
 PAGE 
 
 Albuminuria in animals as an 
 
 effect of heat . . 36, 4a 
 
 — in fevers . . . 89,109 
 
 — in petroleum poisoning . . 89 
 
 — in jjhosphorus poisoning 36, 80 
 
 — in progressive anaemia . . 86 
 
 — in renal diseases proper . 112 
 
 — in venous congestion of the 
 
 kidneys . . . .56 
 
 — meaning of the term . . 5 
 
 — meat as diet for, its draw- 
 
 backs .... 146 
 
 — milk diet for . . . 148 
 
 — mixed . . ... 12 
 • — • normal . . . . .15 
 
 — true and false ... 5 
 
 — without lesion of kidneys . 96 
 Alcoholic beverages and albumin- 
 uria 147 
 
 Alterations in the blood pressure 
 as a cMUsc of albuminuria . 39 
 
 Amyloid degeneratiion of the kid- 
 neys, albuminuria iu . . 121 
 
 Anatomical lesions in typhus and 
 typhoid 207 
 
 Anatomy, patliological, of move- 
 able kidney . . . 247 
 
 — topographical, of the kidneys 236 
 Anaiuiia, progressive pernicious, 
 
 albuminuria in . . .86 
 
 Aorta, effects of ligature of . 44 
 
 Arteries, increase of blood-pres- 
 sure in, and albuminuria . . 41 
 Artificial supports for abdomen iu 
 moveable kidney . . . 336 
 
 Baths, iu the treatment of albu- 
 minuria . . . . . 
 Bleeding, results of, in typhus 
 and typhoid .... 
 Blood, condition of, as a cause of 
 albuminuria . . . . 
 
 Blood-pressure, alterations of, in 
 kidneys nnd albuminuria . 
 — diniinishcvi, results of . 
 
 149 
 
 220 
 
 94 
 
 39 
 65
 
 3(38 
 
 INDEX. 
 
 T.1 T ^^CIE 
 
 -blood-pressure, methods of iu- 
 creasiiig . . . .42 
 
 Bowels, state of, in typhus and 
 typlioid 181 
 
 Cardiac hypertrophy in renal dis- 
 ease 114 
 
 Cases of moveahle kidney, left side 256 
 
 right side . . 249, 344 
 
 Causes of moveahle kidney . 264 
 
 — of typhus and typhoid 163, 167 
 Changes, qualitative, in hlood as a 
 
 cause of alhuminuria . . 100 
 Chloride of sodium as a test for 
 
 albumen . . . . .14 
 Cholera, albuminuria in . 100,111 
 Circulation, disturbances of, in 
 
 moveable kidney . . . 204 
 Climates, suitable, for eases of 
 
 albuminuria .... 152 
 Coagulative necrosis of the renal 
 
 epithelium and albuminuria . 89 
 Colon, obstruction of, due to 
 
 moveable kidney , . . 289 
 
 Colour of eruption in typhus . 200 
 Complications of moveable kidney 330 
 
 treatment of . . , 340 
 
 Conditions likely to be mistaken 
 
 for moveable kidney . . 323 
 
 Congestion of kidneys, various 
 
 forms of 65 
 
 Convulsions, albuminuria in . 51 
 
 Copland, Dr., on exanthematic 
 
 ^ ty[)hus 163 
 
 Crises in typhus and typhoid . 17y 
 Cutaneous uüdema in certain renal 
 diseases, cause of . . .117 
 
 Diagnosis of moveable kidney . 322 
 Diarrhoea in connection with state 
 
 of Peyer's glands . . 214 
 — in typhus and typhoid . , 182 
 
 Digestion, albuminuria of 19, 44, 98 
 Digestive organs, symptoms con- ' 
 
 nected witli, in moveal)le kidney 285 
 Diminished blood-pressure and 
 
 albuminuiia , . . .31 
 
 Displacements of the generative 
 
 organs as a cause of moveable 
 
 ^ kitluoy 268 
 
 Duration of typhus and typhoid, 
 
 ditlerences iu the . . . 171 
 
 Kgg-albumen, results of ingestion 
 
 "^' • • . . 1ÜÜ, 142, 145 
 E])idemic Fever of Kdiuburgli, 
 
 repin-t on ..... 178 
 Ei»ithelium, renal, degeneration 
 of, as a cause of albumin- 
 uria 73 
 
 203 
 198 
 
 -fcipithehum, renal, degeneration 
 
 of, in phosphorus poisoning 80 
 
 — of glomeruli, function of 78, 130 
 Eruption, duration of, in typhus 
 
 194, 196 
 
 — in typhoid, its characters . 204 
 
 — jn typhus and typhoid . 191 
 
 — iu typhus, darkness of, pro- 
 
 portional to severity of dis- 
 ease . . , , 
 ^ — varying statements regarding' 
 Excretion of urine, disturbances 
 
 of, in moveable kidney . . 301 
 
 Experiments illustrating inter- 
 mittent hydronephrosis . . 315 
 
 Fat, absorption of, as a cause of 
 
 moveable kidney . . . 265 
 Features of difference between 
 ^ typhus and typhoid . . 1 63 
 
 Febrile albuminuria . 89 109 
 
 Fcrrocyanide of potassium and' 
 
 acetic acid as tests for albumen 14 
 Filtration in the kidnevs . 25, 51 
 Fixation of kidney, mode of . 241 
 
 Gastric disturbances in cases of 
 
 moveable kidney . . . 285 
 Glands, intestinal, state of, iii 
 
 typhoid . . _ _ 219 
 
 Glandular ecreCion in the kidneys 32 
 Glasgow.epidemic of fever iu 1836, 
 
 symptoms in . . . 135 
 
 — Fever Hospital, cases iu 1836 162 
 
 Globulin in the urine ... 6 
 
 Grape sugar in normal urine . 21 
 
 Hematogenous albuminuria 
 Hannaturia in moveable kidney 
 Hemi-albumose (propeptouc) 
 Hydronephrosis and moveable kid- 
 ney, case of . . . 
 
 — as produced by moveable kid- 
 
 "'T 
 
 — due to angular insertion and 
 
 valvular closure of the 
 ureter . . . _ 
 
 — iu moveable kidney, treat- 
 
 ment of . 
 
 — intermittent 
 
 — its relations to se.xual dis- 
 
 orders 
 
 97 
 
 300 
 
 10 
 
 352 
 
 306 
 
 309 
 
 342 
 312 
 
 269 
 
 Impure air, influence of, in the 
 
 generation of typhus . . 164 
 
 Increase of temperature as causing 
 
 albuminuria 
 
 36,46 
 
 Injury as a cause of moveahle 
 
 ^^'^'"cy 273
 
 INDEX. 
 
 369 
 
 PAGE 
 lutra-abilouiinal pressure as a 
 cause of moveable kidney . 2G5 
 
 Jaundice iu cases of moveable 
 kiduey ..... 288 
 
 Kiduey, moveablo, in women . 233 
 a;tiology and pathogenesis 
 
 of 263 
 
 as affecting pregnancy 
 
 and labour . . . 31G 
 cases of . . . 249, 344 
 
 — — complications of . . 330 
 
 — — definition and nomencla- 
 
 ture ..... 236 
 
 — — diagnosis of . . . 322 
 
 ^ history and literature of . 233 
 
 objective signs of . . 318 
 
 original observations re- 
 garding .... 344 
 
 jjathological anatomy of . 247 
 
 physical causes of . . 273 
 
 — — prognosis iu . . . 332 
 references to authors ou . 358 
 
 — — removal of . . • 338 
 statistics regarding . . 244 
 
 — — symptoms of • . • 281 
 
 topographical anatomy of 236 
 
 treatment of . . • 333 
 
 Landau, Dr., ou moveable kiduey 
 iu women .... 233 
 
 Lymph, formation and flow of, as 
 compared with urine . 29, 137 
 
 Malpighian tufts, epithelium of 
 the,"iu relation to albuminuria . 24 
 
 ]\Ieat diet, drawbacks of, in albu- 
 minuria . . . • • 146 
 
 Memoir of Dr. A. P. Stewart . 222 
 
 Menstruation and moveable kid- 
 ney, connection between . 268 
 — as influencing albuminuria . 151 
 
 Mesenteric glands, state of, in 
 typhoid 217 
 
 Metaphosphoric acid as a test for 
 albumen and peptone . . 14 
 
 Milk diet iu cases of albuminuria 148 
 
 Mineral waters in the treatment of 
 albuminuria .... 149 
 
 Mobility of kidney, conditions in- 
 fluencing 280 
 
 Moveable kidney iu women . . 233 
 (see also Kidney, move- 
 able). 
 
 Muscular action as producing 
 albuminuria . . . 51, 151 
 
 Nephritis, chronic, types of . . 114 
 
 PAGE 
 
 Nervous symptoms in moveable 
 kidney 283 
 
 Neuralgias caused by moveable 
 kidney ..... 284 
 
 Nitric acid, as a test for albumen 14 
 
 Objective signs of moveable kidney 318 
 
 Obstruction of colon from move- 
 able kidney . . . .289 
 
 Operations suggested in cases of 
 moveable kiduey . . . 334 
 
 Oxalic acid in normal urine . . 21 
 
 Pain, abdominal, iu typhus and 
 typhoid ..... 183 
 
 Palpatiou in moveable kidney . 320 
 
 Pathological anatomy of moveable 
 kiduey ..... 247 
 
 Peptone and peptonuria . 8, 102 
 
 Perinephritic abscess in a case of 
 moveable kidney . . .348 
 
 Percussion as a means of diagnosis 
 in moveable kidney . . • 318 
 
 Petechiaj and ecchymoses in ty- 
 phus and typhoid . . . 193 
 
 Petroleum-poisoning aud albumin- 
 uria . . . . . .89 
 
 Peyer's glands, state of, iu typhoid 211 
 
 Phosphorus-poisoning and albu- 
 minuria . . . . .80 
 
 Pregnancy and labour, phenomena 
 
 of moveable kidney during 316 
 
 — as a cause of moveable kidney 266 
 Prognosis in moveable kiduey . 332 
 Pro-peptone, tests for . . 12, 13 
 Pro-pcptonuria ... 9, 102 
 
 — cases of . . . 10, 11 
 Psychical afiiections, as influencing 
 
 albuminuria .... 151 
 
 Rabbits, experiments on, with 
 phosphorus . . . .82 
 
 lleferences to authors ou move- 
 able kiduey .... 358 
 
 Relaxation of the peritoneum as a 
 cause of moveable kiduey . 265 
 
 Removal of moveable kidney . 338 
 
 Renal artery, effects of compres- 
 sing and tying . . .61 
 
 — cirrhosis .... 115 
 
 — diseases proper, albuminuria 
 
 iu . . . . . 112 
 
 — incarceration iu patients with 
 
 moveable kidney . . 290 
 
 — nerves, effects of division of . 46 
 
 — vein, eflects of tying . . 57 
 
 — vessels, occlusion of, iu move- 
 
 able kiduey . . .294 
 Reposition of moveable kidney . 334 
 
 24
 
 o70 
 
 INDEX. 
 
 PiGE 
 
 liest, bodily and meiitul, iu tlio 
 treatuiont of nUjunniiuria . . 151 
 
 Ilütardatiüu of the blood-curreut, 
 as a t'ause of albuminuria . . 26 
 
 Kigbt kidney more often displaced 
 than left, reasons wby . . 27G 
 
 Secretion of urine iu cases of move- 
 able kidney .... 300 
 
 Serum-albumin in the urine . G 
 
 Sexual disorders, their relation to 
 hydronephrosis . . . 2G9 
 
 Shampooing' in cases of moveable 
 kidney 337 
 
 Skin, attention to functions of 
 the, in the treatment of albu- 
 minuria ..... 150 
 
 Statistics of moveable kidney . 214 
 
 Stewart, Dr. A. P., on typhus and 
 
 typhoid fever . . .159 
 
 — memoir of . . . . 222 
 Sweat and tears, secretion of, com- 
 pared with that of urine . . 129 
 
 Symptoms connected with the 
 digestive organs in move- 
 able kidney . . .285 
 
 — — vessels in moveable kidney 285 
 
 — of moveable kidney . . 281 
 
 — of typhus and typhoid . . 180 
 
 Tables of cases of moveable kidney 356 
 Temperature, increased, effects 
 
 of . . . . . 36, 46 
 Theories of urinary secretion 27, 127 
 Tight-lacing a cause of moveable 
 
 kidney 275 
 
 Torsion of the ureter as a cause 
 
 of hydronephrosis . . . 311 
 
 Treatment of moveable kidney . 333 
 
 — of typhus and typhoid . . 219 
 Tvvcedie, Dr., illustrations of fever 160 
 Typhoid and typhus, difference iu 
 
 the duration of . . . 171 
 
 — eruptions in . . . . 204 
 
 — uou-infectious character of . 1G9 
 
 — relapses iu . . . . 174 
 
 — state of mesenteric glands in 217 
 Peyer's glands in . . 211 
 
 Typhus and typhoid, cases of, in 
 
 Glasgow Fever Hos])ital . 161 
 
 PAGE 
 
 'J'yphus and typhoid, crises in . 179 
 
 — — differences iu anatomical 
 
 lesions in . . . . 207 
 
 — — Dr. Stewart on nature 
 
 and pathology of . . 159 
 
 — — features of difference be- 
 
 tween .... 163 
 pain and diarrhoea in . 187 
 
 — — probable origin of . . 163 
 ■ — ■ — state of bowels iu . . 181 
 
 — — summary of differences 
 
 between . . . .219 
 
 — — symptoms of . . . 180 
 
 tympanites in . . 185, 189 
 
 — ■' — views as to treatment of . 220 
 
 Typhus, eruptions in . . . 191 
 
 — petechia} and ccchyraoses in . 193 
 — ■ transmission of, through the 
 
 atmosphere . . . 168 
 
 Urea, increase of, in blood, in 
 fevers, phosphorus - poisoniug, 
 
 •&c .99 
 
 Ureter, effects of tying . 63, 67 
 
 — torsion of, in oases of move- 
 
 able kidney . . . 303 
 Urinary secretion, theories of 27, 127 
 Urine, a product of filtration and 
 
 of secretion . 33, 128 
 
 — condition of, iu venous con- 
 
 gestion of the kidney . 71 
 
 — secretion and excretion of, 
 
 iu moveable kidney . . 300 
 
 Venous congestion of the kidneys 
 
 and albuminuria . 56, 68 
 
 — effect of, on glomeruli and 
 
 secretory apparatus . . 70 
 
 — resulting from ligature of 
 
 vein (57), of artery (61), of 
 ureter . . . .63 
 Vessels, symptoms connected with 
 the, in moveable kidney . . 285 
 
 Wandering kidney, description of 236 
 Waters, mineral, and baths for 
 
 albuminuria .... 149 
 
 Women, moveable kidney iu . 233
 
 REPORT 
 
 TRKSENTED TO THE 
 
 TWENTY-FIFTH ANNUAL MEETING 
 
 NEW SYDENHAM SOCIETY 
 
 HELD AT LIVERPOOL, 
 August 8th, 1883. 
 
 €\wM list of |ublisljeb Movl« 
 
 AND OTHER INFORMATION. 
 
 LONDON: 
 
 THE NEW SYDENHAM SOCIETY 
 
 188 3.
 
 OFFIOEES FOE 1883-84. 
 
 ♦Sir WILLIAM EOWMAN, F.R.S. 
 
 LL.D., Bavt. 
 
 ^ite-^wsibntts. 
 
 »HENRY W. AC LAND, M.D., F.E.S., 
 LL.D. (Oxford). 
 
 G. W. BALFOUR, M.D. (Edinburgh). 
 
 ROBERT BARNES, M.D. 
 *E. R. BICKERSTETH, Esq. (Liverpool). 
 
 W. H. BROADBENT, M.D. 
 
 JOHN CLELAND, M.D. (GLasgow). 
 
 Sir W. yv. GULL, M.D., F.R.S. , Bart. 
 
 Sm JOSEPH LISTER, F.R.S., Bart. 
 
 Sir WILLIAM McCORMAC. 
 
 ROBERT McDonnell, a.b.,m.d. 
 
 (Dublin). 
 Sir JAMES PAGET, F.R.S., LL.D., 
 
 Bart. 
 'Sir G. H. PORTER, M.D. (Dublin). 
 *JAS. RUSSELL, M.D. (Birmingham) . 
 WILLIAM RUTHERFORD, M.D., 
 
 F.R.S. (Edinburgh). 
 HERMANN WEBER, M.D. 
 T. SPENCER WELLS, Esq. 
 
 €oixndl 
 
 JAMES ANDREW, M.D. 
 
 J. H. AYELING, M.D. 
 
 THOMAS BARLOW, M.D. 
 ♦RICHARD BARWELL, Esq. 
 
 R, L. BOWLES, M.D. (Folkestone). 
 *J. CRICHTON BROWNE, M.D. 
 
 LAUDER BRUNTON, M.D., F.R.S. 
 
 THOMAS BUZZARD, M.D. 
 *W. B. CHEADLE, M.D. 
 
 W. CHOLMELEY, M.D. 
 
 W. CLEMENT DANIEL, M.D. 
 (Epsom). 
 
 J. LANGDON H. DOWN, M.D. 
 
 J. MATTHEWS DUNCAN, M.D. 
 
 JOHN EASTON, M.D. 
 
 BALTHAZAR FOSTER, M.D. 
 (Birmingham). 
 
 ♦T.F.GRIMSDALE, Esq. (Liverpool). 
 
 C. J. HARE, M.D. 
 
 G. E. HERMAN, M.D. 
 
 T. R. JESSOP, Esq. (Leeds). 
 
 THOS. KEITH, M.D. (Edinburgh) 
 *G. H. KIDD, M.D. (Dublin). 
 
 STEPHEN MACKENZIE, M.D. 
 *S. W. NORTH, Esq. (York). 
 
 W. B. PAGE, Esq. (Carlisle). 
 
 WILLIAM ROBERTS, M.D. 
 (Manchester). 
 
 G. H. SAVAGE, M.D. 
 
 J, W. F. SMITH-SHAND, M.D. 
 (Aberdeen). 
 
 SEPTIMUS W. SIBLEY, Esq. 
 *E. R. TOWNSEND, M.D. (Cork). 
 *C. WHIPPLE, Esq. (Plymouth). 
 
 OlXtlXBmtX. 
 W. SEDGWICK SAUNDERS, M.D., F.S.A., 13, Queen Street, Cheapside, E.G. 
 
 E. CLAPTON, M.D. | S. FENWICK, M.D. 
 
 F. M. CORNER, Esq. 
 
 JONATHAN HUTCHINSON, Esq., F.E.S., 15, Cavendish Square, W. 
 
 Those marked ivith an Asterisk were not in oßce last year.
 
 REPORT 
 
 Presented to the Twenty-fifth Annual Meeting op 
 THE New Sydenham Society. 
 
 In presenting their Eeport for the past year the Council 
 has little to state beyond the record of the works published 
 and the announcement of those in preparation. The 
 production of the Lexicon of Medical Terms has been 
 continued with as much speed as circumstances have per- 
 mitted, and two numbers have as usual been issued during 
 the year. 
 
 The issue for the current year will probably consist of — 
 
 A Fasciculus of the Atlas of Pathology. 
 
 Selections from the Works of Duchenne (of Boulogne), 
 edited by Dr. Vivian Poore. 
 
 Two or more Parts of the Lexicon of Medical Terms. 
 
 The first Volume of Hirsch' s work on Historico- 
 
 Geographical Pathology. 
 A Volume of Selected Monographs, of which Senator 
 
 on Albuminuria and Landau on Movable Kidney will 
 
 form part. 
 
 The works which have been issued during the past year 
 are the following : — 
 
 Dr. Stokes on Diseases of the Chest, with a Portrait of 
 the Author, and a Memoir by Dr. Acland. 
 
 The Collected Writings of the late Dr. Warburton 
 Begbie, edited by Dr. Dyce Duckworth, with a 
 Memoir and Portrait.
 
 4 REPORT. 
 
 A Translation, by Dr. Hadden, of Charcot's Treatise 
 on the Localisation of Cerebral and Spinal Disease. 
 
 The Sixteenth Fasciculus of the Society's Atlas of Skin 
 Diseases. 
 
 The Seventh and Eighth Parts of the Society's Lexicon 
 of Medical Terms. 
 
 Amongst those which are in preparation are the fol- 
 lowing : — 
 
 A Fasciculus of the Atlas of Portraits of Skin Diseases. 
 
 The Collected Works of Dr. Peacock, with Memoir and 
 Portrait. 
 
 One or more Volumes of Selected Clinical Lectures, 
 from German sources. 
 
 The Society's accounts for the year have been audited 
 as usual, and a balance sheet prepared.
 
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 CLASSIFIED LIST 
 
 OF THE 
 
 SOCIETY'S PUBLICATIONS. 
 
 ON THE TEMPERATURE IN DISEASE : A MANUAL 
 
 OF MEDICAL THERMOMETRY. By Dr. C. A. Wunder- 
 lich. (Leipzig). Translated by Dr. Bathurst Woodman. 
 With forty Woodcuts and seven Lithographs. 
 
 " It is well to recollect that this contains not only observations on the 
 temperature in disease, but also in health, and is a complete epitome as to the 
 history of the subject up to date. It is a work of reference absolutely necessary 
 for all who would keep themselves abreast of the day in relation to so im- 
 portant a matter as corporeal temperature." — Edin. Med. Journ., May, 1872. 
 
 " In short, without pledging ourselves to Wunderlich as infallible, we may 
 say, emphatically, that his is a masterwork, in which every part of his subject 
 is considered with that thoroughness which comes of ripe knowledge and 
 reflection. Let us add that Dr. Bathurst Woodman, following one or two 
 laudable examples that have been set by other translators for the Sydenham 
 Society, has enriched the work with notes of his own observations and those of 
 other English writers, which are of no small value, and unquestionably do much 
 to make the volume complete and iuW." — Lancet, April 20, 1872. 
 
 " The translator has rendered into readable English, and enriched with 
 practical notes, a book which, even in its original form, has started into active 
 work many physicians in England, France, and America, and which now, in its 
 popular form, must render the diagnosis of disease infinitely more accurate." — 
 Medical Times and Gazette, June 3, 1871. 
 
 " The publication of this volume marks an epoch in the history of medical 
 thermometry. The very possibility of such a book — full not only of exact 
 knowledge, but of important generalisations — is an indication that the great 
 problems relating to the alterations in the human temperature — the problems of 
 fever and collapse — are now being studied in a manner calculated to throw light 
 on the hidden processes of disease. . . - . . The value of this great work of 
 Professor Wunderlich is that it lays open his vast clinical experience of the 
 thermometer, and that it sketches in general terms the course of the temperature 
 in various forms of disease." — Glasgow Medical Journal, August, 1871. 
 
 "This treatise displays so much perseverance and thoroughness, such 
 admirable caution and insight, and such wide and minute learning, that it may 
 be said not only to establish this branch of investigation for the first time upon 
 a deep and lasting basis, but also to build up a very great part of the edifice, 
 and to point out with clearness the directions in which future labour must be 
 applied." — Dr. Allbutt in Brit, and For. Med. Chir. Rev., April, 1870. 
 
 LECTURES ON CLINICAL MEDICINE, dehvered at the 
 Hotel Dieu, Paris. By Professor Trousskau. Five Volumes. 
 Vol. 1, translated, with notes and appendices, by the late
 
 THE NEW SYDENHAM SOCIETY. 
 
 Dr. Bazire. Yols. 2 to 5, translated from tlie third edition, 
 revised and enlarged, by bir John Eose Cokmack. 
 
 " We are indebted to the New Sydenham Society for this rich contribution 
 
 to our medical literature Trousseau is an author to be read rather than 
 
 reviewed. He can only be criticised worthily at the bedside We com- 
 mend this great physician's work to the study of every reader." — Lancet, 
 October 15, 1870. 
 
 " The above-mentioned \vorks constitute the nineteenth annual issue to its 
 subscribers of the New Sj'denham Society ; and, though relating to different 
 subjects, we have classed them together, because it seems of more importance 
 to the profession that they should know the very valuable practical information 
 they can secure for one guinea, than at this time of day they should b^ 
 treated to an elaborate critique on Trousseau's Clinical Medicine, or on 
 Wunderlich's Treatise on Thermometry ; the worth of these volumes being well 
 known to all but the merest tyro in medicine." — Edinburgh Medical Journal, 
 May, 1872. 
 
 " We should think any medical librar}' absurdly incomplete now which did 
 not have, alongside of Watson and Graves and Tanner, the clinical medicine of 
 Trousseau. The work is full of the results of the richest natural observation, 
 and is the production of one who was enlightened enough to combine with new 
 methods of investigation the vigorous and independent ideas of the old 
 physicians, whom he so eloquently magnifies. The volume is an extremely 
 rich and valuable addition to the library of physicians and practitioners gene- 
 rally." — Lancet, December 4, 1869. 
 
 LATHAM^S COLLECTED WORKS. 2 vols. Edited by 
 Dr. PiOBERT Martin. AYitli Memoir of Latham by Sir Thomas 
 Watson. 
 
 " It indicates discrimination and taste on the part of those who conduct the 
 New Sydenham Society, that they have selected for publication a work so 
 different in many respects from the ephemeral books which issue in such 
 
 numbers from the teeming press of the present day This is one of the 
 
 few books which deserve to live, because it is full of real and conscientious 
 work, — of obser^-ations, carefully, reverently, and modestly made during a long 
 series of years, — of thoughts pondered and repondered \\ith candour and self- 
 distrust and willingness tobe taught, while the literary execution is unmistakably 
 that of a man of education, culture, and taste." — Edinb. Med. your., March, 1877. 
 
 " The different subjects are dealt with in a way which will always render 
 them fresh to the reader from the peculiarly original bent of the writer's mind, 
 and the acuteness of his reasoning. W^e quite agree with the editor that 
 ' where all are so admirable, it were perhaps well to avoid the singling out of 
 any one as though pre-eminently good.' If we made any exception to this, it 
 would be to specially direct attention to the articles on ' Treatment ' and 
 ' Cure.' We commend their perusal to all practical physicians." — Dublin 
 Journal of Medical Science, August, 1879. 
 
 CLINICAL LECTURES ON MEDICINE AND SUR- 
 GERY. Translated from the German, and selected from Pro- 
 fessor Volkmann's Series. Two Volumes. 
 
 MEMOIRS ON DIPHTHERIA; containing Memoirs by 
 Bretonneau, Trousseau, Daviot, Guersant, Bouchet, Empis, &c. 
 Selected and Translated by Dr. R. H. Sejiple.
 
 CLASSIFIED LIST OF PUBLICATIONS. 
 
 " Bretonneau's memoir must be considered the fullest and most searching 
 that has yet appeared in any country on this extraordinary disease." — British 
 Medical Journal. 
 
 " Like honour is due to M. Bretonneau for his admirable investigations. 
 
 His treatise on Diphtheria constitutes the greater part of the volume 
 
 recently published by the New Sydenham Society. Of the remaining memoirs 
 
 each contains much valuable material There is no part of the volume 
 
 which will better repay study than the researches of M. Empis."^ — Mcdical- 
 Chiriirorical Review. 
 
 RADICKE^S PAPERS ON THE APPLICATION OP 
 
 STATISTICS TO MEDICAL INQUIKIES. Translated by 
 Dr. Bond. 
 
 " We can hardly conceive an object to which the New Sydenham Society 
 could better devote a portion of its rapidly-increasing resources than to the 
 introduction of papers such as these to the profession. It is by such work as 
 this that the Society is calculated to confer inestimable benefits on the profession 
 of this Qoxxniry.'''— Medical Times and Gazette, January 25, 1862. 
 
 LECTURES ON PHTHISIS. By Professor Kiemeyek. Trans- 
 lated by Professor Baumler, 
 
 " Niemeyer's work is eminently suggestive, not only as regards pathology, 
 but also as regards treatment and prevention. There is no work on treatment 
 of Phthisis in the English language so advanced in its pathology ; it leaves the 
 crude theories of Laennec and his followers far in the rear, and by showing the 
 essential dependence of tubercle on preceding inflammatory processes, it shous 
 also how we may ward off this intractable disease from our patients, and how 
 we may most usefully employ the remedies at hand for its prevention." — 
 Edinburgh Medical yournal, December, 1870. 
 
 " The members of the New Sydenham Society must be well content with 
 the \\orks supplied to them for their subscription. Those issued of late are of 
 peculiarly solid and lasting value. We have now three before us, which, 
 besides the recommendation of intrinsic scientific value, have that of high 
 practical utilit}-. We refer to Trousseau's ' Clinical Medicine,' Niemeyer's 
 ' Lectures on Pulmonary Consumption,' and Strieker's ' Histology.' " — Brit, and 
 For. Med. Chir. Rev., April, 1871. 
 
 THE COLLECTED WORKS OF DR. ADDISON. Edited, 
 Avith Introductory Prefaces to several of the Papers, by Dr. 
 "WiLKs and Dr. Daldy. With Portrait, and numerous Litho- 
 graphic Plates. 
 
 " We must cordially commend the decision 01 the Council of the New 
 Sydenham Society, which led to the publication of this historically interesting 
 and practically valuable book. Few names have, of late years, been better 
 known to the profession than that of the eminent physician \\hose contributions 
 to its literature, too few in number, have nevertheless been, one and all, highly 
 and justly esteemed. A brief but kindly and discriminating biography of Dr. 
 
 Addison precedes the collection of his papers " — Edinburgh Medical 
 
 Journal, December, 186S. 
 
 " No one who has studied the valuable papers, published by Dr. Addison 
 in the Guy's Hospital Reports, can fail to be pleased that they are now rendered 
 more widely available by this separate publication. His great and extensive
 
 THE NEW SYDENHAM SOCIETY. 
 
 knowledge of skin diseases renders the articles on that subject of much interest. 
 If, however, we were asked to select the one most likely to be useful to the 
 practitioner, we should unhesitatingly point to that on the Physical Examination 
 of the Chest." — Medical Times and Gazette, July 4, 1868. 
 
 A GUIDE TO THE QUALITATIVE AND QUANTITA- 
 TIVE ANALYSIS OF THE UEINE. By Dr. C. Neubauer 
 and Dr. J. Vogel. Fourth edition, considerably enlarged. 
 Translated by William 0. Markham, F.R.C.P.L. With four 
 Lithographs, and numerous Woodcuts. 
 
 " The New Sydenham Society have conferred a benefit, not only on their 
 own subscribers, but on the whole profession in this country, by publishing the 
 work of Drs. Neubauer ar.d Vogel." — Medical Times and Gazette. 
 
 " It is one of those woiks in which there is not an unnecessary line nor even 
 a word. It is quite a text-book upon urinology for the scientific physician, and 
 may be handled likewise by the youngest student." — Lancet. 
 
 MEMOIRS ON ABDOMINAL TUMOURS AND INTU- 
 MESCENCE. By Dr. Bright. Bepriutcd from the " Guy's 
 Hospital Eeports," Avith a Preface by Dr. Barlow. Numerous 
 Woodcuts. 
 
 " Dr. Bright's object was to bring his vast clinical experience and great 
 diagnostic tact to bear on the elucidation of confessedly a most obscure depart- 
 ment of medical disease — the discrimination and diagnosis of abdominal ■ 
 tumours; and this he has done by briefly stating their principal characteristics, 
 as they are produced, either by the presence of tumours dependent on a cepha- 
 locyst hydatid, by ovarian tumours, or diseases of the spleen, liver, or kidney. 
 Under each of these heads we have valuable features recorded, by which in life 
 they mny be recognised, whilst after death their pathological characters are de- 
 scribed in a manner that leaves but one impression on our minds, that here 
 indeed the author has held up the mirror to nature ; and under each section 
 we have a perfect embarras de richesse, in the shape of illustrative cases. The 
 whole work is profusely filled with woodcuts and outlines descriptive of the 
 several diseases described, by which means the author's verbal descriptions are 
 more vividly presented to the reader's understanding." — Dublin Quarterly 
 yournal of Medical Science, May, 1861. 
 
 " The memoirs possess a permanent value, as models of clinical reports, as 
 exhibiting the method by which the investigation of this difficult class of 
 organic diseases may be pursued with greatest certaintj' of success, and as 
 furnishing the great general outlines of the inquirj-. It is by the study of such 
 models that the difficult art of medical observation may best be understood, and 
 may to some extent be acquired. Certainly no papers in our periodical literature 
 were more worthy than- these of being republished and circulated in a eollected 
 and accessible form.''— Edinburgh Medical yournal, January, 1861. 
 
 A CLINICAL ACCOUNT OF DISEASES OF THE 
 
 LIVEE. By Prof. Frerichs. 2 vols. Translated by Dr. 
 MuRCHisoN. With coloured Lithographs, and numerous 
 Woodctits. 
 
 " Frerichs' book is one of those treatises that will frequently be taken down 
 from the book-shelves to be consulted, both by physiologists and physicians." 
 — Lancet.
 
 CLASSIFIED LIST OF PUBLICATIONS. 
 
 " We shall look forward with interest to the completion of this very 
 valuable addition to the Clinical History of Liver Diseases." — Medical Times 
 and Gazette. 
 
 CZERMAK ON THE PRACTICAL USES OF THE 
 
 LAEYNGOSCOPE. Translated l)y Dr. G. D. Gibb. Numerous 
 Woodcuts. 
 
 " What has been given will, we trust, convince any one who may hitherto 
 have doubted the value of laryngoscopy, that it is a real acquisition. To those 
 who are desirous of becoming more fully acquainted with the subject, we 
 strongly recommend the study of the work [Professor Czermak's] from which 
 ue have chiefly culled our extracts." — Mcdico-Cliinirgical Reviciv, Oct., 1862. 
 
 A HAND-BOOK OF PHYSICAL DIAGNOSIS COM- 
 
 PEISING THE THROAT, THORAX, AND ABDOMEN. 
 By Dr. Paul Gtjttmann, of Berlin. Translated by Dr. Napier, 
 of Glasgow. 
 
 " We are persuaded that if the practitioner will carefully study this work, 
 and conscientiously carry out its suggestions, he will find an incalculable 
 advance in the realistic appreciation of diseases by means of their physical 
 phenomena. The work is not properly a ' students' ' book. It presumes a 
 certain familiarity with the diseases of the organs with which it deals, and the 
 endeavour is made to connect the physical phenomena \\-ith the pathological 
 
 conditions present in these diseases It was a wise decision of the New 
 
 Sydenham Society to place a translation of it in the hands of their subscribers." 
 ■ — Glasgow Medical journal, March, 18S0. 
 
 " The New Sydenham Societ}' has done well to put within the reach of their 
 subscribers a work which not only has attained to a third edition in its own 
 language, but has also been translated into Italian, Russian, Spanish, French, 
 
 and Polish As a systematic and scientific treatise it well repays 
 
 perusal. The book concludes with a good account of laryngoscopy, and of the 
 physical signs of the principal diseases of the larynx. The acoustics of 
 percussion and auscultation are elaborated with great care, and the precise 
 explanation of the causes of many familiar physical signs will be very acceptable 
 to teachers of clinical medicine, who have hitherto felt the want of an adequate 
 scientific exposition of the principles of physical diagnosis." — Dublin jfournal 
 of Medical Science, November, 1880. 
 
 AN ATLAS OF ILLUSTRATIONS OF PATHOLOGY, 
 
 COMPILED (CHIEFLY FROM ORIGINAL SOURCES) 
 FOR THE SOCIETY. 
 
 The Committee in charge of this work consists of Dr. Gee, 
 Dr, Gkeen, Dr. Moxon, Dr. Sutton, Mr. Holmes, and Mr. 
 
 HuTCmNSON. 
 
 FIVE FASCICULI have been lUTblished, and it is in-oposed 
 to issue one every year. 
 
 The following subjects have been illustrated ; —
 
 THii NKW »YDENHAJl SOCIETY, 
 
 FIRST FASCICULUS. 
 
 Scrofula ; Syphilis ; and Lymph-Adenoma. — Plate I. 
 
 Fig. I. Scrofulous Disease of the 
 Kidney and Ureter. Fig. 2. Scrofu- 
 lous Disease of the Kidney. Fig. 3. 
 Scrofulous Disease of the Kidney. 
 
 Fig. 4. A Mass of Syphilitic Deposit 
 in the Cortical Substance of the Kid- 
 ney. Fig. 5. Lymph-Adenoma of 
 Kidney. 
 
 Nephritis after Diphtheria ; Scarlet Fever ; and Burns. — Plate II. 
 
 Fig. I. Nephritis after Diphtheria. 
 — Section of Kidney. Fig. 2. Subacute 
 Nephritis after Scarlet Fever. — Outer 
 surface of kidney. Fig. 3. Subacute 
 Nephritis after Scarlet Fever. Fig. 4. 
 Acute Nephritis after Scarlet Fever. 
 I^'ig- 5- Subacute Nephritis after 
 
 Scarlet Fever. Fig. 6. Acute Nephritis 
 after a Burn. — Outer surface of the 
 kidney of a child who died after a very 
 extensive burn. Fig. 7. Acute Ne- 
 phritis after a Burn. — Section ol the 
 same kidney. 
 
 The Granular Kidney in different stages. — Plate III. 
 
 Fig. I. Extremely Granular Kidney. 
 Fig. 2. Extremely Granular Kidney. — • 
 Section of the same kidney. Fig. 3. 
 Less Granular (contracted) Kidney. — • 
 Outer surface of the right kidney taken 
 from the same subject as the left 
 kidney shown in Figs, i and 2. Fig. 4. 
 
 Granular Kidney of Bright. Fig. 5. 
 Contracted Granular Kidney, in sec- 
 tion. Fig. 6. Contracted Granular 
 Kidney ; exterior. Fig. 7. Large 
 Granular Kidne}'. Fig. 8. Large 
 Granular Kidney with cysts. 
 
 Embolism ; Infarction Processes from Pyemia ; Jamidice and 
 Purpura ; Scrofula. — Plate IV. 
 
 Fig. I. Embolic Changes in Pyaemia. 
 Fig. 2. Embolic Changes in Pyaemia. 
 Fig. 3. Pyaemic Deposits in Kidney. 
 Fig. 4. Pysemic Deposits in the Kidney. 
 P'ig. 5. Results of Jaundice and Pur- 
 
 pura. Fig. 6. A variety of the Scrof- 
 ulous Kidney. — The substance of the 
 kidney is wholly destroyed and re- 
 placed by cavities containing a white 
 mortar-like substance. 
 
 Fig. I. Amyloid Disease of Kidney 
 in advanced stage. Fig. 2. A section 
 of the same Kidney. Fig. 3. The pale 
 
 SECOND FASCICULUS. 
 
 Diseases of the Kidney. — Plate V. 
 
 flabby Kidney. Fig 
 
 4. The same 
 organ seen in section. Fig. 5. Me- 
 dullary Cancer of the Kidney. 
 
 Various Diseased Conditions of the Spleen. — Plate VI. 
 
 Fig. I. Hodgkin's Disease of Spleen 
 (Lympho-sarcoma). Fig. 2. Acute 
 Splenic enlargement in Diphtheria. 
 I-'ig. 3. Suppurating infarction of 
 
 Spleen from a case of Ulcerative En- 
 docarditis. Fig. 4. Embolic changes 
 in Pyaemia. Fig. 5. Rupture of the 
 
 Spleen. 
 
 Diseases of the Supra Penal Capsules and Spleen. — Plate VII. 
 
 Fig. I. Cancer of the Supra Renal 
 Capsule. Figs. 2, 3, 4. Adenoma of 
 the Supra Renal Capsule. Fig. 6. 
 y\ddison's Disease of the Supra Renal 
 Capsule (in section). Fig. 5. Addison's 
 Disease of the Supra Renal Capsule. — 
 
 " Fibro-calcareous or strumous dis- 
 ease." Fig. 7. Tubercle of the Spleen 
 (external surface). Fig. 8. Tubercle 
 of the Spleen (in section). Fig. o. 
 Lardaceous Spleen.
 
 CLASSIFIED LIST OF PUBLICATIONS. 
 
 Microscopic Pathology of Kidneys. — Plate VIII. 
 
 Fig. I. Lardaceous Degeneration of 
 the Kidney. — Section of cortex. Fig. 2. 
 Lardaceous Degeneration. — g. A glo- 
 merulus from the same kidney, as in 
 Fig. I, which has undergone lardaceous 
 degeneration and is becoming fatty. 
 Fig. 3. Part of the same seen with a 
 higher power, showing contents of one 
 of the tubules. Fig. 4. Lardaceous 
 Degeneration in earlier stage com- 
 bined with interstitial fibrous change. 
 Figs. 5 & 6. Lardaceous Degeneration 
 (after Cornil). Fig. 5. Section show- 
 ing the hyaline membranous wall of 
 the tubules a a much swollen, stained 
 violet-red, showing waxy degeneration. 
 Fig. 6. Transverse section of one of 
 the pyramids, near summit of cone. 
 Fig. 7. Granular Contracted Kidney. 
 Fig. 8. From the same. — A thickened 
 arteriole surrounded by fibroid growth. 
 Fig. g. Partial Fibrous Degeneration 
 of Malpighian body in slight chronic 
 intertubular nephritis. Fig. 10. From 
 
 the same kidney ; showing earh' 
 changes around Malpighian body. 
 Fig. II. Multiplication of Nuclei on 
 glomerulus with adhesion of capillary 
 tuft to wall of capsule. Fig. 12. Sub- 
 acute Interstitial Nephritis with large 
 white kidney. Fig. 13. Scarlatinal 
 Nephritis. — Intertubular exudation in 
 a case fatal on 7th day of fever. Fig. 
 14. Subacute Interstitial Nephritis. 
 Fig. 15. Acute Catarrhal Nephritis, 
 showing swelling and granular de- 
 generation of epithelium. (100 diam.) 
 Fig. 16. Part of the same seen with a 
 higher power. Fig. 17. Section of 
 cortex from a case of parenchymatous 
 (catarrhal) nephritis at a later stage 
 (so-called "fatty'' kidney). Fig. 18. 
 From nearly transverse section near 
 base of pyramid in similar case. Fig. 
 ig. Casts in tubes in interstitial ne- 
 phiitis (post scarlatinal). Fig. 20. 
 Col'oid cast, b, in tubule ; a, unaltered 
 epithelium. 
 
 Microscopic Pathology of the Kicluey. — Plate IX. 
 
 Fig. I. Scarlatinal Nephritis. Fig. 
 2. Shows two of the glomeruli from 
 same section as Fig. i. Fig. 3. Sec- 
 tion from the same. — Part of the wall 
 of a Malpighian body from which the 
 capillary tuft has fallen out. Fig. 4. 
 Scarlatinal Nephritis.- — (From a case 
 fatal about 12 weeks from attack of 
 fever). Fig. 5. Scarlatinal Nephritis. 
 — (From a case fatal 15 months after 
 attack of scarlet fever). Fig. 6. From 
 same kidney as Fig. 5, but in a deeper 
 part of cortex, close to medulla. Si- 
 milar growth of interstitial connective 
 tissue. Fig. 7. Subacute Interstitial 
 Nephritis, probably Scarlatinal, under 
 low power; showing diffuse infiltration 
 and cluster of dilated tubules. Fig. 8. 
 Chronic Parenchymatous Nephritis 
 (large white kidney) with little or no 
 interstitial change. — Section of cortex, 
 showing changes in epithelium of 
 convoluted tubules. Fig. g. Kidney in 
 leucocythiemia — to show localisation 
 of changes around glomeruli and ves- I 
 sels. Fig. 10. Swelling of inner coat 
 of small artery in granular contracted 
 kidney. Fig. 11. Tuberculous Pyelo- 
 nephritis. Fig. 12. Fatty Degenera- 
 tion from Alcoholic Poisoning (after j 
 
 Lancereaux). Fig. 13. Fatty Degene- 
 ration in Cancer. Fig. 14. Individual 
 epithelial cells from the preceding 
 section ; in various stages of fatty 
 degeneration. Fig. 15. Cystic Dege- 
 neration of Kidney (after Lancereaux.) 
 Fig. 16. From a cyst in kidney near 
 base of pyramid. Fig. 17. Colloid 
 Degeneration of Kidney. Figs. 18, 
 ig, 20, and 21, illustrate the hyaline 
 changes found in the splenic arteries 
 in certain febrile conditions. Fig. 18. 
 From a section through the spleen of 
 a case of early scarlatina, showing 
 hyaline degeneration of the coat of an 
 artery, transversely cut. Fig. ig. 
 Artery in longitudinal section. Fig. 
 20. Malpighian corpuscle from the 
 spleen of a case of early scarlatina. 
 Fig. 21. Part of the central and inter- 
 mediate zone of the same Malpighian 
 corpuscle as in Fig. 20, only more 
 highly magnified (180 diam.) Fig. 22. 
 Hodgkin's Disease. — Section of a 
 spleen to show the overgrowth of the 
 lymphatic sheath in Hodgkin's disease. 
 (i inch.) Fig. 23. Adenoma of the 
 Supra Renal Capsule, showing the 
 columns stuffed with fatty granules.
 
 10 
 
 THE NEW SYDENHAM SOCIETY. 
 
 Microscopic Pathology of Spleen and SnpraE enals. — Plate X. 
 
 Fig. I. Capsulitis of the Spleen. — 
 Vertical section of fibrous nodule in 
 the capsule of the spleen, showing 
 that the thickening of the capsule 
 takes place by cellular growth in its 
 deeper layers. Fig. 2. Fibrosis of the 
 Spleen. — From the enlarged spleen of 
 a ricketty child. Fig. 3. Fibrosis of 
 the Spleen. — Showing a more advanced 
 or fibrous condition spreading round 
 some dilated veins. Fig. 4. Rluscular 
 Hypertrophy. — Over-growth of mus- 
 cular trabeculas in the spleen. Fig. 5. 
 Muscular Hypertrophy. — Extreme 
 stage of fibro-muscular growth in the 
 spleen. Fig. 6. The Leucocythsemic 
 Spleen. — Section of the edge of a 
 Malpighian corpuscle, showing the 
 compressed fibrous tissue between it 
 and the splenic pulp. Fig. 7. The 
 Leucocythaemic Spleen. — The pulp 
 and stroma are normal. Fig. 8. 
 Hodgkin's Disease. — The texture of a | 
 
 Witli Essay on the Pathology of the Kidney, by Dr. Greenfield. 
 Essay on the Pathology of the Spleen and Supra Pienals, by 
 Dr. Groodhart. 
 
 " We look on this Pathological Atlas, in all its three fasciculi, as one of the 
 best things that the Society has as j'et done. The illustrations are nearly life 
 size ; the colouring is beautiful and true to nature ; and we have not seen in 
 this or any other country any work of this kind that satisfied us so much. 
 Taken alone, it would be well worth the annual guinea ; and will, when 
 finished, constitute a treatise which every practising physician should possess." 
 — Medical Press and Circular, June 22nd, 1S81. 
 
 lymphoid nodule in the spleen of 
 Hodgkin's disease. Fig. 9. Tubercular 
 Spleen. (37 diam.) Fig. 10. Tuber- 
 cular Spleen. Fig. II. Induration and 
 Atrophy. — A section of the spleen 
 from a case of heart disease. Fig. 12. 
 Lardaceous Spleen. — The sago spleen, 
 showing the Malpighian corpuscles 
 and small arteries mapped out by 
 structureless hyaline lardaceous mat- 
 ter. Fig. 13. Lardaceous Spleen. — 
 Transverse section of a Malpighian 
 corpuscle, or small artery, with its 
 surrounding lymphoid sheath. Fig. 
 14. Addison's Disease. — Vertical sec- 
 tion of a supra renal capsule from the 
 exterior inwards, to show the early 
 changes in Morbus Addisonii. (250 
 diam.) Fig. 15. Addison's Disease. — 
 Section of a supra renal capsule, to 
 show the late, or fibro-calcareous, 
 stage of Morbus Addisonii. 
 
 THIRD FASCICULUS. 
 
 Diseases of the Liver. — Plate XI. 
 Lymphadenoma of Liver. 
 
 Diseases of the Liver. — Plate XII. 
 
 Fig. I. Dilatation of the Bile Ducts in the Liver from pressure of a gall stone 
 
 in cystic duct. 
 Fig. 2. Cancer of the Liver, with dilatation of the ducts and staining of the 
 
 hepatic tissue. 
 
 Diseases of the Liver. — Plate XIII. 
 Syphilitic Cirrhosis of the Liver. 
 
 Diseases of the Liver. — Plate XIV. 
 
 Fig. I. Red Atrophy, with acute Yellow Atrophy of the Liver. 
 
 Fig. 2. Microscopical appearances of the yellow swollen parts of the Liver 
 
 (Acute Yellow Atrophy). 
 Fig. 3. Microscopical appearances of Red Atrophy of the Liver.
 
 CLASSIFIED LIST OF PUBLICATIONS. 
 
 11 
 
 Diseases of the Liver. — Plate XV. 
 
 Fig. I. Lardaceous Liver. 
 
 Fig. 2. Lardaceous Liver, showing the iodine reaction. 
 
 Diseases of the Liver. — Plate XVI. 
 
 Fig. I. Cancer of the Liver. 
 
 Fig. 2. Nutmeg Liver, Chronic Congestion, and Atrophy of the Liver from 
 mitral disease. 
 
 FOURTH FASCICULUS. 
 
 Diseases of the Liver, includiug one Figure of Spleen. — Plates 
 XVII. to XXII. 
 
 Diseases of the Liver and Spleen. — Plate XVII. 
 
 Fig. I. Cirrhosis of the Liver resembling the Nutmeg Liver. 
 
 Fig. 2. Brown Atrophy of the Liver. 
 
 Fig. 3. Cirrhosis of the Liver. 
 
 Fig. 4. Lymphadenoma of the Spleen (Hodgkin's Disease). 
 
 Diseases of the Liver. — Plate XVIII. 
 
 Fig. I. Fatty Liver from Poisoning by Phosphorus. 
 
 Fig. 2. Cirrhosis of the Liver. 
 
 Fig. 3. Tubercular Liver. 
 
 Fig. 4. Cirrhosis of the Liver. 
 
 Diseases of the Liver. — Plate XIX. 
 Cystic Disease of the Liver. 
 
 Diseases of the Liver. — Plate XX. 
 
 Fig. I. Lardaceous Disease of the 
 Liver. Fig. 2. Fatty Liver. Fig. 3. 
 Early Cirrhosis. Figs. 4 & 5. Cirrhosis 
 of the Liver (after Hamilton). Fig. 6. 
 Cirrhosis of the Liver. Fig. 7. A Ve- 
 getation from the surface of the Liver. 
 Fig. 8. Spindle-cell Sarcoma of the 
 Liver. Fig. g. Disseminated Growths 
 
 of Fibrous Nature in the Liver. Fig. 
 10. Lardaceous Disease of the Liver. 
 Fig. II. Cavernous Tumour in the 
 Liver. Fig. 12. Acute Yellow Atrophy 
 of the Liver. Fig. 13. Cavernous Tu- 
 mour in the Liver. Fig. 14. Early 
 Cirrhosis. Fig. 15. Columnar Epi- 
 thelioma of the Liver. 
 
 Diseases of the Liver. — Plate XXI. 
 
 Fig. I. Cirrhosis of the Liver. Fig. 
 2. Cirrhosis of the Liver. Fig. 3. 
 Monolobular Cirrhosis. Fig. 4. The 
 Nutmeg Liver (Romose Atrophy of 
 Moxon). Fig. 5. Tubercular Liver. 
 Fig. 6. The Nutmeg Liver. Fig. 7. 
 Miliary Gummata. Fig. 8. Idiopathic 
 
 Anaemia. Figs. 9 & 10. Cancer of the 
 Bile Ducts. Fig. 11. Cancer spreading 
 from the Biliary Ducts. Fig. 12. Early 
 Gummatous Infiltration of the Liver. 
 Fig. 13. "Common" Cirrhosis. Fig. 
 14. Tubercular Liver. Fig. 15. Idio- 
 pathic Anaemia.
 
 1*2 THE NEW SYDENHAM SOCIETY. 
 
 Diseases of the Liver. — Plate XXII. 
 
 Fig. I. "Pericellular" Cirrhosis. 
 Fig. 2._ Cirrhosis of the Liver. Fig. 3. 
 Nutmeg Liver. Fig. 4. Cystic Liver. 
 Fig. 5. Cystic Liver. Fig. 6. Early 
 Cancer of the Liver. Fig. 7. Extreme 
 Tubercular Disease of the Liver. Fig. 
 8. Brown Atroph}' of the Liver. Fig. 9. 
 
 Myxcedematous Liver. Figs. 11, 12 & 
 13. " Contracting Scirrhus of the Liver 
 simulating Cirrhosis." Figs. 14, 15 & 16. 
 Varieties of Cell Vacuolation and Pro- 
 liferation. Fig. 17. Primary Adenoma 
 of the Liver. Fig. iS. Leukemic 
 Liver. Fig. ig. Primary Adenoma of 
 
 Extreme Tubercular Disease. Fig. 10. the Liver 
 
 FIFTH FASCICULUS. 
 
 Diseases of tlie Liver (chiefly of the Gall-Bladder and Larger 
 
 Bile Ducts).— Plate XXIII. 
 
 Syphilitic and Lardaceous Disease of the Liver. 
 
 Diseases of the Liver. — Plate XXIV. 
 Fig. I. Abscesses in the Liver. 
 Fig. 2. Papilloma of the Gall-Bladder. 
 
 Diseases of the Liver. — Plate XXY. 
 Cancer of Gall-Bladder and Liver. 
 Gall-stones, with Obstruction and Dilatation of the Cvr.tic Duct. 
 
 Diseases of the Liver. — Plate XXYI. 
 
 Cancer of the Stomach extending to the Cystic Duct. 
 
 " We have nothing but praise to bestow on these plates, which are wonder- 
 fully good, and well worth the whole guinea subscription." — Medical Press, 
 August 2g, 1883. 
 
 ON THE DISEASES OF OLD AGE. By Prof. Charcot. 
 Translated hy Mr. William Tuke. 
 
 " The New Sydenham Society has been well advised in presenting to its 
 readers one of the most important neurological works which has appeared of 
 
 late years Charcot's volume is a book to read and re-read for all of us." 
 
 —British Medical Joinnial, June 23, 1S83. 
 
 THE DIAGNOSIS AND TREATMENT OF DISEASES 
 
 OF THE CHEST. By Dr. Stokes. A Ileprint Edited by 
 Dr. Hudson, of Dublin. 
 
 " His fame as one of the foremost physicians of his age may, we think, rest 
 securely upon his two main works — on ' Diseases of the Chest,' and on ' Diseases 
 of the Heart and Aorta.' Each of these treatises is to be reckoned a ' historical 
 landmark in medicine,' and it was from this point of view, as it would seem, 
 
 that Dr. Hudson undertook the editing of the volume under notice 
 
 Prefixed to this edition is a graceful and sympathetic memoir of Dr. Stokes, by 
 his attached friend, Dr. Ackland." — Dublin Joitrn. of Med. Science. Oct., 1883. 
 
 THE COLLECTED WORKS OF DR. WARBURTON 
 
 BEGBIE, Edited by Dr. Dyck Duckworth. With a Memoir 
 and Portrait. 
 
 " The Council of the Sydenham Society, and Dr. Duckworth, in particular, 
 have done a good work in collecting these writings together into a volume, and 
 the profession in Scotland and in many places be\-ond will feel grateful to them
 
 CLASSIFIED LIST OF PUBLICATIONS. 13 
 
 for this memorial of one who lives in the affectionate remembrance and 
 admiration of his professional brethren and associates, and who, indeed, had 
 earned in the public esteem the title of the ' beloved physician.' " — Edinburgh 
 Medical jfournal, June, 1883. 
 
 "The New Sydenham Society has acted well within its best purposes in 
 publishing this selection from the works of the late Dr. J. Warburton Begbie." 
 — Lancet, July 21, 1883. 
 
 SELECTIONS FROM THE CLINICAL WORKS OP 
 
 DE. DUCHENNE (of Boixlogne). Translated and Edited by 
 Dr. Vivian Poore. 
 
 " The work of condensation and selection appears to have been admirably 
 performed; nearly all the material is drawn from Duchenne's great work, 
 which bears the somewhat misleading title of ' L'Electrisation Lotalisee.' " — 
 British Medical Joiirnal, Jan. 12, 1884. 
 
 ESMARCH ON THE USES OP COLD IN SURGICAL 
 
 PEACTICE. Translated by Dr. Montgomery, Woodcuts. 
 
 " Esmarch's treatise is of high practical interest." — British Medical Journal, 
 December, 1863, 
 
 BILLROTH'S LECTURES ON SURGICAL PATH- 
 OLOGY AND THERAPEUTICS. A Hand-book for Students 
 and Practitioners. 2 vols. 
 
 " While being rendered in most fluent and unconstrained Bnglish, it is 
 singularly free from obscurities and ambiguities with which translations gene- 
 rally abound." — London Medical Record, April, 1878. 
 
 " Whether looked at as a text-book for students or as a work of reference 
 for the hard-worked and busy practitioner, it deserves to be spoken of in high 
 terms of commendation." — Brit, and For. Med. Chir. Rev., July, 1873. 
 
 INVESTIGATION INTO THE ETIOLOGY OP THE 
 
 TRAUMATIC INFECTIVE DISEASES. By E.Koch. Trans- 
 lated, with Lithographic Plates, by Mr. Watson Cheyne. 
 
 ON THE PROCESS OP REPAIR APTER RESECTION 
 
 AND EXTIRPATION OF BONES. By Dr. A. Wagner, of 
 Berlin. Translated by Mr. T. Holmes. 
 
 CLINICAL LECTURES. Selected from Professor Volkmann's 
 
 Series. 2 vols. (See "Medicine.") 
 
 THE WORKS OP ABRAHAM COLLES. Chiefly his 
 Treatise on the Venereal Disease and on the Use of Mercury. 
 Edited, with Portrait, by Dr. McDonnell, of Dublin. 
 
 h
 
 14 THE NEW SYDENHAM SOCIETY. 
 
 ON THE MORE IMPORTANT DISEASES OF WOMEN 
 
 AND CHILDREN, with other Papers, by Dr. Gooch. Re- 
 
 Xn-inted; with a Prefatory Essay by Dr. Robert Ferguson. 
 
 With woodcuts. 
 
 " The work of Dr. Gooch is so well known and highly appreciated by every 
 lover of medical literature that we need say nothing in its praise. It has been 
 before the world for thirty years, and only one opinion has been expressed upon 
 its merits. We cannot but consider, therefore, that the Council of the New 
 Sydenham Society has done well to republish it, more especially as the Council 
 has had the good fortune to persuade Dr. Robert Ferguson to furnish an intro- 
 ductory essay on the author's life and writings." — Lancet. 
 
 CLINICAL MEMOIRS ON DISEASES OP WOMEN. 
 
 By Drs. Bernutz and Goupil. 2 vols. Translated and abridged, 
 Dr. Meadows. 
 
 "The careful study of these valuable memoirs is imperative on all who arc 
 interested in gynaecology." — Lancet, October, 1866. 
 
 SMELLIE'S MIDWIFERY. 3 vols. Edited and Annotated 
 by Dr. McClintock, of Dublin. With Portrait of Smellie. 
 
 " This book begins with a fine engraving of the author, and had the N. S. S. 
 done for Smellie's memory no more than the publication of this valuable print, 
 it would have a strong claim on the gratitude of the profession. McClintock's 
 life of Smellie is a very interesting contribution to medical literature. His 
 works show that he was a very great man and midwife, but his biography was 
 
 needed to show his peculiarities Let the reader carefully peruse Dr. 
 
 McClintock's annotations, and he will see how Smellie's Editor recognises 
 Smellie's keenness of eye in discerning how to make progress." — Edin. Med. 
 Journal, March, 1877. 
 
 " The New Syd. Soc. has done nothing more commendable than to produce 
 
 the work we are now about to notice Smellie was the Sydenham of 
 
 Midwifery. Although it was a chief part of his glory to have studied deeply 
 and soundly the mechanism of labour as a natural process, and in that study to 
 have laid the ample foundations of the highly finished art of midwifery as we 
 see it practised by the best obstetricians of the present day, we also see evidence 
 in everyone of his 'cases' of shrewd and sagacious medical views, showing 
 that his great manipulative faculties were governed and controlled by good 
 judgment, physiological considerations, and that great respect for nature which 
 
 is a characteristic of all great physicians In short, he was a model 
 
 practitioner in midwifery whose influence grows rather than diminishes, and 
 whose works will be found to contain the germ of most of our practice and 
 doctrine Dr. McClintock has fairly placed alongside of Smellie's prin- 
 cipal views those of modern authorities, including his own, derived from an 
 experience altogether exceptional, and has produced a joint work \yithout which 
 no obstetric library will be complete." — Lancet, August 4, 1877,
 
 CLASSIFIED LIST OF PUBLICATIONS. 15 
 
 DiS)Ctint^ of ttjc lEüc anij 3Eai% 
 
 ON THE ANOMALIES OF ACCOMMODATION AND 
 
 EEFKACTION OP THE EYE, with a PKELIMINAEY 
 ESSAY ON PHYSIOLOGICAL DIOPTEICS. By P. C. 
 DoNDERs, M.D., Professor of Physiology and Ophthalmology in 
 the University of Utrecht. Written expressly for the Society. 
 Translated from the Author's Manuscript by W. D. Moore, M.D. 
 
 " This splendid monograph, from the hand of the accomplished professor 
 of physiology and ophthalmology, of Utrecht, will be hailed as a boon by all 
 lovers of ophthalmic science." — Lancet. 
 
 THREE MEMOIRS ON GLAUCOMA AND ON 
 
 IRIDECTOMY AS A MEANS OP TREATMENT. By 
 
 Professor Von Gr.iefe. Translated by Mr. T. Windsor, of 
 Manchester. 
 
 " This is the fifth volume of the first year, and contains translations of three 
 important and well known essays from the German." — Lancet. 
 
 " The value — the great practical value — of these memoirs will be admitted 
 by every one who peruses them." — Medical Times and Gazette. 
 
 ON THE MECHANISM OF THE BONES OF THE 
 
 EAR AND THE MEMBRANA TYMPANI. (Pamphlet.) 
 By Professor Helmholtz. Translated by Mr. Hinton. 
 
 " This little work is the translation of a very valuable essay published by 
 the great physicist of Berlin, and which is thus rendered accessible to a wide 
 circle of English readers." — Lancet, July 5, 1873. 
 
 THE AURAL SURGERY OF THE PRESENT DAY. 
 
 By W. Kramer, M.D., of Berlin. Translated by Henky Power, 
 Esq., F.R.C.S., M.B. With two Tables and nine Woodcuts. 
 
 VON TROELTSCH'S TREATISE ON DISEASES OF 
 
 THE EAR. Translated, with Notes, by Mr. Hinton. 
 
 Jfoxtnm iltctricinc. 
 
 A HANDBOOK OF THE PRACTICE OF FORENSIC 
 
 MEDICINE, BASED UPON PERSONAL EXPERIENCE. 
 
 By J. L. Casper, M.D., late Professor of Medical Jurisprudence 
 
 in the University of Berlin. Translated by G. W. Balfour, 
 
 M.D. 4 vols. 
 
 " Casper's great work, based as it is upon a minute and laborious observa- 
 tion of facts, must prove the most trustworthy guide in the interpretation of the 
 ofttimes difficult questions which the medical jurist is called upon to solve,"— 
 Lancet.
 
 16 THE NEW SYDENHAM SOCIETY. 
 
 " This work must be regarded as a valuable and judicious addition to the 
 publications of the Society from which it emanates. The advantages to be 
 derived by the reader from its perusal cannot be over-estimated or too eagerly 
 sought for," — Madras Quarterly Joiirnal of Medical Science, 
 
 SCHRCEDER VAN DER KOLK ON A CASE OP 
 
 ATEOPHY OF THE LEFT HEMISPHERE OF THE 
 BRAIN. Translated by Dr. W. Moore, of Dublin. Four 
 Lithographs. 
 
 ON THROMBOSIS OF THE CEREBRAL SINUSES. 
 
 By Professor Von Dusch. Translated by Dr. Whitley. 
 
 LECTURES ON DISEASES OP THE NERVOUS 
 
 SYSTEM. By Professor Chaecot. (First Series.) Translated 
 by Dr. Sigeeson, of Dublin. With woodcuts. 
 
 " These lectures of M. Charcot are too well known in the original to call 
 for any special criticism here. They have, indeed, obtained an European 
 reputation, and it has long been felt that it would be a great gain to our literature 
 
 to have them rendered into English We strongly advise all those of 
 
 our readers who may not yet have made themselves acquainted with these 
 
 lectures to lose no time in doing so The translator. Dr. Sigerson, «a 
 
 former pupil of the author, has succeeded admirably in his rendering of the 
 
 elegant literary style of M. Charcot It is, without doubt, one of the 
 
 most valuable books that has been issued by this Society since their translation 
 of Trousseau." — Lancet, August, 1877. 
 
 " This volume will be highly prized by the members of the N. S. S. M. 
 Charcot's name ranks among the very foremost of those who have advanced the 
 knowledge of nerve-pathology. The work he has done is marked by great 
 accuracy and close observation, and by great acumen in interpreting facts and 
 drawing inferences." — Brit, and For. Med. Chir. Rev., July, 1877. 
 
 SECOND VOLUME OP LECTURES ON DISEASES 
 
 OF THE NERVOUS SYSTEM. By Professor Chaecot. 
 Translated by Dr. Sigeeson. With this volume all the Plates 
 to the two volumes will be given. 
 
 A MANUAL OP MENTAL PATHOLOGY AND THERA- 
 PEUTICS. By Professor Geiesingee. Translated by Dr. 
 LocKHAET Eobeetson and Dr. James Rutheefoed. 
 
 " The thanks of the profession are due to the Council of the N. S. S. for 
 
 the selection of this work We need scarcely say that each section is 
 
 full of instruction, and carries upon its face the evidence of great experience 
 and close and deep thought." — Medical Times and Gazette, September, 1867. 
 
 ON EPILEPSY. By Professor Schkceder van dee Kolk,
 
 CLASSIFIED LIST OF PUBLICATIONS. 17 
 
 CHARCOT'S TREATISE ON THE LOCALISATION 
 
 OF CEEEBEAL AND SPINAL DISEASE. Translated 
 by Dr. Hadden. 
 
 " It will give to its reader a clear understanding of what is known of the 
 subject it professes to treat of." — Edinburgh Medical Journal, Dec, 1883. 
 
 " Dr. Hadden is to be congratulated upon having produced a translation 
 of these valuable Lectures, which, whilst faithful to the text, is not marred by 
 being too literal." — Medical Times and Gazette, October 27, 18S3. 
 
 ^natottt^, ^i^jjgiolos», antf Neutral l^at^olcis:^, 
 
 A MANUAL OP HUMAN AND COMPARATIVE HIS- 
 TOLOGY. By S. Stricker. 3 vols. Translated by Mr. Power. 
 
 " This work, edited by Strieker, and having as its contributors nearly all of 
 the best names in Germany, is one well deserving of attention, and constitutes, 
 we think, a very valuable addition to the stores ot the New Sydenham Society." 
 — Medical Times and Gazette, December 10, 1870. 
 
 " There has hitherto been no work which contained a full and complete 
 account of the various elements of animal structure, still less of the way in 
 which minute examination of these elements should be conducted. The book 
 
 before us supplies this want in a very remarkable degree The work is 
 
 illustrated by over a hundred woodcuts. Modern medical literature of the 
 higher class so teems with histological references, that a treatise in which they 
 are explained has become almost a necessity." — Lancet, December 3, 1870. 
 
 " We must congratulate the New Sydenham Society on their enterprise, 
 and thank them for making so important a work accessible to the English 
 reader." — Quarterly yournal of the Microscopic Society, April, 1873. 
 
 " Ably translated and edited by Mr. Henry Power The members 
 
 of the Society may be congratulated on the addition of such valuable treatises 
 to their libraries." — Brit, and For. Med. Chir. Rev., July, 1873. 
 
 EXPERIMENTAL RESEARCHES ON THE EFFECTS 
 
 OF LOSS OF BLOOD IN PKODUCING CONVULSIONS, 
 By Drs. Kussmaul and Tenner. Translated by Dr. Bronner, 
 of Bradford. 
 
 A MANUAL OF PATHOLOGICAL HISTOLOGY, 
 
 intended to serve as an introduction to the study of Morbid 
 Anatomy. By Professor Eindfleisch. (Bonn.) 2 vols. Trans- 
 lated by Dr. Baxter. 
 
 Vol. I. — " Rindfleisch's work forms a mine which no recent pathological 
 writer could afford to neglect who desired to interpret aright pathological 
 
 structural changes The special part treats of the anomalies of the 
 
 blood, the circulatory apparatus, of the serous and mucous membranes, skin, 
 lung, liver, kidneys, and so on. As a specimen of the scientific spirit with 
 which Rindfleisch has entered upon his very laborious work, the reader cannot 
 do better than to peruse the part devoted to normal as a type of the pathological 
 growths, and that which immediately follows on interstitial inflammation and 
 
 specific inflammation Altogether the book is the result of honest, hard 
 
 labour." — L«ncfC, April 6, 1872.
 
 18 THE NEW SYDENHAM SOCIETY. 
 
 Vol. 2. — " The members of the Society may be cono;ratulated on the 
 
 addition of such valuable treatises to their libraries The Society ought 
 
 to flourish whilst it caters so well for its members. Thsy have every reason to 
 be content both with the quantity and quality of the matter supplied." — Brii. 
 and For. Cliir. Rev., Jul}', 1873. 
 
 AN ATLAS OF ILLUSTRATIONS OF PATHOLOGY. 
 
 (See " Medicine,'' page 10.) 
 
 ON THE MINUTE STRUCTURE AND FUNCTIONS 
 
 OF THE SPINAL COED. By Professor Schrceder van der 
 Kolk. Translated hy Dr. W. D. Mooke. Nnmerous Litlio- 
 graplis. 
 
 ON THE MINUTE STRUCTURE AND FUNCTIONS 
 
 OF THE MEDULLA OBLONGATA, AND ON EPILEPSY. 
 By Professor Schrceder van der Kolk. Translated by Dr. W. 
 D. Moore. Numerous Lithograplis. 
 
 l^ttto<sptcts, auij SOoviksj of €5cncval Itcfcvtncc, 
 
 A YEAR-BOOK OF MEDICINE AND SURGERY, AND 
 
 THEIE ALLIED SCIENCES, for 1859. Edited by Dr. 
 Harley, Dr. Handfield Jones, Mr. Hulke, Dr. Graily Hewitt, 
 and Dr. Odling. 
 
 " Our space will not admit of a further statement of the excellent character 
 of the Year-Book and the other works issued by the New Sydenham Society, 
 but we should strongly urge e\'ery member of the profession, who has the 
 advancement of medical knowledge at heart, to lose no time in forwarding his 
 name, should he not already have done so." — London Medical yournal. 
 
 YEAR-BOOK for 1860. Edited by Dr. Harley, Dr. Handfield 
 Jones, Mr. Hulke, Dr. Graily Hewitt, and Dr. Sanderson. 
 
 " This is, as it professes to be, an improvement on its predecessor. On the 
 whole the editors have done their laborious work well." — British Medical 
 yournal, December 31, 1S61. 
 
 YEAR-BOOK for 1861. Edited by Dr. Harley, Dr. Handfield 
 Jones, Mr. Hulke, Dr. Graily Hewitt, and Dr. Sanderson. 
 
 YEAR BOOK for 1862. Edited by Dr. Montgomery, Dr. 
 Handfield Jones, Mr. Windsor, Dr. Graily Hewitt, and 
 Dr. Sanderson. 
 
 YEAR-BOOK for 1863. By the same Editors.
 
 CLASSIFIED LIST OF PUBLICATIONS. 19 
 
 YEAR-BOOK for 1864. Edited by Mr. Hinton, Dr. Handfield 
 Jones, Mr. Windsor, Dr. M. Bright, and Dr. Hilton Fagge. 
 
 " Of the usefulness of these reports all who have consulted them will bear 
 the fullest testimony. They supply a very valuable bibliography ; they enable 
 the reader to judge what papers or works he may study with advantage to his 
 peculiar pursuits ; and they present a condensed summary of the most im- 
 portant advances and improvements in medical science." — Edinburgh Medical 
 journal. 
 
 A BIENNIAL RETROSPECT OP MEDICINE, SUR- 
 GERY, AND THEIR ALLIED SCIENCES, for the Years 
 1865 and 186G. Edited by Mr. Power, Dr. Anstie, Mr. 
 Holmes, Dr. Barnes, Mr. Windsor, and Dr. Hilton Fagge. 
 
 A BIENNIAL RETROSPECT OF MEDICINE, SUR- 
 GERY, AND THEIR ALLIED SCIENCES, for the Years 
 1867 and 1868. Edited by Mr. H. Power, Dr. Anstie, Mr. 
 Holmes, Mr. R. B. Carter, Dr. Barnes, and Dr. Thomas 
 Stevenson. 
 
 A BIENNIAL RETROSPECT for 1869 and 1870. 
 
 " As to the Biennial Retrospect, it is as good as any of its class ; while ot 
 little value to town practitioners, possessing easy access to large, well-selected, 
 and well-catalogued libraries, it is no doubt of great value to country practitioners 
 whose resources in that respect are more limited." — Edinburgh Medical 
 Journal, May, 1872. 
 
 A BIENNIAL RETROSPECT lor 1871 and 1872. 
 
 A BIENNIAL RETROSPECT for 1873 and 1874. 
 
 " Full justice is done to English observers, and the whole volume is creditable 
 to its compilers and to the Society under whose auspices it is published." — 
 Lancet, January, 1876. 
 
 THE MEDICAL DIGEST. Being a means of ready reference 
 to the principal contributions to Medical Science during the last 
 Thirty years. By Dr. Riohaed Neale. 
 
 " The Council has certainly acted wisely in publishing the work before us 
 It is a section of what has long been a desideratum— a general index to rnedical 
 literature, and as a section its great value cannot but suggest how inestimably 
 
 valuable a complete work of this kind would be Compiled by a 
 
 practitioner for his own use, it is calculated especially for the use of the 
 practitioner." — Lancet, January 5, 1878. 
 
 " The idea of this volume is a good one. Something of the kind had been 
 all along contemplated by the Society, but never carried out till now, when Dr. 
 
 Neale offered his manuscript, exactly as it is printed We have been at 
 
 the pains of testing the index in a good many instances, and have come to the 
 conclusion that it may be relied on for discovering easily the contents of the 
 volume.'"— Edinburgh Medical jfournal, April, 1878.
 
 20 THE NEW SYDENHAM SOCIETY. 
 
 BIBLIOTHECA THERAPEUTICA; OR BIBLIO- 
 GRAPHY OF THEEAPEUTICS. By E. J. Waring, M.D. 
 2 vols. 
 
 " The preparation of such a catalogue as the present one must have 
 entailed enormous labour, such as few men are capable of, and such as rarely 
 brings them the thanks they deserve. We are quite sure, however, that all 
 those who are engaged in the study of Materia Medica, who are not satisfied 
 with merely looking at a few recent papers, but are desirous of learning all 
 that has been done regarding the particular drug which may be the object of 
 their attention, will be exceedingly grateful to Dr. Waring for sparing them so 
 much labour." — Practitioner, December i8th, 1879. 
 
 "We feel sure that, although not exactly what we would like in a 
 work of the kind, Waring's ' Bibliotheca Therapeutica,' with its copious and 
 valuable indices, will be frequently referred to with advantage, and with 
 considerable confidence as regards its accuracy." — Glasgow Medical Journal, 
 Sept., 1879. 
 
 " With the Index of Diseases before him, the student has a bird's-eye view 
 of the principal remedies recommended from time to time in the treatment of 
 individual diseases, and the dates of their respective employments ; whilst 
 further reference to the body of the work, in the manner pointed out in the 
 index, will disclose the name of the authority, and other particulars of special 
 interest to the pathologist and therapeutist." — From Preface to Vol. 2, 
 
 A LEXICON OF MEDICAL TERMS. Edited by Mr. 
 Power and Dr. Sedgwt:ck. Parts 1 to 8. This Lexicon is 
 based upon the well-known work of Dr. Mayne, the copyright 
 of which was purchased by the Society. It is, however, 
 entirely rewritten by the present Editors, and very much 
 enlarged. 
 
 " The work is carefully and elaborately done, and comprehends ^very 
 reference which the medical or scientific inquirer could possibly require." — 
 Medical Press and Circular, June 22nd, 18S1. 
 
 ON SYPHILIS IN INFANTS. By Paul Diday. Translated 
 by Dr. Whitley. 
 
 " The work of M. Diday is of great merit ; it contains all that has be^n 
 written on infantile syphilis, and he puts the whole subject in a well-airanged 
 form for further investigation as well as present use." — Brit, and For. Med, 
 Cliir. Rev, 
 
 ON DISEASES OF THE SKIN, INCLUDING THE 
 
 EXANTHEMATA. By Professor Hebra. 5 vols. Translated 
 and Edited by Dr. Hilton Fagge, Dr. Pye-Smith, and Mr. 
 Waren Tay. 
 
 " Had we space we should have been glad to enter into a lengthened 
 critique of the second volume of Hebra's work. We are relieved from any 
 misgiving, however, by the fact that the work will be very largely circulated 
 amongst our readers by the Sydenham Society, and that they, with others who
 
 CLASSIFIED LIST OF PUBLICATIONS. 21 
 
 aspire to any real knowledge of skin diseases, would not, under any circum- 
 stances, be satisfied without studying the work for themselves This 
 
 second volume contains information relative to the most important diseases of 
 the skin ; andjt will, we are confident, do good service in helping on the cause 
 of cutaneous medicine in England." — Lancet, November 7, 1868. 
 
 " Of all the works produced by the New Sydenham Society this is one of 
 
 the most valuable and most welcome It is to be remarked that this 
 
 book is not a mere translation of the German work ; it is a new and revised 
 edition, undertaken by the author for his English brethren." — Medical Times 
 and Gazette, April 27, 1867. 
 
 " The New Sydenham Society has done good service to the medical pro- 
 fession by undertaking the translation and publication of Professor Hebra's 
 excellent work. In several respects the English edition is greatly superior to 
 the original. In closing its pages we have but one regret, namely, that the 
 New Sydenham Society does not embody the whole medical confraternity, 
 so that every member of our noble profession might have on his bookshelves 
 a copy of this most valuable book." — jfournal of Cutaneotis Medicine, April, 
 1877. 
 
 Vol. 3. — " Mr. Tay has performed a difficult task with great ability and 
 success, and the work is far pleasanter to read in its English dress than in the 
 original. Mr. Tay has enriched the work with valuable notes of his own, 
 embodying the views of English authorities and sometimes his own experience 
 on the question discussed in the body of the work." — Medical Times and 
 Gazette, June 20, 1874. 
 
 Vol. 4 — " The entire work is admirable for its lucidity of arrangement, its 
 simplification of confused and intricate subjects, and not least for the avoidance 
 of those pedantic and repelling terms which a celebrated dermatologist has 
 grandiloquently styled the ' terminological innovations of modern nomen- 
 ciators.' " — Dublin yoiirnal of Medical Science, May, 1875. 
 
 LANCEREAUX^S TREATISE ON SYPHILIS. 2 vols. 
 Translated by Dr. Whitley. 
 
 " The work is the most exhaustive book which has been published on the 
 subject, and has been quoted by all the recent writers in this country, America, 
 and the Continent. It is a perfect mine of information. The translation is 
 well done, and the New Syd. Soc. may be congratulated on having added such 
 an important treatise to its list of works." — Lancet, March, i86g. 
 
 In sixteen Fasciculi comprising tlie following subjects. Unless 
 otherwise indicated, the Plates are original. 
 
 Favus. From Hebra. 
 
 Tinea Tonsurans. From Hebra. 
 
 Lupus Exulcerans. From Hebra. 
 
 Psoriasis Diffusa. From Hebra. 
 
 Ichthyosis. From Hebra. 
 
 Lupus Serpiginosus ; Alopecia Areata. From Hebra. VI. 
 
 Lupus Vulgaris et Serpiginosus (Cicatrising). From 
 
 Hebra VII 
 
 PLATE 
 I. 
 
 IL 
 III. 
 IV. 
 V.
 
 22 
 
 THE NEW SYDENHAM SOCIETY. 
 
 PLATE 
 
 Herpes Zoster Frontalis (affecting the Frontal and 
 
 Trochlear Branches of the Fifth Nerve). . . VIII. 
 
 Molluscum Contagiosum, a, on a Child's Face ; b, on 
 the Breast of the Child's Mother ; c, Anatomical 
 Characters of the Tumours ; d, Microscopic Cha- 
 racters. ........ IX. 
 
 Morbus Addisouii. ....... X. 
 
 Leucoderma. ........ XI. 
 
 Pemphigus. ........ XII. 
 
 Pityriasis Versicolor. ...... XIII. 
 
 Psoriasis luveterata. ....... XIV. 
 
 Eczema Impetiginodcs on Face of Adult. . . . XV. 
 
 Eczema on the Face, &c., of Infant; Eczema Eubrum 
 
 on Leg of Adult XVI. 
 
 Psoriasis of Hands and Finger-nails; Syphilitic 
 Psoriasis of Finger-nails ; Congenito- Syphilitic 
 Psoriasis of Finger- and Toe-nails; Onychia 
 
 Maligna; Chronic General Onychitis.. '. . XVII. 
 
 IMolluscum Fibrosum sen Simi)lex. .... XVIII. 
 
 Psoriasis-Lupus (Lupus non Exedcns, in numerous 
 
 Symmetrical Patches). ..... XIX. 
 
 Porrigo Contagiosa (e pediculis). .... XX. 
 
 Erythema Nodosum. ....... XXI. 
 
 Morbus Pedicularis. ....... XXII. 
 
 Herpes Zoster (with scars of a former attacli). . XXIII. 
 
 Erythema Circinatum. ... . XXIV. 
 
 Eczema (from Sugar). ...... XXV. 
 
 Acne Vulgaris XXVI. 
 
 Scabies (on Hand of Child). Scabies (with Qildema, 
 
 &c.) Scabies Norvegica. ..... XXVII. 
 
 Porrigo Contagiosum after Vaccination. Circinate 
 
 Eruptions in Congenital Syphilis. . . . XXVIII. 
 
 True Leprosy (Tubercular Form). True Leprosy 
 
 (AnaDsthetic Form) XXIX. 
 
 Pityi'iasis Piubra. ....... XXX. 
 
 Papular Syphilitic Eruption, with Indurated Chancre 
 
 on the Skin of the Abdomen. .... XXXI. 
 
 Pruriginous Impetigo after Varicella. .... XXXII. 
 
 Lichen of Infants XXXIII. 
 
 Kerion of Scalp after Ringv\^orm. . , . . XXXIV. 
 
 Eruption produced by Iodide of Potassium. , . XXXV. 
 
 Tinea Circinata • . XXXVI. 
 
 Eupia-Psoriasis (from inherited Syphilis). . . . XXXVII. 
 
 Prurigo Adolescentium. ...... XXXVIII. 
 
 Purpura Thrombotica XXXIX. 
 
 Syphilitic Eupia, with Keloid of Scars. . . . XL. 
 
 Frambcesia (Endemic Verrugas) XLI. 
 
 Lupus Erythematosus XLII.
 
 CLASSIFIED LIST OF PUBLICATIONS. 23 
 
 PLATE 
 
 Ulcerating Eruption from Bromide of Potassium. . XLIII 
 
 Morphaea, or Addison's Keloid. ..... XLIV. 
 
 Purpura Haemorrliagica. ...... XLV. 
 
 Molluscum Coutasfiosum, . . . . . . XLVI. 
 
 " This Fasciculus supplies life size portraits of pityriasis rubra, papular 
 syphilis, with indurated chancres, and pruriginous impetigo following varicella, 
 which are extremely beautiful, and look life-like." — Edin. Medical yournal, 
 May, 1872. 
 
 " They are better, to our mind, than any other plates in use amongst us; 
 and there cannot be a question as to the Society's issue being as popular as it 
 is useful." — Lancet. 
 
 " We have received the thirteenth fasciculus of this splendid collection of 
 drawings, of which no further praise is needed than to say that they are 
 executed with the same artistic skill and fidelity to nature which have charac- 
 terised the whole series." — Dublin Journal of Medical Science, May, 1874. 
 
 A CATALOGUE OF THE PORTRAITS COMPRISED 
 
 IN THE SOCIETY'S ATLAS OF SKIN DISEASES. 
 Prepared, at the request of the Council, by Mr. Hutchinson. 
 Parts 1 and 2. 
 
 " The descriptions, cases, and plates are well given There is one 
 
 good feature in some of the cases described. Take that of Addison's Keloid, 
 p. 160. In it we have notes, &c., of a rare skin disease, which has been 
 accurately described by the observers under whose care the patient had been at 
 various stages of the case. This is, therefore, a valuable contribution to medi- 
 cine." — Edinburgh Medical journal, February, 1877.
 
 LIST OF PUBLISHED WOUKS 
 
 Arranged according to the Year of Issue. 
 
 Vol. 1859. {First Year.) 
 
 1. Did AY on Infantile Syphilis. 
 
 2. GoocH on Diseases of Women. 
 
 3. Memoies on Diphtheria. 
 
 4. Van deb Kolk on the Spinal Cord, &c. 
 
 5. Monographs (Kussmaul and Tenner, Graefe, Wagner, &c.) 
 
 1860. {Second Year.) 
 
 6. Dr. Bright on Abdominal Tumours. 
 
 7. Frerichs on Diseases of the Liver. Vol. I. 
 
 8. A Yearbook for 1859. 
 
 9. Atlas of Portraits of Skin Diseases. (1st Fasciculus.) 
 
 1861. {Third Year.) 
 
 10. A Yearbook for 1860. 
 
 11. Monographs (Czermak, Dusch, Eadicke, &c.) 
 
 12. Casper's Forensic Medicine. Vol. I. 
 
 14. Atlas of Portraits of Skin Diseases. (2nd Fasciculus.) 
 
 1862. {Fourth Year.) 
 
 13. Frerichs on Diseases of the Liver. Vol. IL 
 
 15. A Yearbook for 1861. 
 
 16. Casper's Forensic Medicine. Vol. II. 
 
 17. Atlas of Portraits of Skin Diseases (3rd Fasciculus.) 
 
 1863. {Fifth Year.) 
 
 18. Kramer on Diseases of the Ear. 
 
 19. A Yearbook for 1862. 
 
 20. Neubauer and Vogel on the Urine.
 
 LIST OF PUBLISHED WOEKS. 25 
 
 Vol. 1864. {Sixth Year.) 
 
 21. Casper's Forensic Medicine. Vol. III. 
 
 22. DoNDERs on the Accommodation and Eefraction of the 
 
 Eye. 
 
 23. A Yearbook for 18 63. 
 
 24. Atlas of Portraits of Skin Diseases. (4th Fasciciüus). 
 
 1865. {Seventh Year.) 
 
 25. A Yearbook for 1864. 
 
 26. Casper's Forensic Medicine. Vol. IV. 
 
 27. Atlas of Portraits of Skin Diseases. (5th Fasciculus). 
 
 1866. {Eicjhth Year.) 
 
 28. Bernutz and Goupil on the Diseases of Women. Vol. I. 
 
 29. Atlas of Portraits of Skin Diseases. (6th Fasciculus.) 
 
 30. Hebra on Diseases of the Skin. Vol. I. 
 
 31. Bernutz and Goupil on Diseases of Women. Vol. II. 
 
 1867. {Ninth Year.) 
 
 32. Biennial Pietrospect of Medicine and Surgery. 
 
 33. Griesinger on Mental Pathology and Therapeutics. 
 
 34. Atlas of Portraits of Skin Diseases. (7th Fasciculus). 
 
 35. Trousseau's Clinical Medicine. Vol. I. 
 
 1868. {Tenth Year.) 
 
 36. The Collected Works of Dr. Addison. 
 
 37. Hebra on Skin Diseases. Vol. II. 
 
 38. Lancereaux's Treatise on Syphilis. Vol. I. 
 
 39. Atlas of Portraits of Skin Diseases. (8th Fasciculus). 
 
 40. Catalogue of Atlas of Skin Diseases. (First Part.) 
 
 1869. {Eleventh Year.) 
 
 41. Lancereaux's Treatise on Syphilis. Vol. II. 
 
 42. Trousseau's Clinical Medicine. Vol. II. 
 
 43. Biennial Eetrospect of Medicine and Surgery. 
 
 44. Atlas of Portraits of Skin Diseases. (9th Fasciculus.) 
 
 1870. {Twelfth Year.) 
 
 45. Trousseau's Lectures on Clinical Medicine. Vol. III. 
 
 46. Niemeyer's Lectures on Pulmonary Consumption. 
 
 47. Stricker's Manual of Histolog3\ Vol. I. 
 
 48. Atlas of Portraits of Skin Diseases. (10th Fasciculus).
 
 26 THE NEW SYDENHAM SOCIETY. 
 
 Vol. 1871. (Thirteenth Year.) 
 
 49. Wunderlich's Medical Thermometry. 
 
 50. Biennial Retrospect of Medicine and Surgery. 
 
 51. Trousseau's Clinical Medicine. Vol. IV. 
 
 52. Atlas of Portraits of Skin Diseases. (11th Fasciculus.) 
 
 1872. (Fourteenth Year.) 
 
 53. Stricker's Manual of Histology. Vol. II. 
 
 54. Eindfleisch's Pathological Histology. Vol. I. 
 
 55. Trousseau's Clinical Medicine. Vol. V. 
 
 56. Atlas of Portraits of Skin Diseases. (12th Fasciculus.) 
 
 1873. (Fifteenth Year.) 
 
 57. Stricker's Manual of Histology. Vol. III. 
 
 58. Eindfleisch's Pathological Histology. Vol. II. 
 
 59. Biennial Eetrospect of Medicine and Surgery. 
 
 60. Atlas of Portraits of Skin Diseases. (13th Fasciculus.) 
 
 1874. (Sixteenth Year.) 
 
 61. Hebra on Skin Diseases. Vol. III. 
 
 62. Von Troeltsch on Diseases of the Ear. 
 Helmholtz on Membrana Tympani, &c. (In one Vol.) 
 
 63. Atlas of Portraits of Skin Diseases. (14th Fasciculus.) 
 
 64. Hebra on Skin Diseases. Vol. IV. 
 
 1875. (Seventeenth Year.) 
 
 65. Biennial Eetrospect of Medicine and Surgery. 
 
 66. Catalogue of Atlas of Skin Diseases. (Second Part.) 
 
 67. Atlas of Portraits of Skin Diseases. (15th Fasciculus.) 
 
 68. Clinical Lectures by various German Professors. Vol. I. 
 
 69. Latham's Works. Vol. I. 
 
 1876. (Eighteenth Year.) 
 
 70. Smellie's Midwifery, by McClintock. Vol. I. 
 
 71. Clinical Lectures by various German Professors. Vol. II. 
 
 72. Charcot's Clinical Lectures on Diseases of the Nervous 
 
 System. Vol. I. 
 
 73. Billroth's Lectures on Surgical Pathology. Vol. I. 
 
 1877. (Nineteenth Year.) 
 
 74. Smellie's Midwifery, by McClintock. Vol. II. 
 
 75. The Medical Digest, by Dr. Neale. 
 
 76. Billroth's Lectures on Surgical Pathology. Vol. II. 
 
 77. Atlas of Illustrations of Pathology. (Fasciculus I.)
 
 LIST OF PUBLISHED WORKS. 27 
 
 Vol. 1878. {Twentieth Year.) 
 
 78. BiBLioTHECA Tlierapeutica, by Dr. Waring. Vol. I. 
 
 79. Smellie's Midwifery, by McClintock. Vol. III. 
 
 80. Latham's Works. Vol. II. 
 
 81. Lexicon of Medical Terms. (First Part.) Issued icitJi 
 
 Part II. onhj, as Vol. 83. 
 
 1879. {Twenty -first Year.) 
 
 82. BiBLioTHECA Tberapcutica, by Dr. Waring. Vol. II. 
 
 83. Lexicon of Medical Terms. (Second Part.) Including 
 
 re-issue of First Part. 
 
 84. Manual of Pliysical Diagnosis, by Dr. Guttmann. 
 
 85. Atlas of Illustrations of Pathology. (Fasciculus IL) 
 
 1880. {Twenty-second Year.) 
 
 86. Hebra on Diseases of the Skin. Vol. V. 
 
 87. Lexicon of Medical Terms. (Third Part.) 
 
 88. Koch's Piesearches on Wound Infection. 
 
 89. Lexicon of Medical Terms. (Fourth Part.) 
 
 90. Charcot's Clinical Lectures on Diseases of the Nervous 
 
 System. Vol. II. 
 
 91. Atlas of Illustrations of Pathology. (Fasciculus III.) 
 
 1881. {Twenty-third Year.) 
 
 92. Selections from the Works of Abraham Colles. 
 
 93. Lexicon of Medical Terms. (Fifth Part.) 
 
 94. Billroth's Clinical Surgeiy. 
 
 95. Charcot on Diseases of Old Age. 
 
 96. Lexicon of Medical Terms. (Sixth Part.) 
 
 97. Atlas of Illustrations of Pathology. (Fasciculus IV.) 
 
 1882. {Twenty-fourth Year.) 
 
 98. Stokes on Diseases of the Chest. 
 
 99. Atlas of Portraits of Skin Diseases. (16th Fasciculus.) 
 
 100. The Collected Works of Dr. Warburton Begbie. 
 
 101. Lexicon of Medical Terms. (Seventh Part.) 
 
 102. Charcot on Localisation of Cerebral and Spinal Disease. 
 
 103. Lexicon of Medical Terms. (Seventh Part.) 
 
 1883. {Twenty-fifth Year.) 
 
 104. Atlas of Illustrations of Pathology. (Fasciculus V.) 
 
 105. Selections from the Works of Dr. Duchenne. 
 
 106. Hirsch on Geographical and Historical Pathology. Vol. I.
 
 LIST OF SURPLUS VOLUMES, 
 
 With Prices. 
 
 N.B. — The prices affixed can be continued only for a limited period until 
 surplus stock is disposed of. 
 
 ATLAS OF SKIN DISEASES. Fasciculi 2, 3, 4, 6, 7, 
 
 II, 14, and 15. Separately. los. 6d. each. Most of the stones have been 
 destroyed, and only a limited number of impressions remain in stock, and a 
 few are out of print. 
 
 ON SYPHILIS IN INFANTS. By Paul Diday. Trans- 
 
 lated by Dr. Whitley. 2s. 6d. 
 
 GOOCH ON THE MORE IMPORTANT DISEASES 
 
 OF WOMEN AND CHILDREN. Prefatory Essay by Dr. Robert 
 Ferguson. Woodcuts. 2s. 6d. 
 
 MEMOIRS ON DIPHTHERIA. By Bretonneau, 
 
 Trousseau, Daviot, Guersant, Bouchut, Empis, &c. Selected and 
 Translated by Dr. R. H. Semple. 3s. 6d. 
 
 ON THE MINUTE STRUCTURE AND FUNCTIONS 
 
 OF THE SPINAL CORD. By Professor Schroeder van der Kolk. 
 
 ON THE MINUTE STRUCTURE AND FUNCTIONS 
 
 OF THE MEDULLA OBLONGATA, AND ON EPILEPSY. By 
 Professor Schroeder van der Kolk. Translated by Dr. W. D. Moore, 
 of Dublin. In one volume, with numerous Lithographs. 5s. 
 
 EXPERIMENTAL RESEARCHES ON THE EFFECTS 
 
 OF THE LOSS OF BLOOD IN INDUCING CONVULSIONS. 
 By Drs. Kussmaul and Tenner. Translated by Dr. Bronner, of 
 Bradford. 
 
 ON THE PROCESS OF REPAIR AFTER RE- 
 
 SECTION AND EXTIRPATION OF BONES. By Dr. A. Wagner, of 
 Berlin. Translated by Mr. T. Holmes. Numerous Woodcuts. 
 
 PROFESSOR VON GRAEFE'S THREE MEMOIRS 
 
 ON GLAUCOMA, AND ON IRIDECTOMY AS A MEANS OF 
 TREATMENT. Translated by Mr. T. Windsor, of Manchester. 
 Three Monographs in one Volume. 2s. 6d,
 
 LIST OF SURPLUS VOLUMES. 29 
 
 MEMOIRS ON ABDOMINAL TUMOURS AND In- 
 tumescence. By Dr. Bright. Reprinted from the ' Guy's Hospital 
 Reports,' with a Preface by Dr. Barlow. Numerous Woodcuts. 7s. 6d. 
 
 A CLINICAL ACCOUNT OF DISEASES OF THE 
 
 LIVER. By Professor Frerichs. Translated by Dr. Murchison. 
 Numerous Woodcuts and coloured Lithographs. 2 vols. 12s. 6d. Vol I. 
 separately, 3s. 6d. 
 
 CZERMAK ON THE PRACTICAL USES OF THE 
 
 LARYNGOSCOPE. Translated by Dr. G. D. Gibb, Numerous 
 Woodcuts. 
 
 DUSCH ON THROMBOSIS OF THE CEREBRAL 
 
 SINUSES. Translated by Dr. Whitley. 
 
 SCHROEDER VAN DER KOLK ON ATROPHY OF 
 
 THE BRAIN. Translated by Dr. W. D. Moore, of Dublin. Four 
 Lithographs. 
 
 RADICKE'S PAPERS ON THE APPLICATION OF 
 
 STATISTICS TO MEDICAL ENQUIRIES. Translated by Dr. Bond. 
 
 ESMARCH ON THE USES OF COLD IN SURGICAL 
 
 PRACTICE. Translated by Dr. Montgomery. 
 
 Five Monographs in one Volume. 5s. 
 
 HAND-BOOK OF THE PRACTICE OF FOR- 
 
 ENSIC MEDICINE, BASED UPON PERSONAL EXPERIENCE 
 By J. L. Casper, M.D., Professor of Forensic Medicine in the University 
 of Berlin. Translated by Dr. G. W. Balfour. Vols. II.. III., IV. 
 7s. 6d. each. 4 vols., complete. £2 2s. 
 
 THE AURAL SURGERY OF THE PRESENT DAY. 
 
 By W. Kramer, M.D., of Berlin. Translated by Henry Power, F.R.C.S., 
 M.B. With two Tables and nine Woodcuts. 2s. 6d. 
 
 A GUIDE TO THE QUALITATIVE AND QUAN- 
 TITATIVE ANALYSIS OF THE URINE. By Dr. C. Neubauer and 
 Dr. J. Vogel. Fourth edition, considerably enlarged. Translated by 
 by W. O. Markham, F.R.C.P.L. With Four Lithographs and numerous 
 Woodcuts. 5s. 
 
 ON THE ANOMALIES OF ACCOMMODATION AND 
 
 REFRACTION OF THE EYE, WITH A PRELIMINARY ESSAY 
 ON PHYSIOLOGICAL DIOPTRICS. By F. C. Donders, M.D., Pro- 
 fessor of Physiology and Ophthalmology in the University of Utrecht. 
 Translated from the Authors's Manuscript by W. D. Moore, M.D. 7s. 6d. 
 
 TROUSSAEU.'S CLINICAL MEDICINE. Vols. IV. 
 
 and V-, separately 5s. each.
 
 30 THE NEW SYDENHAM SOCIETY. 
 
 YEAR-BOOKS OF MEDICINE AND SURGERY. 
 
 1839 — 64. Six Vols. 2S. 6d. each vol. 
 
 BIENNIAL RETROSPECT OF MEDICINE AND 
 
 SURGERY, 1865—74. 5 vols. 2s. 6d. each. 
 
 STRICKER'S MANUAL OF HISTOLOGY. 3 vols. 
 
 31s. 6d. Vols. I. and III. separately, 5s. each. 
 
 RINDFLEISCH'S PATHOLOGICAL HISTOLOGY. 
 
 Vol. II., 5s. 
 
 HEBRA'S TREATISE ON DISEASES OF THE 
 
 SKIN. Vols. I to 4, 2is. 
 
 LANCEREAUX'S TREATISE ON SYPHILIS. Two 
 
 vols. 5s. 
 
 NIEMEYER'S LECTURES ON PULMONARY CON- 
 SUMPTION. 2s. 6d. 
 
 LATHAM'S WORKS. 2 vols. 7s. 6d. Vol. I., 2s. 6d. 
 
 CLINICAL LECTURES BY VARIOUS GERMAN 
 
 PROFESSORS. First series, 5s. 
 
 LEXICON OF MEDICAL TERMS. Parts I. to V., 
 
 forming Vol. I. (in Parts), 25s. 
 
 GUTTMANN'S HANDBOOK OF PHYSICAL DIAG- 
 NOSIS. 5s. 
 
 Several of these works are well suited for presents to 
 Students or for Class Prizes. Amongst them may be espe- 
 cially mentioned Stricker's Histology ; Frerich's On Dis- 
 eases of the Liver ; Latham's Works ; Doxdees On Anomalies 
 of Refraction ; and Gtttmann's Physical Diagnosis, &c.
 
 LAWS OF THE NEAV SYDENHAM SOCIETY. 
 
 I. — The Society is institute! for the purpose 
 of supplying certain acknowledged deticiences 
 iu tue existing means of diffusing medical 
 literature, and shall be called " Thu New 
 Sydenham Society." 
 
 II. — The Society shall carry out its objects 
 by a succession of publications, of which the 
 following shall be the chief: — 1. Translations 
 of Foreign Works, Papers, and Essays of merit, 
 to be reproduced as early as practicable after 
 their original issue. 2. liritisa Works, Papers, 
 Lectures, &c., which, whilst of great value, 
 have become from any cause difficult to be 
 obtained, excluding those of living authors. 
 8. Annual Volumes consisting of Keports iu 
 Abstract of the progi-ess of the different 
 branches of Medical and Surgical Science 
 during the year. 4. Dictionaries of Medical 
 Bibliography and Biography. Those included 
 under Nos, 1 and 2 shall be held to have the 
 first claim on the attention of the Society ; 
 and the carrying out of those under Nos. 3 and 
 4 shall be considered dependent upon the 
 amount of funds which may be placed at its 
 disposal. 
 
 III. — The Subscription constituting a Mem- 
 ber shall be OneGumea, to be paid i-i advance 
 on the 1st of January annually, and it shall 
 entitle the subscriber to a copy of every work 
 published for that year. Nu books shall be 
 is urd to aiiy Member until )iis subscription 
 for the year has been paid. 
 
 IV.— The Officers of the Society shall be 
 elected from the Members, and shall consist 
 of a President, sixteen Vice-Presidents, a 
 Treasurer, a Secretary, and a Council of 
 thirty-two, in whom the power of framing 
 Bye-laws and of directing the affairs of the 
 Society shall be vested. Twelve of the Council 
 shall be ijrovincial residents. 
 
 V. —Five Members of the Council shall form 
 a quorum. 
 
 VI.— The Officers of the Society shall be 
 elected by ballot at the General Anniversary 
 Meeting of the Society. Balloting lists of 
 Officers proposed by the Council, with blank 
 places for such alterations as any Member 
 may wish to make, shall be laid on the 
 Society's table for the use of Membtrs. 
 
 VII. — The President, Vice-Presidents, and 
 Council, shall be eligible for re-election, except 
 that of the Vice-Presidents four, and of the 
 Council eight, shall retire every year. 
 
 VIII. — The Council shall appoint local Hono- 
 rary Secretaries wherever they shall see fit. 
 
 IX. — The business of the President shall be 
 to preside at the Annual and Extraordinary 
 Meetings of the Society; in his absence one of 
 the Vice-Presidents, or the 'Ireasurer, or any 
 Member of the Council chosen by the Members 
 Ijresent, shall take the Chair. 
 
 X. — The Treasurer, or some person ap- 
 pointed by him, shall receive all moneys due 
 to the Society. 
 
 XI.— The money in the hands of the Trea- 
 surer, which shall not be immediately required 
 for the uses of the Society, sLiall be vested in 
 such speedily available securities as shall be 
 approved by the Council. 
 
 XII. — The Council shall select the Works to 
 be published by the Society, and shall make 
 all arrangements, ijecuniary or otherwise, in 
 reg.ird to their publication. In the event of 
 any Member of the Council being appointed to 
 edit any Work for the Society, for which he is 
 to receive pecuniary remuneration, he shall 
 immediately cease to be a Member of the 
 Council, and shall not be eligible for re- 
 election till after the publication of the Work. 
 
 XIII.— The Council shall lay before the 
 Members at each Anniversary Meeting a Report 
 of their proceedings during the past year, and 
 also an account of the Receipts and Expendi- 
 ture of the Society; and shall further cause to 
 be printed and circulated among the Members 
 an abstract of such Report and Accounts im- 
 mediately after such Anniversary Meeting. 
 
 XIV. — The annual Accounts of the Receipfs 
 and Expenditure of the Society shall be 
 audited by a Committee of three Members, 
 selected at the preceding Anniversai-y Meeting 
 fr jm among the Members at large. 
 
 XV. — The Secretary shall have the manage- 
 ment of the general Correspondence of the 
 Society, and of such other business as may 
 arise in carrying out its objects. 
 
 XVI. — The local Secretaries shall further 
 the objects of the Society in their respective 
 districts, and shall be in communication with 
 the metropolitan Secretary. 
 
 XVII. — The Anniversary Meeting shall be 
 held in the same town as, and at the time of, 
 the Annual Meeting of the British Medical 
 Association, notice of it having been given 
 to all Members at least a week before the day 
 fixed on. 
 
 XVIII. — The Members generally shall be 
 invited and encouraged to propose Works, &c., 
 and to make any suggestions to the Council 
 they may think likely to be useful. 
 
 XIX.— The Works of the Society shall be 
 printed for the Members only. 
 
 XX. — No alteration in the Laws of the 
 Society shall be made, except at a General 
 Meeting. Notice of the alteration to be pro- 
 posed must also have been laid before the 
 Cüuncü at least a month previously. 
 
 XXI. — The Council shall have power to call 
 a General Meeting of the Members at any time, 
 and shall also be required to do so within three 
 weeks, upon receiving a requisition in writing 
 to that effect from not less than twenty Mem- 
 bers of the Society. 
 
 XXII. — All Special General Meetings of the 
 Society shall be held at such place as the 
 Council may appoint. 
 
 XXIII. — The Council shall meet at least 
 once in two months, unless by special resolu- 
 tion to the contrary. 
 
 6-2
 
 GENEKAL INFORMATION. 
 
 A Third Edition of the Volumes for 1859 was printed, 
 and a second of that for 1860. For subsequent years the 
 First Edition was much larger ; and it is not likely that any 
 of the Volumes will be reprinted. 
 
 Most of the stones for plates, &c., both those for the Atlas 
 of Skin Diseases and those for printed Volumes, have been 
 destroyed, and will not be reproduced. 
 
 The Society is now in its Twenty-fifth year. Arrangements 
 have been made by which new Members can obtain single 
 Volumes, or sets of Volumes, from the Society's stock in hand. 
 Some of the Volumes, of which a larger surplus exists than of 
 others, can be purchased at fixed prices (for which see list). 
 The Society's Agent is empowered to make special arrange- 
 ments with new Members who may wish to obtain any of the 
 past Volumes. 
 
 Carriage, &c. — The Society's Works are supplied free 
 of cost to any address in London, Edinburgh, or Dublin; 
 but the expenses of Carriage to all other places must be borne 
 by the members to whom the}' are sent. Members wishing 
 to receive their Volumes by Book-post can do so by pre- 
 paying the postage. INIembeis are requested to give detailed 
 instructions respecting the mode by which they wish their 
 Volumes to be forwarded, and also to remember that the 
 Society's responsibility ceases when the Book has been 
 delivered according to the instructions given. Members 
 wishing to receive their Works by Book-post can do so by 
 prepaying the sum of 2s. Gd. for the year. 
 
 The Subscription is One Guinea annually, to be paid ix 
 ADVANCE. The best mode of sending money is by Post-ofiice 
 Order, payable to Mr. Henry King Lewis, at the London 
 Office ; or by Cheque to the order of the Treasurer, Dr. 
 Sedgwick Saunders. It is requested that in future all 
 communications in reference to the payment of Subscriptions, 
 or the issue of Books, may be made to Mr. Lewis, the Society's 
 Agent, and not to tlie Secretary. 
 
 JONATHAN HUTCHINSON, 
 
 Hon. Secretary. 
 15, Cavkndish Square, W.
 
 GENEEAL INFORMATION. 33 
 
 \* Any Member wishing for additional Copies of this 
 Report, Sec, can obtain them by applying to Mr. Hutchinson; 
 or to the Society's Agent, Mr. Lewis, 130, Gower Street, W.C. 
 The Conncil will be much obliged by its distribution amongst 
 those thought likely to join the Society. 
 
 PS. — The Society's Agent is prepared to supply, at fixed 
 prices. Cases for binding the Lexicon, and Portfolios for 
 the reception of the Phites of Skin Diseases, and for the 
 Pathological Atlas. 
 
 .IMPOKTANT NOTICE TO NEW SUBSCRIBEKS AND LOCAL 
 SECRETAEIES. 
 
 New Members who subscribe for not fewer than three past 
 3'ears at once (with the current one) will be allowed to select 
 volumes from the surplus stock to the value of one guinea 
 without additional payment. The like privilege will be 
 secured each year by any Local Secretary who has the sub- 
 scriptions of all the members on his list (the number being 
 not less than ten) paid before the end of March for the current 
 year.
 
 LIST OF HON. LOCAL SECRETARIES, 
 
 And of Towns where it is desired that an Appoiximent 
 should be made. 
 
 Tlie Council irill be initch oblir/ed to (nnj 'f/eittlevicn u-'dlinn to act 
 as Local Secretaries in Towns where the appointjiient is vacant, if 
 they uill communicate with Mr. Hutchinson. Ainj sur/ijestiuns of 
 suitable names irill also confer a favour. The duties <f Local 
 Secretaries consist in arrangimj for the distribution of books, the 
 collection of Subscriptions, and canvassin'j for new members. 
 
 England and Wales. 
 
 Aberdare 
 
 Abergavenny 
 
 Aberystwith 
 
 Abingdon ... 
 
 Accrington ... 
 
 Acton (sec Ealing)... 
 
 Alfreton 
 
 Alnwick 
 
 Andover 
 
 Ashbourne ... 
 
 Ashford 
 
 Asliton-under-Lyne 
 
 Aylesbury ... 
 
 Bacup 
 
 Banbury 
 
 Bangor 
 
 Barnet, Herts. 
 
 Barnsley 
 
 Barnstaple ... 
 
 Barrow-in-Furness... 
 
 Basingstoke 
 
 Bath 
 
 Beaininster and Bridport . 
 Beaumaris, Anglesea 
 Beccles 
 Beckin gham 
 
 Bedford 
 
 Bethesda, Carnarvoi s'lire. 
 Btverb y 
 
 Morris Jones, Esq. 
 Paulin Martin, Esq. 
 
 W. J. H. Lush, M.D. ^Fyfield). 
 
 C. Hooper, Esq. 
 
 Pi. Budd, M.D. 
 
 S. Andrews, Esq. 
 A. W. Fox, M.B. 
 J. S. Webb, Esq. 
 
 W. M. Crowfoot, Esq. 
 
 R. H. Coombes, M.D.
 
 LIST ÜF lloy. LOCAL h^ECßliTAPJES. 
 
 35 
 
 r>ewdley 
 liidffji-d ... 
 Bilston 
 Birkenhead... 
 Birmingliam 
 Bishop Aucldaud 
 Blackburn ... 
 Blackheath . . . 
 Blackpool ... 
 Bolton 
 
 Boroughbridge 
 Boston, Lincolnshire 
 Bournemouth 
 Bradford, Yorkshire 
 Brecon 
 Brentwood ... 
 Bridgend 
 Bridgwater ... 
 Bridgnorth ... 
 Bridlington ... 
 Brighton 
 Bristol 
 
 Bromley, Kent 
 Burnley, Lancashire 
 Burton-on Trent .. 
 Bury, Lancashire .. 
 Bury St. Edmunds 
 Buxton, Derbyshire 
 Cambridge ... 
 Canterbury ... 
 Cardiff 
 Carlisle 
 Carmarthen 
 Carnarvon ... 
 Castleford ... 
 Chatham 
 
 Cheadle, Cheshire .. 
 Chelmsford ... 
 Cheltenham 
 Chertsey 
 Chester 
 Chesterfield 
 Chichester ... 
 Chippenham, Wilts. 
 Chorley, Lancashh'e 
 Christchurch 
 Cirencester ... 
 Colchester ... 
 Congletou ... 
 
 J. Gabb. Esq. 
 
 W. H. Ackhaud, M.D. 
 
 George Walker, M.D. 
 W. Wright Wilson, Esq., 
 
 [F.R.C.S.Ed. 
 Matthew J. Eae, M.D. 
 Gay Shute, Esq. (Greenwich) 
 W. B. Eichardson, Esq. 
 
 A. Mercer Adam, M.D. 
 J. G. White, M.D. 
 T. C. Deuby, Esq. 
 Talfourd Jones, M.D. 
 
 W. L. Winterbotham, M.B. 
 Alfred Mathias, Esq. 
 C. F. Hutchinson, M.D. 
 Ed. Mackey, M.D. 
 
 F. R. Cross, Esq., F.R.C.S. 
 
 H. Briggs, M.D. 
 
 G. Lowe, M.D. 
 
 F. Crompton, Esq. 
 F. E. Image, Esq. 
 
 T. Hyde Hills, Esq. 
 James Reid, Esq. 
 
 W. B. Page, Esq. 
 
 J. Hughes, Esq., F.R.C.S. 
 
 E. W. Kemp, Esq. 
 
 J. Langston, Esq., F.R.C.S. 
 
 E. T. Wilson, M.D. 
 
 T. S. Parry, M.B., M.R.C.S. 
 John Carnegie, M.D. 
 N. Tyacke, M.D. 
 
 E. Waylen, Esq.
 
 30 
 
 THE NEW SYDENHAM SOCIETY. 
 
 Coventry 
 
 Cowcs, Isle of Wiglit 
 
 Crewe 
 
 Croydon 
 
 Dalton-in-Fiirness 
 
 Darlington ... 
 
 Dartl'orcl 
 
 Dartmouth ... 
 
 Deal, Kent ... 
 
 Denbigh 
 
 Deptford 
 
 Derby 
 
 Devizes 
 
 Devonport ... 
 
 Dewsbury . . . 
 
 Diss... 
 
 Doncaster . . . 
 
 Dorchester ... 
 
 Dorking 
 
 Douglas, Isle of Man 
 
 Dover 
 
 Droitwicli ... 
 
 Dudley 
 
 Durham 
 
 Ealing 
 
 Eastbourne... 
 
 East Grinstead 
 
 East Retford 
 
 Edmonton ... 
 
 Ely 
 
 Enfield 
 
 Epsom 
 
 Evesham 
 
 Exeter 
 
 Exmouth 
 
 Falmouth . . . 
 
 Faversham ... 
 
 Folkestone ... 
 
 Forest Hill . . . 
 
 Fromc 
 
 Gainsborough 
 
 Gloucester ... 
 
 Godahning ... 
 
 Go sport 
 
 Grantham . . . 
 
 Gravcsend ... 
 
 Great Grimsby 
 
 Greenwich and Blackhcath 
 
 Guernsey 
 
 J. Brown, M.D. 
 
 J. Atkinson, Esq. 
 A. Carpenter, M.D. 
 
 J. Lawrence, M.D. 
 J. C. Weddell, M.D. 
 
 T. L. Gentles, L.F.P.S. 
 G. Way 1 en, Esq, 
 
 T. E. Amyot, Esq. 
 J. Sykes, M.D. 
 Alfred Emson, Esq. 
 
 Charles Parsons, M.D. 
 S. S. Roden, M.D. 
 
 B. Roberts, M.D. 
 
 W. B. Pritchard, Esq. 
 
 AV. Clement Daniel, M.D. 
 
 H. Davy, M.D. 
 
 G. W. Turnbuh, M.D. 
 
 R. L. Bowles, M.D. 
 J. Bright, M.D. 
 Edmund Cockev, Esq. 
 D. Mackindcr, M.D. 
 F. Nccdham, M.D. 
 
 Cr. W. Shipman, Esq. 
 R. Inncs Nisbett, Esq. 
 
 Gay Shute, Esq. 
 B. Collenette, M.D.
 
 LIST OF HON. LOCATi SECRETARIES. 
 
 87 
 
 Guildford . . . 
 
 Halifax 
 
 Hanley 
 
 Hanwell 
 
 Harlow 
 
 Harrogate . . . 
 
 Harrow-on-the.-Hill 
 
 Hartlepool ... 
 
 Haslingden ... 
 
 Hastings 
 
 Haverfordwest 
 
 Heckmondwikc 
 
 Hemel- Hempstead 
 
 Hereford 
 
 Hertford ... 
 
 Hexliam 
 
 High Wycombe 
 
 Hincldey, Leicestershire 
 
 Hitchiii 
 
 Horsham, Sussex 
 
 Hounslow . . . 
 
 Holywell ... 
 
 Huddersfield 
 
 Hull 
 
 Huutiugdon 
 
 Hyde and Marple 
 
 Ilfracombe ... 
 
 Ipswich 
 
 Jarrow 
 
 Jersey 
 
 Keighley 
 
 Kendal 
 
 Kettering ... 
 
 Kidderminster 
 
 KingsLridge 
 
 Kingston-upon-Thames & 
 
 Lancaster . . . 
 
 Langport . . . 
 
 Launcestou... 
 
 Leamimgton 
 
 Ledbury 
 
 Leeds 
 
 Leek 
 
 Leicester 
 
 Leigh, Lancashire 
 
 Leominster... 
 
 Leytoustone 
 
 Lewes 
 
 Lichfield 
 
 L-biton 
 
 K. N. Day, Esq. 
 G. Oliver, M.D. 
 
 J. Underwood, M.D. 
 
 F. B. Lee, Esq. 
 
 Eussell Steele, Esq., L.E.C.P. 
 
 Thomas Turner, Esq. 
 
 C. E. Shelley, M.D. 
 
 John L'ving, M.B. 
 Kelburnc King, M.D, 
 L. Newton, Esq. 
 J. Johnson Baile}^ M.D. 
 
 C. W. Hammond, M.D. 
 
 W. W. Kershaw, M.D. 
 E. Clark, Esq. 
 
 T. W. Thursfield, M.D. 
 
 E. N. Hartley, M.B. 
 Joseph Kenny, Esq. 
 T. Blunt, M.D. 
 
 F. W. Cooper, Esq. 
 H. P. Welchman, Esq.
 
 ^8 
 
 TIIK NEW SYDENHAM SOCIETY. 
 
 Lincoln 
 
 Liskeard 
 
 Liverpool ... 
 
 Llandovery ... 
 
 Llandudno ... 
 
 Llanelly 
 
 Longton, Staffordshire 
 
 Longliborougli 
 
 Louth 
 
 Lowestoft ... 
 
 Ludlow 
 
 Luton 
 
 Lymington ... 
 
 Lyiin 
 
 Macclesfield 
 Maidenhead 
 Maidstone ... 
 
 Malton 
 
 ]\Ialvern 
 
 ]\Iancliester... 
 
 INIansfield ... 
 
 ]\Iargate 
 
 Market Drayton 
 
 Marlborough, Wilts. 
 
 Martock 
 
 Merthyr Tydvil 
 
 Middlesboro'-on-Tees 
 
 Mold 
 
 Monmouth ... 
 
 Morpeth 
 
 Moseley 
 
 Newark-upon-Trent 
 Newbury, Berks. ... 
 Newcastle-under-Lyne 
 Newcastle-upon-Tyne 
 New Malton, Yorkshire ... 
 NcAvmarket, Cambridgeshire 
 Newport, Hants. ... 
 Newport, Mon. 
 
 Newton Abbot 
 
 Newton-le- Willows. . . 
 
 Northallerton 
 
 Northampton 
 
 North Shields 
 
 Norwich 
 
 Nottingham 
 
 Odiham 
 
 Oldham 
 
 Oswestry 
 
 T. Sympson, M.D. 
 
 J. Muir Howie, M.B. 
 D. Thomas, Esq. 
 
 F. Fawsctt, M.D. 
 W. H. Clubbe, Esq. 
 
 H. C. Allinsou, Esq. 
 
 E. Ground, Esq. 
 W. T. Colby, M.D. 
 
 F. M. Pierce, M.D. 
 
 C. Biddlc, L.E.C.P.Loud. 
 
 F. H. Api^leby, Esq. 
 
 J. B. Bunny, L.K.C.P., 
 
 [M.K.C.S. 
 F. C. Coley, M.D. 
 
 W. W. Morgan, M.D. 
 
 Charles Jewel Evans, Esq. 
 Eobert Peart, M.D. 
 Haynes S. Kobinson, Esq. 
 W. H. Eansom, M,D. 
 J. M'Lityre, M.D. 
 T. Piatt, Esq.
 
 LIST OF HON. LOCAL SECRETAItlES. 
 
 39 
 
 Otley 
 
 Oxford 
 
 Peuge 
 
 Penrith 
 
 Penzance 
 
 Peterborough 
 
 Petersfield ... 
 
 Plymouth ... 
 
 Pontefracfc ... 
 
 Pontypool ... 
 
 Poole 
 
 Portsmouth {see Southsea) ... 
 
 Preston 
 
 Prestwich ... 
 
 Ramsgate ... 
 
 Eeadiug 
 
 Redruth 
 
 Reigate 
 
 Richmond, Surrey... 
 
 Richmond, Yorkshire 
 
 Ripon 
 
 Rochdale 
 
 Rochester (& Chatham & Strood). 
 
 Rochford 
 
 Romford, Essex 
 
 Ross... 
 
 Rotherham ... 
 
 Rugby 
 
 Rugeley 
 
 Ryde, i. of Wight 
 
 Saffron Waiden 
 
 St. Albans ... 
 
 St. Austell 
 
 St. Helen's Lancashire 
 
 St. Ives, Huntingdonshire 
 
 Salford 
 
 Salisbury ... 
 
 Scarborough 
 
 Settle 
 
 Sevenoaks ... 
 
 Shaftesbury 
 
 Sheerness ... 
 
 Sheffield 
 
 Shepton Mallet 
 
 Sherborne ... 
 
 Shipley 
 
 Shrewsbury... 
 
 Sidmouth ... 
 
 Smethwick ... 
 
 A. Winkfield, Esq., F.R.C.S. 
 
 J. B. Montgomery, M.D. 
 Leonard Cane, M.D. 
 
 Council Whipple. Esq. 
 
 S. B. Mason, Esq. 
 
 R. Allen, Esq. 
 
 T. L. Walford, Esq. 
 
 J. Walter., M.D. 
 E. Fenn, M.D. 
 
 J. Langston, Esq., F.R.C.S. 
 T. King, M.D. 
 
 H. D. Foote, M.D. 
 
 H. Stear, Esq. 
 
 R. R. Lloyd, Esq., M.R.C.S. 
 
 E. P. Twyford, M.D. 
 W. R. Grove, M.D. 
 
 W. D. Wilkes, Esq. 
 R. B. Cooke, Esq. 
 
 E. Swales, M.D. 
 
 M. Martin de Bartolome, M.D. 
 
 E. Andrew, M.D.
 
 40 
 
 THE NEW BYDENHATiI SOCIETY. 
 
 Soutliamptoii 
 
 South Molton 
 
 Soutliport ... 
 
 Southsea 
 
 South Shields 
 
 Spalding 
 
 Stafford 
 
 Staines 
 
 Stalybi'idge ... 
 
 Stamford 
 
 Stockport ... 
 
 Stockton-on-Tees ... 
 
 Stoko-on-Trent (Potteries) 
 
 Stourbridge... 
 
 Stowmarket 
 
 Stratford, Essex ... 
 
 Stratford-on-Avon ... 
 
 Stroud, Gloucestershire .. 
 
 Sunderland... 
 
 Surbiton 
 
 Sutton, Surrey 
 
 Swansea 
 
 Swindon 
 
 Sydenham [see Forest Hill) 
 
 Taunton 
 
 Tavistock ... 
 
 Teignmouth 
 
 Tenby 
 
 Tewkesbuty... 
 
 Thetford 
 
 Tiverton 
 
 Todmordcn ... 
 
 Torquay 
 
 Totnes 
 
 Tottenham ... 
 
 Towcester ... 
 
 Truro 
 
 Tunbridge Wells ... 
 
 Twickenham 
 
 Ulverston ... 
 
 Uptou-on- Severn ... 
 
 Uxbridge 
 
 Vcntuor 
 
 Wakefield 
 
 Wallingford 
 
 Walsall 
 
 Walthamstow 
 
 Warminster 
 
 VVarrinatou... 
 
 T. W. Trend, M.D. 
 T. Sanders, Esq. 
 
 W. H. Axford, M.D. 
 J. Train, M.D. 
 E. Morris, M.D. 
 
 W. Newman, M.D. 
 J. A. Ball, Esq. 
 E. W. Foss, M.D. 
 Samuel Johnson, M.D. 
 A. Freer, Esq. 
 
 J. J. Nasou, M.B. 
 
 M. Douglas, Esq. 
 
 W. W. Kershaw, M.D. 
 
 T. D. Griffiths, M.B. 
 G. M. Swinhoe, Esq. 
 
 W. Liddon, M.B. 
 
 P. Minns, M.D. 
 
 E. H. May, M.D. 
 
 E. Sharp, Esq. 
 
 F. Manser, Esq. 
 
 C. Braddon, Esq. 
 
 F. H. Wood, Esq. 
 C. A. Barrett, Esq. 
 
 J. H. Gornall, Esq.
 
 LIST OF HON. LOCAL SECRETARIES. 
 
 41 
 
 AVarwick 
 
 Watford 
 
 Wednesbury 
 Wellington, Salop ... 
 Wellington, Somerset 
 Wells, Somerset 
 Wem 
 
 West Bromwicb 
 Weston-super-Mare 
 Weybridge ... 
 Weymoutli ... 
 
 Wbitby 
 
 Wbitebaven 
 
 Wigau ..; 
 
 Wimbledon ... 
 
 Wimborne ... 
 
 Winchester ... 
 
 Windsor 
 
 Wisbeach ... 
 
 Witney 
 
 Wolverhampton 
 
 Woodbridge 
 
 Woolwich ... 
 
 Worcester ... 
 
 Workington, Cumberland , 
 
 Worksop 
 
 Worthing ... 
 
 Wrexham ... 
 
 Yarmouth ... 
 
 Yeovil 
 
 York 
 
 Aberdeen . . . 
 Airdrie 
 
 Ayr 
 
 Banff 
 
 Brechin 
 
 Campbeltown 
 
 Crieff 
 
 Cupar, Fife . . . 
 
 Dumfries 
 
 Dunbar 
 
 Dundee 
 
 Dunfermline 
 
 Edinburgh ... 
 
 Elgin 
 
 Falkirk 
 
 Forfar 
 
 W. Fairbanks, M.D. 
 
 J. Manley, M.D. 
 E. Alford, Esq. 
 
 J. F. I'Anson, M.D. 
 G. G. Tatbam, M.D. 
 
 J. EUison, M.D. 
 
 A. Batt, M.D. 
 Vincent Jackson, Esq, 
 
 W. J. Harris, Esq. 
 
 C. Palmer, Esq. 
 
 [M.E.C.S. 
 W.H.Jalland,Esq.,L.R.C.P., 
 
 Scotland. 
 
 John Wight, M.D. 
 G. McKerrow, M.D. 
 
 W. Whitelaw, M.D. 
 
 A. D. L. Napier, M.D. 
 E. Sinclair, M.D. 
 
 W. Husband, M.D. 
 G. Duff, M.D. 
 
 W. F. Murray, M.D.
 
 ■iZ 
 
 THE NEW SYDENHAM SOCIETY. 
 
 Glasgow 
 
 Greenock 
 
 Haddiugton... 
 
 Hamilton ... 
 
 Helensburg ... 
 
 Inverness ... 
 
 Kelso 
 
 Kilmarnock... 
 
 Leitli 
 
 Lerwick (Shetland) 
 
 Linlithgow ... 
 
 Lochgilphead 
 
 Montrose 
 
 Paisley 
 
 Perth 
 
 Pienfrew 
 
 Piothesay 
 
 St. Andrews, Fife . 
 
 Stirhng 
 
 Thurso 
 
 Wishawton ... 
 
 Ardee 
 
 Armagh 
 
 Athlone 
 
 Ballinasloo ... 
 
 Ballymena ... 
 
 Belfast 
 
 Carlo w 
 
 Carrick-on-Suir 
 
 Cashel 
 
 Cavan 
 
 Clonmel 
 
 Cork 
 
 Corofin 
 
 Downpatrick 
 
 Dublin 
 
 Dnndalk ... 
 
 Enuis 
 
 Enniskillen... 
 
 Galwayj 
 
 Killarney . . . 
 
 Kilkenny 
 
 Kingstown ... 
 
 Letterkeiiny 
 
 Tjimorick 
 
 Lisburn, Antrim 
 
 Londonderry 
 
 J. W. Anderson, M.D. 
 James Wallace, M.D. 
 
 A. W. Maefarlane, M.D. 
 James Struthers, M.D. 
 
 G. Hunter, M.D. 
 
 James C. Howden, M.D. 
 D. Taylor, M.D. 
 D. H. Stirlmg, M.D. 
 
 Charles Gibson, M.D. 
 
 Ireland. 
 
 Thomas J. Moore, M.D. 
 H. Fräser, M.D. 
 
 J. W. Bycrs, M.D., M.A. 
 J. Martin, M.D. 
 
 Denis Donovan, M.D. 
 G. N. McNamara, Esq. 
 
 J. W. Moore, M.D. 
 
 ... T. Kane, M.D. 
 '.'.'. W. Bernard, M.D.
 
 LIST OF HON. LOCAL SECIIETARIES 
 
 Mallow 
 
 Monaglian 
 
 Mullingar 
 
 Nenagli 
 
 New Ross 
 
 Newry 
 
 Omagh 
 
 Parsonstowu 
 
 Queenstown 
 
 Rathmines . 
 
 Roscommon 
 
 Rosstrevor 
 
 Sligo 
 
 Tipperary 
 
 Tralee 
 
 Tullamore 
 
 AYaterford 
 
 Wexford 
 
 Youglial 
 
 .. J. Harrison, M.D. 
 .. T. A. Vesey, M.B. 
 
 ... 11. H. Boxwell, M.D. 
 Paris. 
 
 India. 
 
 Calcutta 
 
 Madras 
 
 Bombay 
 
 Lahore 
 
 ]\Ioulton 
 
 Adelaide 
 
 Melbourne ... 
 
 Sydney 
 
 Cbristclnircli 
 
 Nelson 
 
 Napier, Ilawkes' B;iy 
 
 Toowoniba, Brisbane 
 
 Montreal 
 
 .. E. F. Brockman, M.D. 
 .. K. R. Kirtikar, L.R.C.P. 
 
 S. Australia. 
 
 Victoria. 
 
 Edward Barker, M.D. 
 
 New South Wales. 
 
 New Zealand. 
 J. Irving, M.D. 
 
 F. L. De Liblc, M.D. 
 
 Queensland. 
 
 Canada.
 
 44 
 
 THE NEW SYDENHAM SOCIETY. 
 
 Abingdon, III 
 Baltimore .. 
 Boston 
 Cincinnati . . 
 New York . . 
 Philadelphia 
 
 United States. 
 
 .. Madison Eeece, M.D. 
 
 .'. E. H. Salter, M.D. 
 
 Messrs. J. H. Vail & Co. 
 Eicliard J. Dunglison, M.D. 
 (Mr. Presley Blakiston). 
 
 Barbadoes. 
 Eobert E. Walcot, M.D. 
 
 Japan. 
 
 Yokohama and Yeddo S. Eldridge, M.D. 
 
 General Secretary (Hon.) 
 
 JONATHAN HUTCHINSON, Esq., F.E.S., 15, Cavendish 
 Square, London, W. 
 
 Agency and Depot for Books. 
 Mr. H. K. LEWIS, 13G, Gower Street, London. 
 
 >c 
 
 )NLION : WEST, NEWMAN AND CO., rRINTEIlS, 54, UATTON GARDEN, E.G. ^ .
 
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