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Full text of "Diseases of the urinary and male sexual organs"

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iLA^Miiii 



OCTOBEB 



DISEASES 



4a Tint 



URINARY AND MALE SEXUAL ORGANS 



BT 

WILLIAM T. BELFIELD, M.D., 

xirraoB of "bzutionb or laoBo-oBaunBiia lo oanam' (cuKTWBiaHT LicmD, 1888); tAtnouy 

OUT TO TBI OOOI COCHTI HCaFIT^L. BDBOBOH TO THI OEKITO-UBimBT DEPi^TIIIIIT. omKU. 

oaranAKt, cmaiao ; fbtsiciaii id ihb oazvood utbeat. qiskvi, wu. ; raormoB 
or mCBOsooFT. chio&oo oolusk or dimt&i. sumaun 




NEW YORK 
WILLIAM WOOD & COMPANY 

66 & 58 Lafatsttb Fiaos 
1884 



•;,: ■ ■ ": : .; .*. 



> -MtMlMiT. MM, 

|i» »UJJUI W<M1> L OOKPAVT 



tWHri 



PREFACE. 



Wimx the preparation of t.liU volume was iindertalcen, it -wan tlio 
fiuUior*6 liopo to prt'Sf-'fit a ivhuiih* of (*iirreiit ktiowledgo of the topics 
liorviii i]ii>(!iis»o(l, witii aoiiiiiieiitii siiggesttjil by (icrsonal olffierratioB and 
uxporieace. In tlio execution of tliie plau lie has been eerioasly Gm- 
bttiTasecd by \lie brevity of the period sllottod for the work, whicli has 
penuicted iio opportunity for a minute atrruUiiy of pertinent literatnre, 
for a cawful revigion of tlie text, nor for the addition of a biWioj^raphy. 
Yet, as tlie patience of the publishers lias hecn already 60%'erely tried 
by tbe author's uiiavoidablo tardiness, ho prefers to submit tlio origiiul 
draft of ibo book, incompletu and crude as it may seem, rather than to 
p)^t[>ono etill furthvr the appearance of a volume long i-inco due. 

There is ii gunerully adtnittod tendency in medical practice to regard 
dia^nostH M n reooguition of morbid »yinptoiiiM only, to neglect an in- 
qniry into the c»u«e of the phonomeno, mid lieitce to proctim; a rontina 
treatment of ^yfMjr'/oiTwnither thiiii an imlividual trcntmcnt oi patiettis f 
thU tendency contributett largely to what Or. Ilartliolow terms "the m- 
discrlminntc dnij;adiiiiiii!tti'ation which \» one of the cvilsof the time.'* 
Wliile it must bo admitted that in many inetancea n'eatment can bo, in 
tbc present state of medical knowleilge, only empiric, ^mptomatic, or 
tentative, yet it is eq^ually certain that available means for ultimate 
dingnosiii — and hence opportanities for rational treatment — aro not 
uuivcreaily iitilii«;<i in medical practice. 

<7onvinced that a lack of care and ihoroughnese in the inveetigationa 
of patients is responsible for many faiinrcB in the management of nrin- 
ary and genital diaordons especially, the author has cndeaTored to pre- 
sent fully tlio necessity and the meaui^ for diai^osis as an essential 
pniliiniiiary to treatment. To this end he ha!( devoted a conaidcrahio 



IV PBATAOB. 

{x>rt)on of tho book to a discassion of means for tlie recognition of 
iiiorljid conditions; has emphasized the familiar but freqnentlj neg- 
l<!(;t(Hl fiu^tH that cystitis, gloot, ^bominiiria, spermatorrhoea, are not 
iirililiiiH culling for a routine administration of drags, but symptoms 
n!i|iiii'iiig 11 tliurongli investigation of the patient; that the microscopi- 
(Mil iiKiuiiination of urethral and seminal discharges is quite as essential 
for llin rtKuigiiitiou of sexual disorders, as is a similar inspection of the 
iirinii for thu dotuction of renal diseases; in short, he has endeavored 
ilii'< mahout tho vuluiiiu tu portray ttic important bearing upon treat- 
iridiit of the pathological factor in diagnosis. 

W. T. Belfield. 

'tllC'LAUH HrilKKT, (TlllUAUU, 

Novumtwr, ItlM. 



CONTENTS. 



DISEASES OF THE UEINAEY ORGANS. 

CHAPTER L 

FAOK 

Ahatohical and PHTaioLOaic'AL Conhidbrattokb 1 

The Kidaey, 1 ; Tha Pelvis and Ureter, 6 ; TheBIaddersnit ProsUte,9 : Th(> 
Urethra, 17 ; General S^rmptomatologj, ^. 

CHAPTER n. 

Methods of Exauinatiok 38 

Questions to the Patteut, 29 ; Examination of the External Organs, 33 : Ex- 
vnination per Rectum, 84. 

CHAPTER nt 

The SoDtm asd Catheter 37 

Dangers of Catbet«riBDi, 43. 

CHAPTER IV. 

Urethral Fkvbr 4D 

CHAPTER V. 

PBECAt?noNB TO BE OBBERTED BEFORE CATnETBRIBH 59 

CHAPTER VL 

DlOtTAL BXAUIKATION OF THE Bl.ADDRR 03 

CHAPTER Vn. 

IXSFBCTIOS OF THE UrETHBA— ENDOSCOPY 09 

Uie of the Endoscope, 71 ; DiagnosiB nitb the EndoBoope, 73. 



VI CONTENTS. 

CHAPTER VUL 

Determikatiom of the Urethrai, Calibre by ths Urethroueteb 84 

Oath etvrt nation o( the Ureter, 93. 

CHAPTER IX. 

Physiology op thk Urine 9.1 

CHAPTER X. 

Patiioloov of the Urine 100 

Variations in the Ifonnsl Ingredients of the Urine, 100 ; Inorguilo Constfta- 
eiits of the Urine, 100. 

CHAPTER XL 

rATIlOI.OOY OP THE UniNE (CONTIKCED) 112 

Abnormal Ingredleuta of the Urine, 113. 

CHAPTER SIL 

Albuminuria 115 

Phrsioloeiral Albuminaria, lliS ; Albnminuria from Pathological Conditions 
uilit-r than Renal Disease, US ; Albuminuria from Renal Diseue, 122. 

CHAPTER Sm. 

<5i:YCt>sri{L\ 125 

l'liys>iulo,=ical Gl.vcoanria, 125 ; Glvcoaurift Independent of IHabetes, 125 ; Glv- 
coauria in Diabetes, 137. 

CHVPTER XIV. 

Kv-KRCl' OK AriDS ADD PlOMEXTS ON TRK BlOOD 129 

Chgiiiri,!, 120 ; lI.TmoglohiHiiriB, 130; Oiyluria, 1.12; Llpuria, 133*; Fibri- 

nuriii, 134 ; Hjdrothioiiuria. 1S4, 

CHAPTER XV. 

liAiLY Amount op Urine 13.5 

Rvactian of the Urine, 138. 

CH.APTER XVI. 

Ukinauy Reiumknth ViS 

Unorifnniziul St'.1iment!>, 188 ; Orgnniied Sediments, 148 ; Tube-easts, 147. 



C0STEHI8, 



VII 



CHAll'EU XML 



ajnKAi. ESAMCtATEOM or TSB Urisb 
B»iaid> TwU fur Urinu, 100, 



run 



CHAFTEit XVia 

t-DrTifB KinsEY 171 

Tm^iu CongMtlon, 171 ; bohiNnJs o( ihu Kiiliuii', 174; Atropli; «f tli* Kid- 
nay, Xlti; Amjloid OegenunUou u( tliu Kidiut^, 175; EmtinliBin «nd 
lufariM of tli« Kldnnjr, |6I ; DilTiUHi Neplirlti* iBrighfm DImmv). ItHS : 
Acuta NvpliritlK, \V4 : Chronlo rareQeli.v mulous Nepbritb. 1S8 ; CirrhcMte 
of tti" Kiiliit^v, 'iOO : Tutly TivgviinaXion of ihu Kidney. S30; Buppuritiva 
KephriUe. 231 ; ryulitin and I>li>-i)«p)irilU, 2S4 ; Oentl CbIciiI!, £81; 
RydronopkroxtB, Ht ; Kirpbiliaof tbo Kidnap, S.^0-. TuliorcnloKiM of tlM 
Kidii«}-, -JUI ; Caiiour u4 the Kidn«)', 3M ; Hydaiif of tJi« Kidtiajr, MO ; 
lUniLl Caxu, 2(1!) ; reriiupfarilu, litM. 



CHAITER XIX. 

DuBAiHSt or TiiB BiJinnKR 960 

Opma, «»; Tamon of tlio B1add«r, 28S; NonrocM gf Uio Bladder, SOS; 
Spam ot tint BlBdd«r, 294 i Puvris of 11h> Itlitddvr, SBT ; Icoontineiim of 
Urlna, 8Q0. 



DISEASES OF THE MALE SEXUAL ORGANS. 

CHAPTER XX. 

PROdTinC DlBORDBRS 301 

ProaAtllii, 8M J Chranfo rrtaUliUi, 8V7. 

CHAPTER WI 
■CriOKAI. DnORDRIW , ,.., . SI4 

CHAirTEJt xxn. 

iKAi. IxoosrnNKxm , 890 

Kwlnnul Pallnllons, SSI : SpamatarrluM, flSO. 



CH.\PTEB XXm. 

iHi'OTKxrs AXD 9rERn.nT TBfi 

»«rlllty. 9*9. 



DISEASES 



or Tm 



URINARY ORGANS 



CHAPTER 1. 

ANATOMICAL AND PHYSIOLOOICAL CONSIDEKATIOXS. 
The Kmseif. 

This organ in, in consequence of its anatomical rcltltioI)^ so inAcoviislblB 

to aJl luetkodu o( direct psuiniuntiou. ttut ve ue lar^ly depondciit for 

our lLiiowlv(lg4t of iU condition u[>uit Uie sx&minatioD of its secretion, tlio 

nrilie. Y«t there are a few points conceming it, uut recopiiiuble by 

J mwinB of the urine, which may have p^reat pmetical importiuice. 

j^B Tkx tdiylit aUavhavmt vfthii kidney \a t)tu Kurn>un(]iug tiasuei resiJtA in 

^Btbe a»j displfuwineut of the orgaa, a fact wliirli luw hh yet 8can»ly re* 

^Eniv«<l tliH f^ui^rul rtiuo(;uitiou whieli it <Ie«erve& Unlike the otlier ab- 

Vdoinitial Tisceni, the kidney is pruvidod with uo liKamcuts or utticr Kpixiul 

meojiB of Hupport. The ixtxition of the eland, ecpftrated as it is froii) the 

Kbclominnl iir({Tuii« by Uki purtloiiuuiu, iliuI protected by tb« t^iiiuU column 

and tlie Inst two ribn, securen it in great niaasure from direct tjoIodcc ; 

vbile the nature of its fimctions n>quireJi noither of the Icidnoj itwlf nor 

of th4i orgiitiH with which it is pby biologically oonu«Ot«d, any cJuui|^ of 

position in the Ixidy. Htitice the anatomical pmvidionH for the mainto- 

naiioe of its potiitimi lu-u very slight Theae cunHiBt parUv of the Tessela 

which enter ami leave it. but liiTRclyof tbo pcritonoum and of the ntltpoao 

tiwiie which MUi-roiiuda it and tho Hupmn-uftl enpsulo ; for tlio kidney lii-a 

botwcvti thu iwroiiK ix>rtion of the jM-riluwouin on its anterior surfucA and 

tlie fibroiia hiyer whit-b covt'rs itH postfrior Hiirface. 

Tbt-ae nttachmontfl aff^inl a support which ia by no meuns inconsidei^ 
able. While tho Te^iSL-ls whicli cciunuct the ktdnoy with tlto aavin and rviut 
oATa ore quite elastic and eoHily permit a rather extennlTe range of movO' 
meat on the port of the kidney, yet the connectiTe-tiasue attnchuenta 
between the reiiul vapnule and tho adjiicutit pcrituoouin and fat luv qiiito 
firm. Their importsuco con bo rendily demonstrated oa tho cadaver bv 
1 




2 



DISEASES OF TUB URINAKT OitOAlTg. 



Hbreriii^ the reoal ressels, otter which it will be found that the usual (oros 
IH i-eiiuii-eil to remove tlie orgao. 

Wlulv these attacLmoDtB suffice doabtlcss in tbo great tnajoritj of in- 
dividuals to pKVfiul (lifilocatioii u( th» kidutr, yet in uiuut^rous itifltanBCA 
tLov ore OTeroMUKt hy nu-iuuit ciuuo*. TIiih luostemng ainl dbtiiluwiucDt of 
the kldoey from ita natural poatiOD has been often recognizeiC and (loubU 
IcM cxista far more frecjuentlj* thnn we are in tlie habit of heli^vtng. It 
is ceDcmUj regiu^cd lus on anatomicHl curioeitv. riitltcr than a clinicid pos- 
sibility to l)u k(<pt iii iniud in the diflTflreutiftl uinguosi^ of ulxlouiiaal miid- 
jilnintK. X)i!'i>Uc<'m(:i)t of tbo liidnry biut Lcn-n oftvii ovurltMilcoI, partly W- 
onuse of the difficulties of diogDosis, but largely because tJie physidau or 
surgeon has neftleoted tlio possibility of its ovouneBce. In r recent work 
Burot has oollatcd more thaji fifty instoncrs in vrbirh obstinntc attd eeriooa 
offoctions ■fnre aacribcd duritiK iifu ^^ varioiu aiuwt«, and found poot- 
mortem to bo oauiunl by dixplim-d kidueya. In no inittanco was Uio true 
cause of the difficulty n^ctrtaineJ befoix^ death, nod is rery few wns then 
ewn ft Huspiciou enti'rtuined tliut the wyuiptoniH obs«r<>-ed might be due to 
displaotiniciit of tli<i kL<Inoy. In thum cuscs iu wliidi no tumor vras de- 
tected, the coinpliuot \fa» proaounoed neuralgiat hysteria, chronic poritooi- 
tis, renal colic, etc ; in otlier cases in which a tanior was (hHtiDctly rcoog- 
niKod, tlio spoiling was coneidered on ^nlArgcmont of the cnlt-nladder, 
ovari&n cyst, tumor of the hver, eulargcment of thi^ livL-r. diiqMaLicnient of 
the spleen ; in short, tlie greatest iiig<>nuity was exhibited in dfvinng mis- 
tnken din^oBce, presumably because the possibility of dinploceiueiit of tho 
kidney had bei-n ignored. Ebstein records a case in wluch deUvery vos 
twic<i BoriotiNly iniiieilod by n tiitniir which could he folt horn the Tsgine. 
At tlie autopsy, many years kt«r, this tumor was found to be a deeply ^^ 
situated kidney. ^H 

So long an the trootment in confined to the admiuistration of drug^ ^H 
ffiiluru to rccot^tiizc lUsphicement u( the kidney, though n-sultiug in lock 1 
of Biioocaa in treatment, can hardly lead to the commiiwrioD of disa6tn>us I 
blunders ; but in these latter days of abdominal surgeir, esj^ciol core I 
and nlteutiou to this posabiUty in required befure operative interferesce I 
is undertrikirii. A Htriking «xiuiii)tn of the cliiucol importance of tlu§ point i 
occiured in the experience of Uilirotli. At the time when this distin- I 
(fuiidiad Burgeuu performed his first e)[ciRion of ttie cjincuroiis pylorus, in ] 
February, lti81, his coIleac;ue Bamberger bad under tj'e'nLment a middle- t 
Bged, emaciated vfoimm, viho bad lonp exhibited the Mymptoms of chronic || 
gastric diffinilty. and who had a diMthiet firm tumor at the pyloric tat- 
tremity of the .stumoch; tthu vtwa bc-lkved to have cancer of the pyloiUft 
Encouniffed by the recovery and apparent curp of the patient from wliom 
Bilhoth lisd excised a pyloric cancer, tliis patient of Bamberger 6n>re8sed 
her vriUin;^e8B io uiidert;o Lite Home operntiaii. After aatiafj-ing Limwlf 
08 to the noceHsily for it, Billroth li(>;^i the oiwration for excision of the 
pyloruH by iiiciiiiiiii tluvugh tlm abdiiniiimd wiUI. Ho found, however, tut 
cnucer Dor other diaeane of tlie pvlorut*. but an atroxihied dinplaced kidney 
preasiug upon the duodenum. The Idduey was removi>d ajid now adoma 
Biilroth's muecuin ; the patient dit'd of roUapw in twelve houn. 

The faet that the most iiu))(.)rL'iut RupportH of the kidney ore the p<ai- 
toneol foUU nccountii for the fi-ciiui^iicy of rtnid diHpliic^-nient in women 
(U£M percent, of all nnaes), and explains il^i aliiicint exdnmvi; occurrence 
in uoBO women who have home chilth-eu. For the luity of the abdomi- 
nal walls eaiuMid by repeated prc^iaiicit^s pi-miits the intestines to drag 
heavily upou their" peritoneal attachments aud thus iudirectly loosen tlia 



F AMATOMIOAL AND PHVSIOLOOICAL OONSlDSKATlOTtS. 3 

^dt\a«J ; poEuIliljr an enlar^ged and diHplaced womb mnv hy traction on the 
uroter faTOr tiin name i-efiiilt. The ubHOrptiuti ol periiii-iiltritic tnl wbich 
AccDtnpaniea general ema<^iution olao wo-nkiing the renal attncluuoDtB ; jet 
while doubtlcw fflVTiriii); ruutil Ju^laceiueiit, emociatioa b bj iio menus an 
easentuU (actor for its occuneiice. ITib iillcKfd i^elatire frenoency of wan* 
dering kiilnov in oiimcialed iudividoals is probably one of oiftgTMieQB oulj- ; 
for laobility of tbe kidney is (uuiid jjo»t inoitoia cjuito an frequently in 
stotit Oft in spare pt^niouM, tbou^'b for obvious raa«oii8 it itt r()Vi>giii7«d dur- 
ing life nlmost eKcbisively in tlio latttr cIohh. 

Wliilu audi iibiiuriiJiUity in tlie poBition of the kidney-, congenital or ac- 
nilirod, in in geiieml iinieuable only to surtjica! treutmeut. yet a correct 
diagnosis is a luattei' of iniportuucc- to tbo pliyaician, and often nfTorda the 
p&bODt 1,1(^1 ttiUHfnctiuu. by diapL-llin^ U)o fear of graver difficulty. lu all 
COsos of obscuniiLffvctionxoftboabiloniuuil organs, and in pelvic, luinbrtr, And 
onu^ ueui'al^ia», a careful palpation of tbe nomud reuiu region ebould be 
mode. In case of n failure to loonUi Mie kidney by external uumipulation, 
inlorouilion can oftou be derived by rxplonititiu through tlitt rc<rliua. 

Aihuminuria u/Ulwnl rcnid diifea»c hm been observed in severftl coses of 
wandering kidney. Hinco any impedimoiit to the eHcape of tirine through 
the ureter may, by increasing tlie pressure in the ui'inni'y tubules, cause 
albuiuiuuriii, the occurreuce of tbia symptom in CAnea of disj>tiu.'<Kl kidney 
U quito comprebt-nnblo. For in conflcrinence of the displiu^ment tha 
passage of urine through the ureter may readily be impeded either by 
pre.isure of this duet sf^ainst adjacent orgaoM. or t>y tb« exinteuce of a 
sbari) curvature in tbe ureter its^'lf. Uucc«»iiv« changes of ]>o«ition of a 
Tii'aud«nnh' kidney may oauao iutermitteot olbuuiiuuria, which luay bo pro- 
dufitivo of diagitQittio orroni if the rcniU mobility ba not diHcuverad and 
piroparly interpreted. 

I%e rKiation of tke kidney to the lower Tibs is a matter of mooh iuterest 
to ths sorgcon. A« a rule, tbo kidney may bo »aid to extend from thfl 
«lerentb rib almost to tho crest of the Ihum. In some cases the twelfth 
rib is so short as to be readily overtooked, the eletenlb rib being then niis- 
tak«n for tbo tn-olfth ; tluii error may lead to noriouH cod»<.^^uvuccs, ns 
ma illustrated in uii ex]>erivuoe of Duioreicher. lu perfonaiug a ueptirot- 
otny, lie made the inrrision as usual from ttie lower border of tlie last ribi 
To hia surprise he discovered that he hail ujwned tbe pleural cavity. At 
the autup»y it ^aa found that tbo twi:ULh rib in tluH kvlsv utut only Si 
cm. lonji ai'id luui br-en regarded iw tlio ftiunon-s proecits of n liiinlwu- ver- 
tebra, the ele\'euth rib having been mistaken for the twelfth. Incitetl by 
this wxident, HoU examined the ribs of sixt^' skeletoDa, and as a result 
ouno to tbi; follnwing concluuons : complete absence and abnormal brev- 
ity of the tnvUlb rib oucun more frequently in men than in ^iximcu, and 
OD the right tlian on the left tiide. In these cases the position of Uio dia* 
fliramn is not chaoji^ed. but ri jjortion of it and of tbe pleura ii* uiipro- 
tented by the rib^, aud is eoHilv injtiroi) by an iumioii extending to the 
lovnet (ebivontli) rib. It is, tlierefore, doBirable tliat in nvi^rj- <»tae of 
operation in this liciuity tbn ribu shnuUl Iw counted from above down- 
vranl aod tbo incision limited to the level of the twelfth rib, even thuugb 
thifl bo<M be absent. 

The <Ji«eivx of one kidney is a comparatively rare occurreuce aiid yet 
one pooeauDg great cliuitial iiui«»rtauce. For it ia esi^cially ui those 
ciiMHi iu wlucU lue ui'iuary tixcrc-iiun inunt be [M.TforRiod by a single organ 
that interference, natural or othem'ise, irith the fuuctloua of the organ causes 
the gntatttst rii«k to the patient 



4 DISEASES OF THE rRIXARY 0BOAK8. ^^^^ 

The congenital uJweiic* of one kidney w so ra« m to be an anntomiwU 
curiosily; I luiTe be*D abl© to fiml only fifty-four cnaes rwMrJwl in lli© 
litemtur* of-thc^Bubjcct. Yet it must bo rttnctnlierRd tlint an ncquired 
defect of one kiiluey — the tibolilion of it« function by atrophy, fatty degen- 
nmlion, cystic dcgi'iieratioii, iinrecogiiizwl liydroDi-jihroids, etc — is broo 
raeans n rarity. In lh«»e litter dnys operation* upon llie kidney, neph- 
reetomy and neplirotomy. bave beootne reoog^iuEetl Hurgic«1 proredureB ; 
AD<1 mora thaa oao bui'^coh hue, after tlio performance of a brilliiint and 
skilful oponiUou. seen hia patieut ilie of uneuiia, and has disconTnl to big 
aroazemeut, upon iJOBt^mortem exiunimttiou, that the kidney opemted uihmi 
wiw eitlier the only one poue«MHl by llie patient, or at Ictwl the only one 
«iipab]e of pertonniiiu its fnnctione. Now mncc in cnsr-a of coit^-nitAl ab- 
sence or noquired incflicicm\v vt vna kidney tlie other organ beeomee liy- 
SertiHiphiLHl and pcrfoniis tiic functions of both, no eviJence of anch 
rfiridiicy miiy 1>* di»ci>viml)li« 1hrfJU}^h the urine, «nce tlda ia pf^rlutps 
furoishfiu entirely bv one kiiln^v ; hoiirc in 8Uob cases the operators hare 
had no ttwpicion o? thd oclual'coinlitioii, notwjlhstnndiiij^ a thorough ex- 
ftiuiiuitiou of tlio Hrino prerioun to the ©iwrntion. 

LftHKO romoveii (lie rij-hl ti.ltiey in a woman forty-wmin years old. 
Tbo ^iiiplomB. which hinl ^xinted f»r Ifiree yoar*. hftd nlmyg indicated 
diiowo of tlio i-iKlit kidn<'r A«d hiul Icil t« a dingoosisof pyonepbrow* and 
' «viitiQ d<'K'M»>i-n(i-m of tliw nr^n. Tlio correctiiciw of th« diognons ms 
I «it«il>li>ihi->l ti|"'ii ihp onunination of thomrtirpatod kidney. TbeopMatioo 
iru iiiilfiiUv iN'iformwl and the pntiont itiK-tcX u-ell ; yet complete nnuria 
loUoWKd i»i.d til.' palinnt dlt-d on Iho fourth iJay of unDimB. The autorwrj- 
ihowtit Hint til.' hfl ki.liKy. vrliich luwl alwiyti bcpn considered healthy, 
wiv ftl«i« far adviim-ed in cyHtin doKfiierftlJon ; ito pelvja and ureter were 
wiiiphlxN ..hliti'iwtoil, 

Pi, W. M l^'lk, of New \ork. extirpated A nniylaced kidney in a girl 
idiiolorit .Tram t>l<l Tlin pnlieiit dUil eleven days later of unemia. and 
llii> «ii(ii|wv rvvi-rtlod the coiifri'iiitnl nbwnce of the other kidney. In his 
iVlioi't (if llin ea«t,' Pr. I'"lk refera to other inetanceH in which tho BUne 
■iiieiatlitu baa hvfu fiUlimocI |jyUi*iNuao roKult from the sniue singular 

Nlli>ll «MM>i Imvp I""*!! Iiitherf" (iuit« rare ; but with the increasing fre- 
iiiiwiiiiy of iiiHinlio)!* ujion tlm kidney tliey will doubtletts become more 
liil'OKh'iia ll«iii'<< II iHMiomuH an imiK't-ative duty for (lio iiurg:con who 
i>ittit«iii|iliil<'M Ati ti|H<r>iMoii ii|H>n thekiancY.to l>ear'in luind the [xiAsihility 
id KiiiJt iiiilovranl Hiu'hleiit, and lo tske evi'ry precaution afiainst its oceur- 
ivni'" I'.l tiHiM<il<dt>it>|( 'ho jiriTW>ric-e and condition of tbc remaining kidney, 
liSiKiiiiitliily ihlH I'nii l)o il'iJio nitli corlAinty iti females nt least, l>y cathe* 
|i<iUii>|f fho iirtilr'!'. (I itiiiiil]iulalJoa lo be pr»Hi-ntly d(-i><'n)>ed. A oongen- 
Ihll iihnt'HMi i>r Olio ltli|ii"y hiiM beeu in miuiy though not in all cases osso- 
iiIhImI "I'll iiinlfoipiiittioii, anoiniilv, or defect in other urijiary or in the 
■(etilfid iiif(Hii« TliiiH In onn ciiho in which tlie left ki'lney wiui nbi«eiit> tJie 
li'K Mniilii'd vonlrln tviui vnry ■mail i in other inittancef) a coiTCaponding 
ni'i'i>4l of i|iiVMlii|iiiiri|il of till t(t«lieUi hiu boon abw>rvRd. In n-omen anoni- 
fltli'" "f lli» viiKliin and iil'onia liavu he«n lepontodly noticed in caKOM of 
. .1, < r,{|>d nlrNiuien id oiiii kidney. Miwb niaUoniliiUoQ Iibh tlerefcHiv diag> 
.Imd III a ihiiihtful eiuM. 

t jMii ill" kldtii'V i» » ji'iriiou tifihi^ iirAiorycAaTinW Asirell as a eecretins 
ni'lliKi la II imli'iit aritl (•Hiili'ully 1niji(>rlniltfaot. ^V« ore ftuniliar witli the 



' KoH Yiiik aivdlaal Juuriiil, robriiary 17, 1W8. 



ANATOMICAL AND PHYSIOLOOICAL CONSlDKKATIONi 



atiou that clii-onic obstnicUon to Uie pvntriiation ot urine U rejrulwly 
foUowwtl by ililiitAtion not ouly of tlio bhuMer and iiretorB. but aUo of tlie pc^l- 
vui uJ the kidney atxl of the renal tubitlua ; aud it ia vqunJly true, tlioii<;h not 
Mt lumUnr, that tho sudden remoral of such olMtmetion u usiudly followed 
bj byperwmia and ev«n indammntioD of the previously distended channel. 

It u a frequent cUuii^al ubtwrvatioa that the Eudd«n remorat of a long- 
Btanding impeiUmoiit to tho ovncuiitiun of urine ia followed Ly HeriouH 
loonl oud own (j^cnerol dinturbaacu on tliu piirt of tltu jjaticut. Thuti 
if nn old aiiil niurow stricture Im> out i>r rapidly dilated; if a liliuldw 
whloh ia iu a state of dilatation in tri)iiii(-i]Ut<iiet' of clironio eularf^enieiit of 
tbe pi-oHtate he opened for tho rflinoyal of a stone, or even simply eracu- 
atea by tlio iiitroJuctton of a cnthet^r — iu these and analogous coDcUtiotifl 
tlie jiuticnt nulVvrti frotii oliill, fervor, oftf^n liiciiinturiii, Bnuria, cyrtitii, 
OT evoj] Kiippiirative nophrititi. Tlie injury is utnually wanifented primanly 
and chiefly oy the liladder ; cj-sUtis anil pericystitis occur 6rst, and may 
ovnstituto the cntiru atlci^tdon. Yet in these caseii pont-mortom oxamioa- 
tion oftou shorn also on iiiteutio cougeatiou of tlie entire uriuni^ tmct abav» 
the fonuer impediment ; heinun-liAgoi in tlie kidiMiy lut well na in ita peliis 
are not iiifrequenL In other cnaen tlie sudilen evacuation of tlie blwldcr 
im folloir«d by complete anuria and death. In these instances post-tnoi-tem 
examination may Hbuvr no ucut« aHcction nf tliv uriniirv tract exuipt au iu- 
tente coiig^Htion of tlie IcidneyH. 

The explaoatioQ of this congeation, hemorrhage, and inflammation in 
the kidney and of anuria foUowiug tho sud<loa ovucuotion of a vhrotiicaUy 
distended" blaiMer, i« found in thn Aimtomicttl relations of tho vrowcla to tlie 
renal tubulta. For tha luiiuite braucLeH of the iwiial art«ry and \ein. con- 
ducUnj; tlie blood to and from tho cortex of tiie kidney, liu cloacly packed 
betwo^n the straight titbules in the modidlary portion ; only a rery small 
amount of conuoctive tiHKiic — thn Htrouia of tho kidney — iulerTenea be- 
tween the blood-Tessels and tlie tubules ; the two Mts of Teiaela are indeed 
practically in contact. Now the tubules of the kidney are in caaea of tight 
Kthctui'D ur culur(;cd pruatato kopt diatonded with urine whoso oKape ia 
proTented by tho imiMidiiJUiLit below. This dtstentiou of tho tubule* most 
ot itecesslty taJce puce largelv at tLe vx)H;iiHe of ilio <:outigiioua blood- 
TMBols, wltich are con'eepondini;;ly coinpreHHcd. Ko aoon aa the iiupedi- 
MMlt^the stricture, for iuKtauiri' — ia removed, tho kidtioy lubulcti ta% 
emptifed, aii<l tho habitually (■ompreHwid blcicid-veaseli) Kiijfcr cn^orgemeDt, 
which may lie »o great aa to caura rupture of tlie veHsel-'i and eaoape of 
Uood into the tubules and hence into the uriue, or even anuria. 

Thu oonjjtwtion of the uriiiiuy tiiict in conacqu«nco of tho audden 
relief from chronic dtat«nlion i« dcHi<;uat«d an " iiof^tivo nnrntara" ot 
"hypenemia ex vacuo." It is a fniuueut owiuiTMice clinieaUy, and con- 
etitutoa the esplauutiou of many familiar and nnpleaaant focts in thf^ sur- 
gery of tho urinary oifroua : a general reoo^tioo ot its iinpurtAQce would 
olmnte aoino of llie <liaaatrDua coinpltcatioDa which ara so conmon in the 
treatment of bladder, prostatic, and urettunl diMSftes. As rdready atated, 
the bladder suffers pritnarily and often nioe*t iteverely ; for the ohronic dis- 
tentioD begins in tl^a or^on and may indeed be confined to it witJiout ma- 
tcriaUy inorasaiiig the uraasure iu the iirelerK and kidueyis. Yet while 
inflamuution of Uie bladder aa thn rcxiilt of neentiTo preMuro may|>erhapa 
bo ooQtrnlleil, ))i\rtidpatioQ of the kidney connituteB an irrenae^Dle and 
almost invariably fatal complioation ; heuoe the propriety of tuentiouing 
tha mibject here. 

Every aurgeou of experience has seen casm illustrating the principle 



D1SKA8S3 OF TOE VRIHABr OKOAN9. 

ntromW ntiitod, thoiigb perliap8 not recognized as afuoh. It in n fnmiUar 
clinical Iftot tbatone of tli© prila attandunt upon lithotomy in elderij- men 
■a Ui« lUuRcr of cyato-pyelitia and 6«ppur6tj%** neplmtis ; smd it is u furtlier 
lut tliut thuHu 04:1:111 M a M»qutil to tlie 0|>enitiuu cliicQy, if not exclusively. 
In Ihowi COHSS ID nhidl tbB blnil(lc>r hoK been liabitiinliy diittfudfd witb more 
or 1mm mMdual tirine;. Lithotomy is noloriouaty safer in boyM nnA youth 
Ibkn iu elilf^rly odiilt^ merely LcenuHc in Uii: formor cWh thf blndder (uid 
kidticjTi b»vo iiot bean distendtd tiirougli prostntic euliirgenient, or Btriet- 
iirc. KfttDT caacH nro on nicurd iu which dorioiis, <<vvii fiital he ni o i T l liiga 
luid partial or complete suppreneiioii of urine. Iinve foUoired tht ajm^e 
introdneiioa of a eatbeter m coses of prostAtio hyp^rli-opliy or iiritdw 
Ntricturo. I^e occurrcuce of towr nf tvr tbv rapid ditatntiou of a stricture, 
after tb* eonipl^U encuatiou of the bladder in eldorly persons, and after 
lliv oporatioii of vouodiiig for stouo. in so common that Ibt; tt-nD " iiretliml 
fever bas ocnoe into general use to designate tbem. Tlii» tenii ie. ^vbuu 
qiplisd to tbese ooaes, ubuoUv a mi&noiuer. There ore doubtless rnany 
ouw of fever follovring tlio iiitrodiiciion of im iiutrtinicnt into the bladder, 
wbitfh am be pUiuibly n«cribti1 to the iiiipretsHion ninde ii]iou tlio urethra : 
Inil iu the oltm of auia^ tiiider diaoussion the clinical syD))>to>i)s oiid post- 
iiiurtoiu appearances show that tho phwiomcnft obocrvwl are to be attrib- 
ut*'il. Lot to imtatioii of tho un-tbra. liiit to the coo^'estiou of tbw urinary 
tjTicl, iiichuliug Ibi! kidneys, wiiiBeii by " npgatjve pressure." 

Tbe some princiiile isiUustrated in other pathologicid conditions. Tbus 
it IiOH betu repeutMlly obsencid iu cnsos of ^biucoain tliat tbe Hiidden ro- 
litff of tlio babttiiid tciisioti in tbe eye cousequent upon the porforiniuicp of 
trldoctomv, has been followed by heinorrhag'e into tiio vitrroiis and retina, 
though t£iese have siiffered no direct injury (luring tlie operation ; the 
removal of fluid from tbe plearul ixnd {KTitononl cn^ntitHi, in coses of 
cluDBic pt«uritiy attd wtcit^s, lias b«eu Hiiuilarly followed by licuorrhags 
from tbn rmwlii of the serous luembraues which wiiro thuK suddfnl^r r** 
lievod of on aceustomed preefiure. The oozing of blood from the walls of 
lui Rb«MM!Hs. after evacuation of the pim, is a. familiar example of Uie Bame 
prituriple Migorgejpfeot and ruptAiro of vchmcIm from th« Kuddeii removal 
o( aticiistomed pressure. 

The procticaJ dediictionB to ba made from this intimate a-isnpjatinn of 
Um ki^ey with tho lownr portion of t!iii urinary c}iiumel ^-ili bo <1i»cUB«ed 
10 ooDQOctioii with the use of instriiinents in the bladdeir. 

It will suffice here to mention an inslxince fthowing tluit the Ict<lno}* also 
is involved in the general ooogestion : Hobuokl relates a case iu which be 
iwrforined bthotomy upon an old luoii who bad proistatic bypi^rtrophy and 
connoquont dilatation of ilio bliulder. A few hours Inter ilit^re owiurreil 

frufuHO hemorrhage, which, however, was not fi'oia the lips of tbe wound. 
>eiith uc4.-unied twenty boui's after tba o]}eiiitioii. At tbe autopsy there was 
found iatitiiNM byju'iiumiu of the entire iii'iuiiry tract, cn^rf^enieiit uud 
miliary hemorrhages of tliB kiilneys, and fresh extravaaatiou of blood be- 
tween, the left kimiey and its capsiUe. 



Tbj: Pelvis axd Vttxraa, 

Ibe proooDce of aapflrsBmcrary pelves and ureters is n not infrequent 
AOOniBly. though one whidi posstMsos but little clmical iuter«at. Three 
nod even four ureters liave been found in tho same individual, each soiiic- 
tUucs pervious tJiroughout, though in the majority of lustances at luaat 
000 of the euperfluoUB ureteis is occluded at some port of its coarse. 



AMiTOMlOAt AND PHYSIO UtOICAI. CONSIDEBaTIONS. 



' IV ahnormai itwertion o^' Ike ureter into thi; pelvis is a matter of «linu«I 

jpipnrtntiiw, nnco it in oftttii TUsfjounibln for cuM'H <if livtlFOUpphrosls ill 

vhich no iiupe<Umi'iit ia the 111011017 cliacnel is liiaooveralile duriuu life. 

It iuiH IxK'n n-puatedly ob«erved in cases of supcenumemiy ureters^ Uio ro- 

I suit being imrtial or complote bjdroncpliioiitii, accordioK bb one or nil of 

lithe uret«rK wero tliu» itbiiurutdl^' iiiiwrtttii Hiicb aaommouH iuaertion is & 

congonitiil mttlformittiou tuul of voutm) irnnuocUablc ; jrot thu puHHibiliH' of 

its ocoiirreDoe should be borne in niinil in fomuQg an opiuiou as to tlio 

L-«haract«r of an nbdomiual tumor ; for the absence of any hiBforj- of rounl 

f- calculi oik! of other caiiMrH fur >ijilroaPi)l)roKiH Iiah rppeat«(Uy iiiiale'l ex- 

pBtieuoed nurgeoits, even nillrotli Iiiiiiself, iiitonn erTou«ous diugnoHiu of 

antiiw] tuniur, whijn! tlio ItHion wns roally hydro iiephrotoit. 

Tlie ubuorm&lity of this iasertioQ is luually that the ureter oi>i-iis ob- 
liquely into the pelviit, just us its luwtir exlreuiit^* upeiw into tlie bladder. 
In aooUter clfuM of oiwctM ihu iirtitcr iit inMcrtcd on ibe mde instead of at the 
boUom of tlie pelvjtt, oft«n at tlie anterior or o:(temal surfncei This mol- 
fommtiou re^iiltti necessaril.r in the retention of some luine in tho pelris of 
the kidney, thftt wliiub ownjivs l>oiD^ iw it w^ro the orerdow from the 418* 
tended pelriH. In Mine of these atMt-s the rvcumbeut puutioin favors the 
kMoape of uriuo from tlio ju'lvi^ m> tlmt a. tuiaor whicii linM existed at night 
poaa almost or ^uite disappeared iu the morning. 

Eupfer'a reeeorcbes uitu tliu LluveLopmont of these oreana expbtin aoiuo 

ol these congeaitnl Anuiiudu-H. Ho found tlmt llio umtvr at firet opene aa 

La short catiul into the posterior wall of the AVolfHfkii Ixnly. and is at u cct- 

r tain period tum6<l towatii tlie back of Uio embryo. At a later <int« tho 

TVolillfLQ body anil ureter lonke a half rovolution (180 degrees) OD itii &xi^ 

the posterior portion now becoming antorior. Sometimes this ruvolution 

is not oomplotod, in whivh ciuao thu iiinrrtiou of tho ureter will of ooturse 

r Iw on tlie nut«rior, external, or even |H>»terior wiUl of the kidney. He oh- 

MM r e d seren caeea of such anomalous insertion of the ureter, in four of 

vhicb bydronephnrais vm» present 

A mora fre(|ucut anoiunJy cuu8i8t8 in thepreaenceo/vcUveaeiiihcx ut the 

L^vnil oriliflO or at certain pointa in the ureter. Tlieae fslves, wlueh oro 

lilbetely folds of aupevfluouEi mucoiia laembmiio, seem to originate in tbe 

MzMHive length of tho cmbryouit.' uret<^-r (which isdevL-luptd iudc']>eud«!nUy 

fit ib« kidoey). Such valvtm are found far moro fnj<iui-nt!y in tJir. fi^tus 

and iu yotuig infants than iu adult& WOlder exfrmined the ureters of 

fit) new-lK>m children ; in 20 of the^ he found from one to fire more 

wr leas loarked folds of mucous membrnne which were situated nlvrnys and 

riaxclttsively at the Hiuue point, uaiuely, one to one and a UaU ccutiiaetres 

IroBi tlio pclvio orifico. In tno8t nf thctie there was a dtlatatiou, more or 

iJeas prououuced, of the pelvis ; in 10 tbe lu^ter was almost or quite iw 

HBrmeable.. In 5U lulull coses, on the other hand, he found not 11 single 

'^cfa fold, indicating that they am often obliterated with ago ; yet they 

aoinetimea persist, and bevome morn pr»uounco«l with adx-auoing age, onus- 

ing decidnti hydronephrofibf. Thuii Ijillroth o)Krmteil upon acaae in which 

tlwre was no lustory to indicate the poHsihility of liydronophroaia ; Uie tumor 

ytmant vnut consiiivnxl ovarian, oven after tlie abiloiniuLd iudaiou. Tho 

PlamMOf tite hydronophrusis wiiua Ipi-obiibly con^renital) seiuihmar vtdve of 

mnOMiB uiembrario At ihn p«lvt(! oriticv of the iirotor. The lu-rauguineut is 

tikeoed by Woltier, who i-eport:* the caee. to a sranJl nortic Talvo with 

siniia Vfll^TiD an<l coronary artery, tbe latter correeponding to the unter. 

TIki preasQTo of this vnlvo ngainst the wall of tbe pelyis by tbu cnoloited 

mine completely obstructed the ureter. The history of the case showed 



5 



I 



8 



DISSASB8 OF TIIE VSJSlk&Y OBOAHS. 



I 



I 
I 



tlwt lUi donn mut faitre been for « Ifmg time tempotu^ and txmiMiaB^ j 
md tlMt It bad be«D in crc — c- i bjr repeated pregnaDcica ; in fact ImI 
doame had been oonafant {m ahown bjr tba iwnaatiant ioeraase at ttol 
tonMT) rfnoe th« lasi pngnaney, three jcan prenondy. 1 

Tht onatemiaU f^aUoKM r^ thp urtterin Ihf loierr part nf Un eowe lairvA 
aapadftlly in faulM^ gn^t practical iiiiportnDc« ; (or tiie ur«ter pMM*] 
aloof Ihadda oi tha nipr«>VBgmal portion of the utcrua and of the Tspna ;l 
IwDM dlaplAiiMimanta, Milarftf^niAnta, and tainon of tbi> utn^8. an-X peti-i 
meiritlo infiaminaUona, may cause an angular ciirvsture of one or both 
nntan mJtvinA to obrtruct Dio paaaaga of tlu) niise. 

Tha nxiiilt of Nni^li olxttnuHioi) mr^ ba otttiiminurHi or eren Ayfajwa j 
jArwtM. Hililnbrnrult rolotea twocaawi in wlikh he vraa enabled to denum*! 
alrato thn deitMidnntw of bjrdroncphroBifl upon retroflexioo of the ntara&-l 
In finn tvmn Uia |ialipnt complAined of eitrerne imud during roicturitloi^ 
ami nxliilriUMi a lari^ fliictiiatinK ttimor in the Wt ilinc region. Hilde- 
lirafwU nganled tbo NirAlling >ui n bydrontpliroeia prodneed by obetniction 
io thn iirvlar tfUUH") iiy th» dcxifni of tlie utema, and d«inon«tnt«d tba 

SmwttiiiM of ihf< dintnioxiH by tintt Htnu}(htfininj; the atenu vith ft Roaii<l. 
Ml In triH hieing n catheter aoil itroiiHin^ Hpoo iho abdominal wall over tba 

^" I" Hwraling rapidl; dLinmwlwil in aiz« and n copious flow of nrinsj 

ii ■ ly ffillowad. 1 

TliP iimiminrf) f>( bvilroiirplirOBlB in consequence of cancer of the 
iilnrin In n rriHiiituit Uld fiuniliikr olmerration. Ulau found that distention 
«ir ntm (ir lioih untora onciirrod Afly-anvAn timea in ninpty-three casea 
tit niiri'ltiotiia ulnrL The liutnodiAte chum of death in tliis affection ia 
firiKM iiiiixnin. TliK obRlniclimi to the Dow of urine anpeata to be«ome> 
Uitiaa l)i*t nmill of itnpli^nlion nf IhauratAr In tba na^laam, while at c^er 
UiiioK ilin iiroUir HmiIi nliowa nn nignu of canearoua diaeasc, but ia merefy 
eiiiimiv^MHl by Ibii inilnrtfoil ncnrii or tlia thickened periuterine tisme. 

AlbitiiittiiiHN limy «!■>> iHiriir In onnaoquenno of the ob»«tnictioQ to the 
fl"<v of iiMiio i'niiimhI li.r H>iii|ir«Nilc») or nurvoture of th« ureter aaeociated 
Willi iU>i|i|iii<ilii,i,i,(hi,|' nitliirifammta of the atenbi — a fact of diagMStie ia- 
l"" ' " ' f'X' It In Willi Uii'ivrn Ibiit lui incr«Haed pressure of wine in llie 
*" ' ' " I |<fiUlit U nf llwll niiini'ient tfj caune the racape of albumen from 
lli'> uli>iM»nii|. TiiU liHM liaan damoaataated exper im entally by eompr c a. 
*■">• "t tl.o Minitir, mid U aMo oUnlcallyln eaaea of bydronephroaia la 
**'' iirolur In ntlll |Mir*imui; for in mich cnaea the urine is tnuisiently 

"' '■"> I'll ". Tlift (act that albuminuria may thus result dj- 

< ' Ilia i4 tbo utema or from pehateiine iiiUanimationB 

lit riTORnixed am to mahe it possible to seenro data to 

ft«i|iir>(ii<]r of Mich occurrence. I liavo inj-atlf seen one case 

< <<iiiH nf fnuMO and ef&ct Helmed clearly ilemoiieli-ated. A 

■ 10 'ill!, (he mother of four children, hod been fr«<[U&i)tly 

• >■ • III* conflanaoDt, dghtaon monlba earlier, with iti^cully 

1 1." 'I'l wu aeoompaoied vith ooiisiderablfl pain and luul 

I Ftt. pi||f.rl Intortal*. Tbeae qrnmtonis had been e8i>ectiJly 

'"'tiiif iiifi |an( friur niontlis. Her bat labor hud bcca eoue- 

'*''(. amt bail bwii followed by pcriut4?rine inflammation. Tha 

'"<<■ t |.| to <«)ntnili albumen; the nttendinp physician aua* 

' ,.., lljiofi oxaminntioii I found the utemn Homewhat 

' ■ I ri,,,|„M»l 1 tint urinn contaiaed aisnall quantity (about one- 

) of alliumon mill nn oocaalonBl hrahne cn«t, but kvm other- 



»*..il,r if,.. 

>•• flKl M, 

•atnldlttb I 
III »vlti. I. > 
lailr ti 
ftinibl 
til Oil' 

•ipi ,, ■' 
1*1 ' 
llr. 



( , 



I: 



«,,„_ ■ j'f,,.,! Ill wna di»etiid entirely to the ulerua; in ih« 

""■ Irf It tu^ MHiiillm wi yron waBWed to bocuto a decrease in the size 




ANATOMICAL AKD PHV3IOLO«lCAL COKSIDK BAT IONS. 



y 



and on improvement in Uie pottiLion of this organ ; lueimvhile Uie albumen 
fnfulually iliaappearecl from the urine, unci tbo oiuioj-iag iQ-mpU)m» during 
mtctuhtion oeaxed. 

Th« uorninl enlargoinoDt of tino uLeruu in pregcauoy may llkcwiao 
ouiM albmuiuurla by roinprosHion of tlio ureter ; it would seem probable 
that a sicDiUr teault may be produced by the pressuifi of oTaruui or other 
tumoi-8. 

Xbe ulbuminuriii wtiicli ig some'tiiiie!) Beeu in iirHaiAe iitai(» of the 
Hadder i^pesrs to ba duu tu comprosHiuii of thu tinitcr by m^mwdioiHc oon- 
tractiOD of tho luuitoutur coot ol ttie bltnlder wliicli is pi^rfor&ted by it. 
Sash BMBiB to bo tho cxpluDiifJoa of tho olbumiuuria which occurs when 
B gonorrhceol iollamiaation exteada into the posterior uretlufi and involvea 
the neck of the bladder ; the irritatiou of the murous mumbnuiu trnuitcii a 
qiaatn of tho musctdar hiyere, in consequonco of wUicJj tlio distC'utiuu oc- 
CMkxicd by «veu ou ouucu or tno of iiriue Ktiiuulat«6 the organ to contrao- 
tion. TLiK ftamn spaiua causes comprowdon of the veaic^d ends of the 
uret«rB ; Itencv there rOBults a frequeut evacuation of aiua.ll quautities of 
idit^htly albuiumoiw urino. The Hamo plieaoiaciioa itt HumctimM witueeaod 
in conAoqii«iio« of the irritation catiged by a oaIcdIus in tlic bladd«r. In 
detertniniug the coudition of the kidiieyrt prtlimiuary to au operaiion for 
titoiie, it should thprefore be remembered Uiut albuminuria may be due 
directly to tbo preseoc^ of the stone nml uot to renal dieeaAC ; thd micro- 
Boope aoi] thv pativut'a symptoms must dccidv. la otlivr uiws npasmodic 
fxmtmetion of tbe venienl inuHclfis — Initnbilityof the blarldt^r — accomiuuiied 
by alight albuminuria, may be the leeult of irritation in the rectum, Togina, 
cgr uUiruH, 

IXtnwn in the bladder may obtrtruct nod disphwe the vesical orifioen of 
the uterus and thus occasion albuminuria, or hydronephrosis, or both. 
HiiB ia true not only of tboae tumors whom taia pennita their dt'tection, 
but aI»o of tiiinut« growths in tho bhkdddr uiutMOgrDiznlilc during life, tind 
ereu by simple thickeuiii<,' of tho luucoua membraue. I have obHervt»l 
and reoorded ' a curious example of tliis uature. The subient was a man 
WvoDty-four years of age, dead of pueuiuouia. The muscular coiit of the 
bladder was considorabty tbickciioa, ami ita mucous mt'mbnuio in u »tuto 
of catnrrhal iaflammatio]i ; thoro w»h derided culuj-^i:<m«ut of tlu< ruiddle 
lobe of the proatate. Th<i luft iiHTtor wmt much diltttud and the i-orre- 
BpoudiDg kidney vaa hydro nephrotic ; the right kidney and ureter were 
nomuiL The cause for the diktation of the left ureter and kidney was 
found in a Hmall tiunor tdtuatcd under tho cuicoun niembnuie just bdsw 
the ori£c« of tbe left meter, nbiob was tliereby compresxed aod almost 
doacd. This Uttle tumor was no larger than a small pea, and was found 
to he a purv m}-oma Neither itfl exi«t«noe uor tbo bydruDophrobis hod 
been auiiiiect«d duriiig lifo. 



Toi BlaDDEB and PftOSTATK. 

The macular nupplij of the bladder presents two pointa of clinical im- 
portADce : tii'st, the venous plesua iii the neck of the bladder and prostate 
■OJMtomosefl fi-evly with tho radiclvo of tho hEcmorrhoidal veins ; svcoDd. 
tbe blood returning from the bladder, )M-iniiuil vnsi(dc«, and pouis iHwses 
Uirougb tJte prostatic venous plexus. Zuckvrkandl has demonstrated free 

>Wt«n«r Ued. Wo«li«nB<l>rin, Msr 10. 16^1. 



to 



omuara or Tm watucr obsajr. 




of llw pToalMia pfaxia aot oalrwiat a» 
flURivsh tiM fartmal IEm mo As vtna em, bit ah 

' MBf^ into Um pnrtal rein. Tim maUoa^al tmet i._^ 

wt flbmal olMnmrtlofBi : tin* ddcity noi whoae babito imiiliwi I 
M mmat/ml p-MAl e n t^ gmtti/m, an ofl«B troobled wiih Ajmrm-wmA 
iortlrl irrrtJUa, from eonantMa of tb* win nooBd Ok UhUv 
ftwk. I ^iibJMti^ npaefillj \S Hmj alM> Ibtc pnMUtie 

«mtr-hvt 1 ^ in tb« p l iM iu w of tba tobk aiaf atlaea 

firm rjf iirtnA. Thi* in ratiivtl hj Mm oo ag i Mt iop of ' ^ 
ftitt<"^-f, "■'*■ 'Itflt fif Um jiortnl njiAKia gtttmBj. *'■*''*'—* i 



-l.i 

r 



Irivii 



in mieoMUmior tb* vwrieal mm j »owti<ie' 

'. «, wJili^h «u* orauricmjiDj ol)«er«d 

iilririiK aimiilMtiiiff atonA iukI U>eir rtiptUM 

' -'-tirn ffri^iii- ThMM bladdtr pOn an n— By, 

i| witli rtiptAl li wiM o nb o i di. In a lev 

<'i |.«.<,i, i.lf^rT^slnllanMtalyfnMDtbftraetalaadvMi 

uf lirirfinhrrlii nll«matitig iriUi hnnorrluieo crf Ok pOlK draie 

'II lit (lift i>r"«t/>li<T |ili'iiin ftT'vtti'vl hy portal coB^itioB OT habifc- 

<ii>'<<> III, <li'iil>ilf«M rinttrHniUm lorj^ly lo the pwalatac bjperfeRif^ 

I I Iri filit Hwn; Juataaofcrome waoiM — — -^— — * 

, lining i.lMHfh*ra— 1(1 tba Udaay. tba rida «r tba : 



! jFrMr>i»ll"ri "f '" 



,4 fif II— >-rila Mnfit; Into tldi proatalie pl^xna; 



tfaa 



U nil 



!■ I 










Irnftwrtaiii ItMn hi tb* trr-atm«^iit of iafln^ 
*ttt, awl olber gcniul oi;pBa, aa vdl 
UN, «i«: For flOBgcatiae of tba ] 
I inli|iiifiiwi iiiaiiilMi»i I 

rxlHiiu^an 
'I Uta anaal cvgaoa, 

ffflrt hy iiiDaniWMfiiB'Iha :^ 
!•* cnwtMsa wMcB oantf n 
'h,i rn.H-riin|(,ttt««nO**>'l«ddOTl» Sled with' 

i.t; MMpa ■ u am n iia tfan «a «a 
' it«iiilai!na Ibe veiiia of tba 
1 1 of tba Bntbn; at any 
...Mj tbaec w ad witb tb* 
lifwIiMja iMMiMai Hid panifal 
4f.'i t'l^T lAfW pforaaa mtnfal bawm rfaaga 

:i '"iiia-^lboaawfaidintanilbefaloodfroB tbet 

rj..44«f— ala» aiaply bto lb* pnitetia plana; Msca ^ 

'••^m a conraatioD of thuptexuA tatda alao to tndnea 

«(i<rt> of Uw Uatltlcrr. Porul coogaatioB, faabitnal 

M*\titv»mtftl may Ibotlbre all eaoaa a d*>aoM- 

4<4 wftil a* tlw ftuuTtiona of fbe blidder. la o^ 

'Iah Iff lb* bladder nunr be indicate omrIt by 

f r.. (HUM mad by vaaical bfitnlnlin^ — botb ^■""'*nT 

"iiMfTit, if prrmouDcad nod patmtcnt tfaan 

l'> •)»' /MiiMetir* tiastM a ar tft oa dmji tba 

<4 wm* fatty degwi ei ation of theee 

- " '" n '.'ii nrtnir»iil«r ton* of tbe orgm, a teo- 

.1 lUMmlU'ff HtMHtttr or Uter » cateubal crttttisUde- 




1 



ANAT03U0AX AKD PHTSIOLOOIOAL COSSIDEEATIOXS. 



11 



v(3lopi>rl frani fhia venoiui obstruotion cnuHctl l>y prostatic eulargoment ; 
just OB eczenin mwurs on the leg ftota vtuiooHe -vtms. 

2'he nerve siii/pbj to tJie bladder ia also a matter of cliniea! interesL 

The nack oF Uio bluddcr, iticliiding the sphincter, is supplied directly with 

LQjinal neires, which proceed from th« iiiit^rior roots of the thirtl, lourib, 

I'ftad fifth sanral ; the body oi tlie bliul<li>r, on tlib olbnr hnu<I, (it^titiii^ itii 

nerres b-om the sympathetic hypogaati-io pleiua. The spiuol ceatxe of the 

motor tibroH is iu tlie viciuily of the third laiutiiir vertebm. 

TlitD iLtintDmicid dif1V>ri>tic« in th« ucrve supplj of the different musdes 

of the bladder corre-8pond8toUie knon-u pb,vstutu'pcnlautagouiHmbetirwa 

I thfl fipbin<!tar and i\w ^iotmsor musoleia. l^e former in, iii the normal state, 

r completely under the conti-ol of the will, while the labt«r is practically in- 

depL'udi-nt of Tolition. The uct of miotnritioii ccnuistji Bimply in th« lol- 

, outAry (lilntAtion of tlio B])biucter : the oxpnlaion of the unno i» aq invol- 

I'UntuT act, e3tc«pt tm it is assisted by the coutracUoa of tlie abdomisal 

FviUBeleB. Iu cHseB of injtuT to the Hjjiiie nlxtve the third lumbar rertebra, 

Lwhereby co in roi in i cation between the brain and the spinal ccnlro of the 

Vf-8iciil ntTYtJM in iiit^rniptod. tbero ocoura retention of uriut iu coD8e(|U(rnco 

of th(! inability of tho patinut to dilute th<* «pliiiict«r ; when tliis iniisde is 

dilated meclmniMiHy by the introduction of a catheter into the bladder, the 

detnuor muMck^ coutrat-t lu ticfure. 

Anothor fnat of clinical importiuioe \» the di«tribatiou of thn wunn nerra 

(tlw pudif) to the bnae of the bladder and prostate, the integument of the 

l-^eniK, lorotuni. and perineum, the iiretliral muHclea and mucous membrane, 

r and the sphinctcra of the anus ; iu tbo female the utcniH, vn^nn, .inil vulva 

art- aupftLicd by biTuictiea of tliv natno triuik, which in diHtributed also to the 

, bsBO of tho bliwlder niid urethra. An a roflult, irritation exerted upon tbeiie 

I Tsrious mffons — the urethra, rectum, anus, perineum, vagina, etc- — may 

* b« maoifeatcd by functional iibnonniUily nt tlio baao of tlio blndder. It 19 

ft familiar clinical obAcrTfttion that imtAbiltty of the bltuldor, indicated by 

tret|ueiit and pxinftd uriuaUoti, may t>o coused liy eouditioua of the most 

diveme nature in other portions of the area supplied by the pudic nerve. 

L-ThoB fimires nud ulcemtion of tJie rectum, littbituiJ coRdipation, tVi pr<?»< 

Mnoe of wonuti iu the buwi-1, ulceration and iulluinmutiun of the uterus, the 

I tRcum Illation of raucKmn under the jnejince, pbininsiR, stricture, etc, may 

I not only be accompanied by nn irritable state of the blndiWr without 

■Gtasl lesion of this or;;iui, but may eTen manifest thciiificlTcs subjectively 

by MDMtions ntfcrrcd to tho bladdor rather than to tbc actual aeat of the 

irritatiun. Heuco it Is neoeaaarv, in every cose of obscure difficulty affect 

ing the bhulder — especially if toe snbject be a child — to examine also (lie 

Tariaoa other organs to ivhich the pudic nerve ia distributed. Conreraely 

■B actual irritation of the bhvdder or pi-OMtat« may produce abuormalitiea 

in the area tuuued — rectal tenesmua. urethral tipnam, noctumnl pollutionii. 

I H* aphitwten of the blwiiier are in the male two iu niunber : one con- 

P lists of n ting of unstriped musoulai- Hbrea oonlained in the resical bonier 

of tbs pTOfitiito : the otiior is tbe stripMl muftcular tube which ouiTounda 

Ihe membranoua portion «f tlic un^thro. Stridterand Dittvl demonstrated 

t the function of these two nimM-ijlar rinp* in the following way : A dog was 

letliuiz«d, wliereby all striped muscular fibi-es, including those smround- 

I log tho mcuibiimuuB urcthrit, were j^orulyzod. The bladder reiuuiued fidl, 

r no niino cwapiug. Kvcn after n vortical section liitd been made through 

Um prostate (excluding the |)oaterio[- edge) no urine escajw*! This con- 

, Ititnted circamstantial evidence th.it the prostatic muscular ring }>erformeci 

I Uio function of a splunctor. Positive dctnonstrutios was furnished by in- 



I 



at mx iTiuHARr qhqaixb. 

tOsd wilb water from the bladder into U)» 

* Tj" juiaiwcithif): it witli ft gItUM tube ; uUctriKatioa of 

,^ ^ , t f <j JaJ aBOent of the water in tlio tube Since in 

4i *>niwl tbiM were iiicap*ble of contractioD bccnuM 

,^j^^ UMt Ifae ooatniction uuMerred must tuivc bc«ii Clint 

0m» te tbft piofltat*; 

^■jiktoKttTM. tliu LUt«mal or proatntio oud tbc eitcninl or 

- _"^. rial fur ]»>rffirt pontiueiice iLiid control of Ibe tiriue. 

[ iiifut or lAck of (levclopmeni of ouu or the oliinr 

h ! by iiiKoulindico uf urine. Thiis, prerioiis to 

M iim ofl«u ti^> be- Ok* result eitnply of a laok of deveIo|>- 

..L,ti nphiuctvr; for tliia Hj>Lui(-ter in a purt of tlie piv»- 

L»il, in oommon vitli iho genital orgaos genaraUy, r«Duuiis 

111^ Iho iirat jreora of Ufa The compreesor oretfane, but- 

. iiilimpous urvtlim, wbichis u ittripi.'d uuBcle iiud under 

1 Htifliafui for iim dosuro of the blndilcr dunti); th« wakini; 

. »p lliiscoiitrol itt li-Ha perfectly exercitieJ, atitl bccnuae it 

"niiui.ucv*.! by tile intoniol Kphiuctor, noclumal incontiiieuce ofteo 

\ < ' ^' tl>(> prostate portinipates in tlte general drvi^lojuucut of tb« 

u 1^ uiid the inteniR] Hpiiinct«r performs ita ftjU functions; at 

. , i( itot before, uoctiinuU iucoutiii«uce usually erases. In coui- 
iL,. . ,.. iv m«i i;a«(!B, t-aureaia pereiats after puberty, cvvq until tbo iudi- 

L\(tUtiU wHiiiriH tliu ago of Mxteen, eitTlitcen, or tTConty ycftra ; iu suvL coma 

'tUtXM t" »■> iutpiirfect development of the s«xunl organs. 

'I'liH uiiiiiiiain or "w(;uktii.-HHof tbo bloddor" of old in«n can often bo 

I iMit*t<d lit ati impninuoikt of tbo proHtatie sphinclor. Li tlie&e &mo6 thero 

tilt, IM Initio) hut aliown by nuicroacopio examination, a fatty def^ iteration 
iif llui tiiUJioulnj- fibres of the bladder mid prostate, including the inteaiiol 
«p)iiiiolvr. Fatty degen«ratioD of tho i>^liiuctor only or cliiedy ie luaui- 
loaltid by incotitiiK^K^u of iiriiie ; when it affects tbe detrutKir tiiusdea hIko, 
Hut ubihtr to Dxiifl the urine ia impaii'ed ; these ore the canea in which 

L»itil(Ii'ii iirtrulynia of the bladder occurs in conaequence of OTerdistention, 

Ifl-iiiJi linldinR the uriuo tuu bug. 

Kntty dcfjencmtiou luwy affect the spLincter in casc« of proBtAtie hyper- 
(rojihy, but i» more fi-equent when the prostate is atropliiea ; ilus atrophy 
oL'ciint oftcner than onlivrgemeiil. (lu^conlint,' lo Dittel twice aa oft«D) even 
iu old Di«a. It in an oc>caaioujil result of goiiorrbtea ; hence there is aome- 
(iim<M tM^un aa a sequel to goDorrhi^a, even iu younc or middle-aaed men, 
a " weakueM of the bladder," which may manifest itself by actuu inconti* 
nenoe, but more frequently takes the foi-m of dribbbog after micturition ; 
■ometimw tbere is merely auccusaity for frequent uud immcdutv uriuutiou. 
bapoinaetit of tlio oxtornnl 8phiuct«r, the int«rnBl remaining intact, is 
also at times the eauHe of iiioontiuence. This happens usimlly aa a retJiilt 
of Hlrictui^. An intlammatorr deposit involrinK the membranous portion 
of tbo uretbm raust of coune impnir its rniisculnr oontrAction : mid tut a 
oUlkical fact KucL impairiuoiil, uiiitufeMted by eiiurtiKiii, is freijueiitly observed 
in OBSas of stricture involvinir the ])osterior m^tlira. 

Even a atricture in the peuduluUH portion niny occasion the Bnm« result. 
Poff wbou it bvcomcB iytutv iiiurow tht^ru ouours u uhruuic distention of the 
lUretbrn posterior to the stiioture ; and thiK may extend ho for hncV an to 
dilute the meiubrauous portion of the canal, depriving it of its normal con- 
tractility. PiLitjitiou 01 the Htrictui-e cures the enurcaia by purmittiog tlte 
comprcHSor uretlirte ootre more to resume its functions. 



ANATOUIOAL AND PmrSIOtOOIOAL CONSIDERATIONS. 



13 



In the female tlie entire urethm, correspoDdinf; to the m£in1jMnouit 
portioo of lh« iiinli;, is provided witli circular mmtculiu: fibres, aad perlorms 
the function of a Hphincter. Oases hate l)een obseired hy Wincke! ami 
ottiers ill whicli the Deck of the bladder aii<l the u[iper {Hirliun of the 
arctlim limi bceu CDtirely disor^fanized bv %'e6ico-Taginal lii^tilit, nnd in 
wliioli after the oloam-o of'tlie tistiila by operation, the' reniTiining (ixt^rnnl 
porlioa of the orothru bail been fouud niiSIcic-ut to cotietitute a perfect 
Hphiiicter. 

Tlio cxi*mf»!. vrtltintary sphincter may in rarioun conditions conse to 
obcv tb« will. Thus in cjweo of irritation at, or operation upon the atMt 
or pf rineiim, in Htntes of inc'iitiLl tvoKion. such ax iirolcinped nervous ex- 
citement, hj'8t*ri«, Rpxiiivl fxliimittioti, etc., there may occtu- a spasmodic 
contraction of Uiin inuacle wliicli no etTort of tliu will 18 able to uviruuine, 
tho It'll:' of ihf> cntboter btiin^ ncceasrirr. In other caaeit the opposite con- 
dition occm'9, the sphincter ililnting without voluntary impuLae or even in 
opp(i§ition to the will. Thus terror, nor^'ous shock of aiiy kind, find even 
inordinftt« lAU^htor may bo ncoompanied by an inTOluntan,* dilntAtiou of tlie 
Bpliinttt<ir and expulsion of urine. 

Vie poBiCion ijf tite vexictU orijice of the urethra vHh reference to the 
symphysis is a matUtr of clinii-nl impoftnnoe. It is ns n rule ]oont«d in 
adults about ouo inch buliiud auU Uiree-fourths of an inch above tliu arcu» 
inferior of tha symt^iyoiit ; in rhildren it is alwavs bif^her, sometimea even 
above the boa& The poeitiou ia influenced by tlie iuclintitioii of the 
pplvis ; for the urcthm in firmly boiuid to the pelvis in front of and 
iinderncfttli tb« Y'^P'^T'^^- bouce tli& inclination of the lt\tt«r influonccs 
the posilion of the bladder neck. In youtti the syiuphyBia is uiure iu- 
clineil than in age, and the position of tha veracal orifice is correspondingly 
higher. The distention of the rectum and of the iscliio-rectnl fossn is 
onotiivr fuotor which iuorooiioit ttu) height of the nvok of the blndder, for 
rinra this cannot KoeAe from the qmiphvms, such dist^mtion taunt miw 
iho vetuoal orifice toward the Upper boruev and compress it agftiost the 
■rmpbvsis. Hence it aomctiracM bappona tliafc fluahy old men. in whom 
tIte tsokio-rActnl foiun in full of fat, must dofo(>nto l>ofore tfa«y con nrinatflv 
«inc<-- wbilo the reotum itt distended the neck of the bladder is high and 
the pi-oatalic urethra corapresaed. In cases of proslatic hypertropny the 
vesical oritice moves upward nnd bitckvrartl from itf^ normAl notntion. 

Tbe tiiguuum — thu IriJiEi^uIur |)ortiou of thu floor of the oladdttr whoso 
wiglrtsare loCHted at the vesifJi! orifice of the urethm antl of the two ure- 
teni reajiectively — is <li4tin<^iished nomially by an nbundouce of muscular 
tissue. The upper bonier of thin triaiiKlo, strctchinK botweon the oriti«!a 
of the uroteot. wiTniitini-^n booomcs fiyperttophied ^ as to oonstituto ft 
ndgo which oppottM the eutTotice of tlie ciitlieU-r. In a few reconled in- 
BtAQcM this ridRo ha» become ho developed na to constitute a partition l>e- 
tweea the body of the bladder and that poi-tion l>«low the ui-et«i*s. Id 
oao case obiwrvod by Dittrl this muscubir layer completely iilitit off the 
Umer iteotioii of tho blailder from tbp body of tlnj orgiiu. bo that (it the nn- 
to|isy. after the c«lhot**r bad niacJied aiul (-^-ncuatftd thii former, tho blud- 
der BtiU remitiiied full, and was emptied only by a si>ecifll eHbrt whereby 
the cntbeter was forced over the obstniction. 

Hfrnia nf tht^ htad'hr, <txtrti«inii of tht? whobt or n pwt of tho orfptn, 
mny occur throiifch the abdotniniil wid[,thc intrutnnl or crural CAiial. throuj^h 
Ihe foramen ovole. into the perineum, scrotum. Ubia. x-n+fiiia, or urethm. 
Tb? moBt frequent forms ore, in make, tho scrotal ; in fenuilc«, vn^iial, 
femoral, uud ui'etbrtl cystocele. These am comparatively mre couditioow ; 



14 



DISEASES OP TUB UBIHABY OBOAlfS. 



yet tlio jioxiiibitity of tliuir occ^urruiicc tihould bo rcni4]nib<ired, since a (&U- 
ure to i-ecoguize them maj be followed b; diaaiitroua remits. lu JOMaj 
of the recorded inBtanceB, the true nature of Lbe bemia Ima not been di»- 
ooverod untit niicr (loath Erom opoTntUtn ; mntx the cUnf^oHls is usually 
easjr, 1^ obaemng tiie decreaso in the size of th« tumor uftur t\m intro- 
daotion of tbe natheter, Mch iiiiatalc«a uauaily rtinilt moTvly from lock of 
care, oud not from inherent difficulties in diagnosifl. 

Ingnioal liemia uf tii« bLulilL-r in uninUy ft oomidioation of ordinary 
intastiual or oiiu-iitnl lioniim tJumgli in u few mre oaaos vyErtoc«Ie liaa been 
found to constitute tLe euLii-e liomia. It iimy couunso almost the mtira 
organ or onlv the fundus. v,hu'\i is <«unGcted with the baae of tbo blwld«r 
by a narrow channel poiising through the inguinal oanaL Id tliese latt«r 
coHes, iu wliicb u portion uf tho bhiddur is tbun cut olT fmm tJie remainder 
Aud protrudes i»to Uio Kcrotum, calculi mny forra in the extruded por- 
tdoD. V'idier refen to a <?a«a ia which a cystocd« coDtAiiiiii^.' a iflono was 
coDtridered a bubo, and caustio was applied, resnltin^; in the production of 
a tirinairy fistula. Adbcsionn of tho bladder to the adjacent inteaiise or 
sac liavv been frcquoutly observed. 

In tbo fomnlo, ingiUDal cvatocele in lowi frcigucnt than in males. Itmay 
constitute n swelling of th« ^ibiuni, and may possihty be mistaken fur dia- 
teutiun or abaceaa m Utu rulroTaginal t;laDd. 

Vaginal M'lttooelo oocum rspocinlly in women who kaTS borne children 
sad have suoared laoeration of the jjei-iueuoi ; it may also result from diii- 
plaoemeutti of the utt>nia : indeed, a idii^hl degree ot displacement of tlto 
floor of tlu' hliuiblor in » not uiicoiaiuon (imtura in uterine complaints. 

In cases of vetiioo- vaginal fitttulA tliere 6om«timua oucurv uu ovcmiDD of 
the bladder through tho opening, forming a red, ooft tumor which blocka 
up the vagina. Crosse saw a case in wliicli tbe bladder after evcrsJon into 
the vogiuu bad actually tuicapcd between tho labia, forming a tumor exter> 
nal to the vuIth, from whioli the nrine drippod continuously ; the orifices 
of the ureters could bo det«ct«d. 

Inreraiuu of tbe bladder through the dilated urethra has been obeerred 
in females, cspecinlly during infanoj* ; it may even he congenitoL Id 
adulta, it oocunt as the renult of chrouio oystitiB, with coustont and violent 
^urtsat micturition. In most ofttiese oaaes the entire parenchyma of 
the vesical wall is disjilaoed ; but iu a few inatanoes the mucous membnne 
hoB been detached from tho muttcultir oout and baa prutruded alone. 
Noel recor<.ls a ctiee in which obstruction to the ureters had caused the 
urine lu burrow lietwecii the mucous and mmicuhir coatit of tho bladder; 
tile mncoUH membrane protruded through Ui6 urettira in the form of a 
tranfljiarent sac filled with clear liquid. 

Urethral cj-Htocele baa been miHlokon for u polj-p. 

DLBpluc4>ments of the bladdermny csiut for yeiuv without causiu[* uymtw 
tome i«f«rable to thia timcum ; and tmiy oreu then cause u dilllc\ilty mig- 
eeeting disturbnace in other abdominal nrKnns. A curious inataace of 
Siis sort is recorded by Dr. Briddon.' In this case a boy nine years of 
age exhibited s;v-mptoQiB of focal uupoction and perit)-plihtt». A Huctunt- 
iog tumor occupied tbe right inguiDsl regioa. ext«udiiit; im high as the 
umbilicus. Thire were no aymptoma indicating uriniir;' difUimlly. After 
malting an incision pftrallel willi and one inch above Foujiart a li^'nment, it 
vraa diacorered that this tumor vtaa the laterally tiituiLted and distended 
bladder. 



< Hvdieal BoOQrd, NovcmlMr !W, 1881. 



AXATOMIOAL AND PHT8I0L0OICAL OOMSIDEEaTlONA 



15 



Dr. I. G-. TlKimas ha» uiUvtl uttculiou to Uio uc«uinoii(U udlicaioD of tUo 
bladder to nu ovaiiou taniai', resulting ia » Kiireoding out of tbc blutldtir, 
liko an upton, over the aDt«nor aur(ac« of Uie tumor as lugli or even liiglier 
than Ute umbilicus. In snven caafs recorded, tbe case 1^ termioated h- 
Utty either from cUi-«(.-t iDJiirr to tlie bladder — the sur^on fniliug to no- 
OKuuti the compUcatioa — or from failui-e to remove the tumor ou ocoouut 
of tbe adhetiiou. In a casa iu liis own practice, TUoiuhh succeeded iu Ub> 
erfttiug tbo bliuldcr from iU ottnchiuents imd removing tlie tiimor, with 
fftvomble rctialts. 

Dieerticula — looael; called " cysts" of tbe bladder — protrusioDg of tbe 
muooua uembnuio between tbo muscalnr flbree—aro frequently found. 
In some onacs these bave uo especial oliiiicul impurtauco ; but iu most in- 
|Atancefi tboae protruaiani) ore foand in oUlerly men who hnvo long (mEEorod 
^ftoin prostatic b^'}>ertrophy or hom stricture of the uietbiti. In such in- 
dividuals these diverticula constitate an important factor in explaining tlie 
origin and obstiiuicy of vesical catitrrb. For since tliese »u?s consist 
baerely of luaoous lutjiubruno devoid of tuuHuuIar llbrvti, tbuy nro uftTor 

ytiod by the coiitraetion« nf tbe bladder ; indeed they nre a^ravatAd 
inureased in size by audi muscular action, Tbe m-in©, therefore, ia 
fiiot expelled frum them, but Htu^^iutcH jndutuiitdy ; tbe urinot^- Baits are 
RirocipitAt«d and ikcmiiiiulntA, soiuotimos aggngatod as eolcuU A cystitis 
'wbicli ori^nuateii from any oause a pi-olouged iudefinilvly in tlioM) tncn ; 

for DO meoicated injection can be maHe to enter theiu thoroughly, nor can 
^e stagnant urine and products of ijidammatioa be removed from them, 
nritljout capuuiol effort. 

Tlioso aa^M fi'etjuently perplex the surgenu in still nnotbcr way, namely, 

by preventing him from toucLjng with tbe sound a stone which the symp- 
|tinuui prove to cxisL Iu nuuiy caaott the hIouu itt formvd uud I'Ciuaius in 
mib diverticulum ; in otitcr oomh a calculuH formed olmfrboro drops into the 
Hko, where it may reiuaiu permanentlv or only traitneutly. Sometimes 
FUie ntoce is founcl now in the diverliculum and again in the body of the 

bladdei", according to ibe movements of tbe putient. In such instauces 
^Vaa surgeon often bucouuMi au uuwillijig piu^y to a giuuo of bidu-uudisouk 
■ll bwMareb after a 8I0110, fiomatimea rpacblng it with the Konnd at tba 
*mfA attempt, but failing at subBeijuent sittiugH to deteot it. Sir Uenjamin 

Bnxliu relates an insbuice in which he discovered a stone in Uie bladder 
ipt a tnJiQ, w 10 bowovor declined an o|>«rfltioii. " He went oix, in general 
biiferiug Uttiu or iiutliiiig. Hver^* now uu<l tb<!ii, bowcvt^r, )tc wan nw\- 
Baoljr aaized with the uHual sjnnptoms of ntone in tbe blailder. and v«[y 
■Brere ooea too. He then sent to me. I kept him in tho horizontal jpoe- 
nuro, prewribed him on opiata. ol>'st<-r, and iu the c-oiuveuf u fvw <1u,vh. 
nonutime<i iHHiiicr, sometimca later, tiie attaiik Kul>Kidod. ho was again at 
piis €ase and enabled to return lo hia uaual habiia. I bad been oooaaion* 
■ally in attt-ndanco on him for three or four yean, when he vraa seiEod vrith 

a savers eold, which ended in a pleuhiiy, of nbich be died. On euuiuuing 

the body I found tbo stone imbedded in a cyst near the fun<luH uf tbo 

bladder. Tlie cyat nas formed in this catw not by the protrusion of tbe 
rlDUCOUS membrnuft between tbe muscular fibres, but by a dilatation of 
wotU tui)ic« of the bladder, the muaoular its well as tbe mucoua. Tbe atone 
nnw not so closely embraced by the cyst as to prevent it OGCooionally slipping 
IduI of it, and I suspect tliat thin nctually Iiappened, and tbat it was when 

tbd atone lay iu tlie ryat that tlio {iiktiL'tit wih uvc from the uaual ejnnptonig 

of ealeulus. and thnt'hiA sutToringvttook placu when tba stone aniiped from 

It into the general caWty of tbe bUuldtir." 



DI8B&8KS or THE UBnfAET ORGANS. 




K Ib naaarfpiMil ItMrtanoo* iitont wica Uave been known to bUiuq eDonnotw 
■feK la one com rnwrted by Dr. Miirchisnn to the Lontlon PalbolDg:ic«l 
IjiMblf, Ibo* wa« B BtTfie abaomiual tumor extencUng as for iw tha s^jne 
hft Um Uiuin, tb» tixMict iuitiir« of wliicli wtM tl^t^rmined only by punctura 
l|Mw1 •iiAitiitiittiui) of tliu fluid witbdmwu. Fifty-four ouucen of urine 
Pta«»|i»l !>■ Iinlf ftii liDur thnmgti the piiiicturv luiil tlirough a eaihttter 
ptnnillniiMiiiBly ititnxluc^c] into tbe blmlcler. 

f ^iiiImiii rjuolM frrmi ^Varmi tlio follon-ma coae : "A man ngod eij;bty> 
bfvn, wlw ImiI MilXbriM] fi-ijii) (lyauria for Mvonu years, mot with ua itocidrnt 
MitilHi iwiwmI liimijiupluuiH to iucreoBe. His nbduiaeD Knulunlly lienuue 
b*iilMrif>-'l M (lu^ii|/li he woro mifTpring from oxcitf'tt, and ouly a small quan- 
||)l; "f uriuii ptnil'l bo obtained by the catbet«r. On exaiiitiintioii after 
llUntli tli4i Imiior, mIiiHi reacliiNl ns liif h nn the stomach, vna foiiiid to have 
tlMMifi (uiiiMtd by itii onoriiKiiiH (liwrticiihuu from the bladder, the vntlbt of 
(vlit'^ti wi'n> tiiudi lir[>i*rtn>[pliiod. On tlie left siJe, a littJo ubovo the neck, 
Dka ft round uiHUiin^t linuliii); iiilo tlie larger tumor, which vos formed of 
lltK )t»rili>iii<nl iitid iiiiKvittH <?>i»ib) tuid held a gallon of uritio. tVom t3>s 
ikUUirf of tlio nuH< it wim i>vidiint tbut tlio »rustotic enlargproent hml let] to 
Hhn*nm|4iy of tho mUHcular nut At iLo timo of the injnrv tlii^ ttiuio 
Hmm ihVfll WHY, nrxl »■ tinio irontoo the mucouM and pvntoocal coveiiogs 
HhhI iMtrotii* fhainiidi"! luitl foiTSod the euonnoas cyst." 
■ Tlii-m iliti'tltinilii kreuauoUy the resolto of a chroiiio iiii|>ediiiiestto tho 
imiiiiiiLiuit lit uniic -ohtallT pnMtatn hypcrtiopby uid urutbral etrietore ; 
llliiiy nni ll>iin)(iin> itminioniT ol>M<rto«l in «kb>rly adults. Thoy soi]ietiiu4» 
UHHiiir (n tihdi)i-t>a nlmt, bt'Utg fnipic it tly produced by tight phiino^iH or 
Hinrrnwliiu <■( llm tumttiu, uid tliey have l>efa seen in cnscsin which Uierft 
^mnm !«• tllwKivcnible iinpoilimeut to the evaouatiou of urine, awl therefoia 
In I iMij)i«i<liil>lt) (<auMi tor tltrir vxi»tr»oo. 

Kiit'UMUi iiientiiMiB a cum in whirh a lonooth, flariaating tumor irag 
liiiiinl t<ilt<n<liii([ (mm tlm atotnacb into the pelvis, in a inan thirty-fivo 
tlitiim i>lii 'J'lio tiuitur could be felt through the ractoai, though tbeze 
[Mult lilt •unhmlly iu defecalioD or urination. Uwu pnnetarMl utdflvvea 
|iliitia iif tiWr iiriiw w-ithdniwn. Hie patient died of ^noope. At tlin 
lltllo|My|lii>rit wan fuumldilatatioo of UuDladdcr.iirctvni, and renal pelves, 
itiid m'li (iY«<a. one on «aeh ade^ whieh ootninunieaUxl with the bb^er by 

(ij iiiKu laripi enough to adadi tlie flnger. I^eae wt-re <lirerticala from 

Iht' liliuhlnr. opening into ita untyatjout an tDcfa and a half abore the 
ui'llti'iiii lit lh» tirrters. llie mo«t aiagular feattm of the eaee wa« the en- 
[1)1 II (tl)M<ii<-ti of lurcluuiical ituiiediiDest in the uxinmy chansel; both the 
Itriiklaln mill unttiira wer« Domuil. 

HotmiJH iilitivrTed a caae in which a lar^ge «onceiut«l oyst eouaBluig of 
h luiliiinm iiitiiidinuiB and peritaoeum conunuaicatcd with the bladder. This 
ImiM 4)ipiu-uiitly a congenital malfomiatioii. Ifany of the caew of so-called 
[^.itiblu UliMhlor appear to hare been inataaeea iu which oonfiviutjd cytts or 

fli Kutinulaaa large as the bladder ttMlf«adMed. Thus Heyfelder detected 
<.y IliK ttoiuid a oaleulna in the bladd«r of a boy ax yean ot ape. After 
1>tii'f>iiiiintt; liHiotomr, the anrf^coB failed to find tbs etoocu At the au- 
t>\my It wiM found that tbe Uaddar ooowtod of two afitki^ an anterior 
Aii>t a iH»t><ri(H-. (H^nnMlted by la «nftoe httX^ eaongfa to pennit the pa*. 
tngv of a wiuiid : Uie stone wia diaoonrcd in the poeteiior portioD, which 
eiuwiHiwd iif luuixiuH membtisc and poitoneum. 

Hu' /inuihWiV HrwAm or prostatic "KnaB" ia aometimee, eepeciaSy in 
wtMa of ureat liyportruphy of the prootste, eo capadottt as to bocooudo- 
dule u lai-git 4]unutity ol fluid. In a few lecordea inataaoMs the l ur geca 




ANATOMICAL AND PllVSIOLOGIOAL CO KSl DERATIONS. 



17 



N 



iIkcd deceived into Bupposiiig thnt the oatbeter had putered tha bltul- 
tier, vhen in rmditj tt rcuicd in tk« dilnted pro«tutic HmiiK, from irliich u 
Goontderable (itinntity of ittitio bud eaciiped. 

Tho M-catled "middle lobe" of the iirostnt^ in tDcrel; a povdon nf Uia 
chuid uniting the two latent! lobes which constitute the bulk of the orgau. 
Tills Dud<U0 loba uiiij bo much «u1arB«d without any decided increaae in 
sizo of tlio romiiiiidi^ uf tbc pruittiitc. It in ■tittutU.'d poHtnrior ti> tlto V4;id- 
caL orilicfi of the urcthi'a, and when enlarged it projects from behind for- 
vard over tliis oritifie. 

3V- afjj^orhcnt ponY'r of Oie vesioaJ mw!ous membrarte haa been the eub- 
jcct of much diwiitwluu nud cxpuriiiivtitutiuti. Variuutt uiithont have bL-vti 
unitblci to dciuon&tnttfi such povr^^r of n.l>i>nr]>tiflii n.i\i\ iuu-o utterly denied 
its existeoL-e ; aiiioug tliese is Sir Henry Th< nut-oil. M<>r« extended uid 
oocurate obHervntioiw hare, bowev-er, demon !>tnit4><I tiiat the normal tnuctnm 
morabmng oF the bkddor tibiiurbi;, 'though far mori> slowly tlian mucous 
loumhranes i^Qomlly. Tim ruauuii for tiiin dilTeruuce a[ipciu-s to liu ui ihu 
BbReoOD of fteereting (nnd thfircforQ nhwiibin}^) Rlands. I'or tho epithflimii 
of tbe bUidder consists of severnl layers of cells, the up[>ei'moBt of the 
H(]iiiiaous TiLriutv : thi» is priivtically impLTTiouu tu fluids. It is ouly tlio 
follit^loji, which oro lined witli r ttinglo layer of cells, tlmt oiFer a fnvorable 
opportunity (or absorptiou ; and in tJie bladder these follicles are few and 
art- located almost exclusively in aud aruiuid the trigonum. 

lu CTWVit of ilisorkso i>r injury to tlio mucouM raeiobnuie, whereby the 
Dormal epithelium is removed, abnorption may occur with estrowo rni>iJily, 
ft fact to be remembered iti tUo use uf iujectiouit into the bladder in cases 
of c^titis, beuiorrhnge, etc ; for when the liuiug epithehiira is remove<l, 
eitber by iiutrumeuts or by morbid couditiouM Much an aitarrh and iilc«n- 
tiao, the Gontento of the bladder are brought into clone proximity to tl>e 
TMSela of the submucous tissue, whereby absoq>tion is factlitatei:!. 

Tho mucouH mcmbmne of Llic uretlira presents a marked contnust iu 
tbiiirMpect to that of tho bladder, ftince it readily and quickly ab«orbs. 
This (act — which possesses physiologic-id rather than oUaical iiitereut — in 
reuUly explained by the anatomy of the part ; for the urethra ia lined by 
only a few, in some parts by u single Inycr of cylindrical cells, and is 
ricolv provided with iwcr«tiii^' and almorbiug foUicloa. 

Ihe tolenuioe of the bhulder t^a mechaiiical aud chemical irritants is re< 
morfcable, and is scarcely appreciated. Htroug solutions of nitrate of silver 
■nd ewD the undiluUnl ttulutiun of the pcrcliloridc of iron hav« been io- 
iectod into the bladder without prorokiiig a pronouneed renetion or eaiiH- 
ing much pain. This can be safely dune only throuf^h a |ierineal opening ; 
for the urethra is extremely eensitire, aud a few drops of such BolutdODS 
applied to it cnuse inteom pain and sharp iDllammntoi*v reaction. HeaM 
aucb tcritant solutions abould not be injcol^jd through the urethra, since it 
ifl jinMtioallT imnojuiibla to prevent ootitact with the mucoua niemhrane of 
thiscbacmel When, however, the bliulder has been rendered accessible 
tij • pcriuuitl incision, either fur exploration, lithotomy, or for the relief 
dlajstitiit. strong solutious may be employed, if ueocBsory. 



The URETmiA. 

The mucoua membmae of tho urethro is fumiahed witli Dumeroua 

microscnpir> meemose t^lnads, cnlletl Littr^'s glauds. There are, moreover, 

in the mucous membrane tubular pocketa, the so-called laounie of Mor- 

gigni, which may have tho depth of on inch or cvcu (w inch aad a half. 

2 



QfaSA8£9 OF THE rBIirABZ OBQAITS. 



*• lociUd clitefly upon the roof of ihe tiretbra, tliongli itltito found in 
itM Mm mati iloor, In Uiri iuteriur portion ot Ibc pencluloua ureUtm tlifse 
pttektlM atUiin tiittit greatest tUpth. ftoil are usuftUy loc*t«d ao that lh«ir 
Ofm Mxtr<itiiitir« lire tovnrd tlie lUCAtua ; ia tlie postoior jportion of tlio 
|iMilnlmM ufftUirn iitid in the memlinuiCPOB part, on the other uiuid. tJie nnett 
MMIn of tllM« |>oclict« aro turnea inward, that ie^ toward the liliultlcr. Thie 
I* ifii Ml ooeaaiuiiiil or uxooptioiul amaRenient, as lui^ht be iDferrcd fram 
Ml* ■Mitdanl toxt-booln on anatomy nnd on f^euilo-nhiiury diReaecs, most 
4if wlil'iti n*ir<rt tlmt llio Inmiiiiit (ill nppii ton-ard tlift nK^ntiis ; a few m«DtioD 
iJff. fiu't lliitl III II fdw inRtnnres Midi follicles have bpoii seen opvuin;; in- 
m ' ' "d llio 1>lndd«r. In reality the hicuiii£ of Moruagni exhibit in 
rx "irn, undo uid foamlo, this diversity of arnmgcme&t — those of 
(I r piii'lioii upuuing outward ttntj lho«o of tbs ponterior portion 

S' •: •iiMKnl -11 fiMit which I proMaUKl wad illuutrntod to tho Bofal 
Mifir 'if l*lt><tl<>liviiii in Vienna in 188L 
Wlii'Miur or md IhiH |«oaltBr arr&ni^nieut of the kcuns in the poB> 
iMfl"*' (""li'iii of I'll" iir>>thra liaaaptK'inl clinir-al iiniMirtiuioo, remains to he 

tinifiHt. Ittirliiit r.lin ilimundon in the Vtemia Hocietj it ynoi suggested hj 
'ritfiMMir l>llt«l tliid the obitlinMy of gonorrh<e« in Boue caaee might he 
flit* ijr llui |iitrli<<i|iRUou ot these lAtnuue in the postenor portion of the 
tifwihmi Mxil Ihti itiflAiutnRtion may i>eni«t in these follicles, iuiLcce».-ibIe 
t^i iiiJontiiiiiM m' ittltiir iiiflilicAtion, aftor Uiegmend un.-lliritig hiis subsided.! 
fl wiildd «l<iii MMiut Uut the*Ni lacuuiv fxffim a favorable opportunity tot 
lltA iWHiiNiililriUoii of urinary Ralta; pnawbly foUioulitis, wluch Bometituea 
iMmm litddpntulnntly oif gonorrh<Ea as voU lu clurin)^ tlie course of that in- 
llNiiiiiinlhrii, in fATonHl by tlio anfttotuioal airangenicQl of theae lacimax In 
III'- Iniiiidx I hnvu r«|>uii tiddly found, post mortem, theae foUieles distended 
Willi i'|t|lli«llnl dobriH luid iHBpimated pus, oveii to the saw of a lutzel-iiut. 

Ill lliti fitiiuile tlio foUicleH are uuusuidly d«C'p and numerous at snd< 
errHiiid llui (iilornal oritice of the iiroUirn. In 1854 Sinfrer, then oMistAiit' 
III lliii Cltiilo for Syphilis in Tienna, demoitHtrat«d the dependence of o1>- 
ntlfiaU friitiorrlKPA upon the partictpatiou uf these liu.-uiiie ; io several cofles 
ftt ifdiiiit rbiiMt, biitli vnginal and orethml, the disoliiu-ge peinited in ^tsi 
«<f «ll iiiiiilirntion until applieationB irere made diret-Uy to theae indiriaadl 
/•(lUiihiH. Ah (Leii' oriUccs nro Iaeat«d external to and just htiavr the nwi^i 
J*l<ti lliuy tinii be uusUy slit up if neceesary. In the male, too, h similar > 
niMUiii'p may lie nooemaiy. PhdhpH (quoted by Bimurtead and Taylor) 
hIaUm llial he eured four ok«tiiuit« «mm of glc<et " by introducing n ilirMv 
i/rr ttUnm lUo upper surface of the urothra until its extremi^ entered the 
Jhiuiiu muffiio, nod then aUttiog up the wall of the follicle with a nmroir 
lA«l^>iiry," 

Thu nituxniH membrane of the urethra in the mnle is, in the flaccid con- 
Dillon of (lid iioiiifi, thruvm into uumcruus traoHverse and longitudinal 
f'd'lll. Tlixno favor Iho iirrrxt and mt«ntion of solid ingredicntA of thfl 
iii'liiii wliluli iiuiy bo precipitAied iii thi> bladder ; they oon»litut«. iiioreorer, 
iiliit iif I.Iki olmtoclos to the introduction of iuHtxiimcntn. If tliour«thrS. 
Wdni iiioin ({i>iiflrally examined at autopmee, nnd especially if the exiuuin^j 
tiiiii wiK'ti iiiii'lu tn titu, the oocumoicD of mich fuldx as a pathological bi^j 
Vn tvxiilil |iiviliid>ly he demonslnvt^ii] more fn^ipir-titly. PoBsibly eome so- 
Mllnd irtrl«t iiti'ti of large calibre, congenital and acquired, Are renlly due to 
UiiUNitnlly liiruo folds of urethral maouas memhtane. 

NfUTiilar dilulAtion of tlic urothra bi oocasiottally witnessed, not only aa 
I ruNull of Mtrirtiu^, but aLw witjioiit apparent cnuscs. In the few cases - 
wliliili lutvu been observed in females, it woa aasumod that the dilifatitiml 



ANATOMICAL AND PHYSIOLOGICAL OOirsiDEBAllONS. 



ID 



liiul Xmen fartherecl by coinprcminn of tlie uroUim hy Uie diild'a lieatl <luiv 
ing confinement. Such dilatatiQn RometimeH cauwis nneoaness snd pain 
dufiug miotuntion, dribbliuj;; of urine, and may even induce n sliglit. gl«6ty 
discharftv tivta iLc irriUitiun of the mucous uicuibi'Uiitt cnuacd by tbu r«- 
toiued iiriuo. In fcninJri^ nnd orton in malos, « Blight protrunon cnn \3a 
Jteitielcii in tbe coiuae o! Hia unithra ; yet the dilatation m&j be discover^ 
able only by tlie iwo of the uretbromettr or endoscope. 

GQTi'jenital abnormalitifA of the uretUruJ mucous inenbruie aro not tn- 
frenueut, (uid powMcss oonwilcnible cliniciil iiD^xjrt-iiici-. Anioiig UieHe aro 
occluinoii of the ciuutl b_v uimplo adhesion of its waUit, hypertrophy of the 
opitbeliuin. saccular dilHtnLioii, luid cotigvintal cttricturci. Tlieae may occa- 
eum retention of urine in the new -bom, and rarious anomalous Hymptonu, 
BUch as enuresis and dribbliuff. in KubHequent years ; an uitHuepwted diia- 
tatioii tuid hy|iortrophy of the bladder, nephritis, luid own unt:inia (seldom 
TMOigBized aa nucli), inny occur iu a uhild na Lho result of aD undiscovorod 
conf^enital impediment to the evacuation of urine. 

OerliiHion of the urinary channel throu-jh l)u! simple adhcnon of ojtpo*- 
ing mucous »tity'm.vx ot^cura in VHrkHiii; di'i^i'ee and iit diffcrenl lociUitleR of 
the urethra. Tlie lulhesion of tliv iirrpnco to tlio glanii ia a frequent oc- 
currence in the uen'-born, and ia known to cause uunici-ous moi'bid symp- 
toms. The examination of the parts, ond if uece8S!U7 the lepantioQ of 
tlic propuoo from tho glans, should bo mado ut tho birth of every male 
infant. 

Ailheaon not infrequently occurs between tho Upii of tlie meatus, and 
may exist anywhere in the course of tha urethra. Enghsch, who Inut tn- 
TMtig&ted particularly this siibjucl, found forty-six cases of stuiple adhe* 
veto D^Treen the wails of the urethrn in ncw-liom infanta. 

In other instances the occlusion of the «anal consiate not in simple nd- 
heaioQ of the mucous surfiwes, but iu ati obliteration of the urethm to a 
nvnbor or lem extent br cicntiicitd tissue. The same observer collected 
39 caaes of this sort iu uifuultt ; M 'niru found iu tho fossa navicularis or 
at the meatus, 6 in the meinhranouH and 2 iu tho proRtatic portion ; in 1 
ease the entire uretljn wna oblitaratet?, and in 6 others the canal was oc- 
cluded at HCTcnU plftccs. 

JCagltAch lias also called attf^ntion iio tho eongcnitnl occlunon c^tha ori- 
fice oflkf *tima p'Kutanu, in the pi-oelatic uretlira, as the cnuse of reten- 
tion of urine in the new-bom. Such oc^clusion is fallowed by the disten- 
tion of tho sinus through the accumulation of Mucrction from the glands 
lining its walls. He found thia nbuormahty in over 8e«'en jyet cent, of 
namerouii dissections of infanta ; sometimes the sinus wna distended to 
only a slight degree, constitutiug au unimportant encronchmont upon the 
proHtatic urt-thru ; iu othf^r cases it was so disteudud as to rival the ulnddcr 
in size, ooufititutinf; a lluetuAting ttuunr extending from tlie posterior 
margin of the pro^tiite and UlUiig uji th<* spn<?e between the bladder and 
rectum oven as high as the i-et^to-vesical fold of the peritoneum. Iu moib 
of tlieee cases the blatlder. ureters, and kidneys exhibited tlio inevitabla 
«fliMt« of urcthnd impediment to the oracuatiun of uriuo ; hyi>ertroiAr 
and dilatation of (lift bWUk'r, bydronephroHiH. and ovt'n atrophy of tlie fcid- 
ney was found iu iufatils &.■* Uie result of this diMti!ntii>u of the utriculu& 
The poBHibility of this nbnormality should Ijo reiuemhci-ed in Uiosc cunea 
of roCentiou of urine in the new-born in which no occlusion of tho tvinary 
eLanuel in ti.iible ; tho iiiipodiiuMJt ta readily ovorcoute by a onthetcr, nud 
the utricnlua can be emptied by preaeure between a sound in the urethra 
and a linger in the rectum. 



«4MU«ni or THK tmiNARr OftOAKd. 




.'%.■ j*v>Mt<* urielvrtm of tlie urethra Are most &«qiient at ttie 

. ■ ; .> ^ht f'^MM DkviriikriH. Uiouf^b tiic^ are aImo obaenred at ttie 

.^>^»^NM« jitDcUxii. It U iK>t«wQrthT that in manv of these cacea 

,«!»•< «-\t-U TUi» (-■ouditioa vf tb« prtpuee sbotud tlicrcfuii b* 

iMMi ti*it)-'<>ll>»i foi' *'"' exploration of the nrctfav in those owes 

.JFii-niv iiiiiiiir^ diffictiUj persists after tbe remoral oi the phi- 

. i>f ninfCMiilAl u w«U as of acquired Btrieture^ tb^re toaj 

-It Mt tliv uretlm aod even urinitTT fistula |Nifltenor to tlio 

I Iht lliatiuins there may be uothuif; to aiYHue Riqiioioti of 

-.1 1 t«l iiHi excerpt incontinence or ilnbl>ling' of aniie. 1 baxa 

I Ivii fiHUn uf age, who bad alw-are exhibit«^l mcouliticDC« of 

Lt iiiiUHiuil ilittiT^e, tbe niiue fmiaently csmpin^ invnluntAiily 

< iliky iu> wtll aa b^ ni^i. AJt«r tL« measures uauallv emplovc-tl 

: . I. •Illy iri'^l, find tud failed to improTC this condition. tJte urethtu 

. I .. .'•! IiikI ft Htri(!tare, anpiur«nt^ oiigaiiir, which tightly gnsp^ a 

>(> No. 7, wan fouitd at the junction of the bul1>ou^aDdu>enibnuiouti 

.1. 'I'liii •tmture van slowly dilated, alter nbich proceduie perfect 

^Hiiii. <f iihtM foUowc^l 

I 111. I ''iKiitioaa JuBt described coustiLute constrictiotui of thourvthza 
uf feii'ilt aiiiall calibre an to be readily appreciated by the ortlinon' instro- 
14ll>ll|j| tMod f'>r explomtion ; tbe ftict that micb decided atHcturea have 
\muu ui (ifltn rtooguiiHxl as coageuital uiakes it prubable tbat coDgenital 
idhiiliimii of larger calibre than tJie mGatUi^ and therefore not diseo%'erabl6 
lijr |||4: iieual modes of exploration, which cannot be distinctly recognixtxl, 
iikiMl ami lira overlooked To Dr. Otis, of Xew York, belongs ttie credit 
<tf lidTiu;; fint devtBHl and practiMcl nccurato methods for discovering such 
ttrUUtna oi Urgo calibre: Tliv cxpcrieoce of Otis and of the otuucrous 
HUgaona wbo have been induced to employ these methods has demou- 
atrateil tho existenoo ol audi stricturee in a cortain porceuta^ of casetk 
TIttt olimoU iinportaDoe of these stncturrs baa doubtk-i<K bct-u oTi'mti- 
IWatsd Ij* cothUttUtK ; yd tliero can l>e uo qiicstinn tliat they nn at titues 
reipoiuUile directly and indirectly for TmiouH abuorntaliiiea of aenaalion 
luu! function in the Rcmto-nriDaiy tract — Rteet, ooctumal pollutiona, etc 

TLu urctLml iqucouh tn«mbmn« may exhibit uailcftd kypfrlropJit/, (be 
MlMu^ning DuiiatilutiuK in bet a Mtricture. In theaa oases there is uMinlly 
noma incr«aiiG in thicknens in the Kubniuoous comiectire tissue, but tho 
•{litJieliiua itself presents tbe thickening in much greater degree. I have 
■Djrsrif txaiuiiicil post-inortum two uuses iu which tbe epithelium wu about 
on»4w<-iili4'tli nt nn ittcli in tliicknesa, the section reseiubling tbe skin from 
thv jmIiu of tbe bond In one of these cases the iiiibject tvns a uiau thirtj> 
ofjut jeoni of age, wbo Iiad experienced an uttiuk of gouorrba?a, and woo 
had an ordinafy dcttrieiol stricture tindor the hy|)ertrophii»lnmcoaBmcm- 
bnui« ; the other Buhject was a iiiaii tweutr-one yeai-e of ii^t<, who, so far os 
kiniirn, had oerer had gonorrli<*a, ami whose uretlun was otbemise nor* 
maL In both easas the hypertrophy existed aWxit Italf ftn inch iti front 
•( iIm bulb ; iu each there was some increaao of the submucous cotiaoc- 
tiva tJMoe below tbe epithelial thicheniiig. 

Hypertrophy of ih^ vemmonlanum is occasionally observed, possibly as 
A nsiilt of masturbation ; in ono case I have seen it enlarged to nt least 
tiiras times its usual volume. In this subject then* wru a decided di^teo- 
tioD of the right aeuiual vesicle in coasequenoe of the imperrious oonditioti 
of the eJBCubitoiT duct, which was compressed by and in the bypertropbied 
tisna. Id a fdw rare oaaes the Teru montonum has attmncnl on enormous 
Civiale mcntJiMg two wwh iustaaces ; iu one recorded by I>e BUgoj 



AKATOMICAI. AND Pin'SIOLOQICAL CONSIBBBATIONS. 



21 



nWHa as large as n. small waliuit*. tho cjnaiJAtory A\ici6 were difiteudet], 
tmd ooataiaotl several ImrO cuitcretious as large an peaii. lu the uthor cum 
tlic vt;ru moiitnnuiu hah frtill larger. Uotb Hubjecls were olil meii. 

21ft« mu«:(«s «/' Oj* urethra possess much importance (or the diaF^noRis 
auJ treatmeiit of iiriniir>- miil genital (ItKOrdcriL Tu Uie diHorilerod actioa 
of these mut«'l«)t. ittiiiniiateii liy irritetiou either in Uie urinary diauiitrl, in 
adjacent polvit- iirgiuia, or even iu distuut piu-Ui of the body, are n.ttnbu- 
tablu uiituy of the Bo-called fimctional disorders of the gouito'uritiurj' 
orgtuiB, KUcii 08 enureaia, iiTitnblo blailder. dribbling and rctentioa of 
urine, obnomudity iii the cjiicidntioii of somon ; indeed there cau be no 
doubt tliat orjrnnic Btrioture of tlio iirtlhrn itHolf cau be so dowly raniu- 
lat«d by Hi)(Utnio>lio contractions of tho urctlirnJ musdeii aa to docoive the 
•UTKeon. 

The following muscles iire so situated as bo compresft by their cootrAO- 
faons various portions of thu urethra : 

1. A ring of uuutrijwd uiuMultu' llbres situated ta tho posterior portion 
of tho prostate and ROrrounding the vesical orifico of tho urctlira (tlio iu- 
tenial spliiacter). 

'2. Vnstriped fibrca in the pubo<pn»tlatic UgomcntB, drawing the blad- 
der and prostate towani th© syinphyHiH. 

3. UiiNtri[K'd fibres in the tst-hio-prostatic lij^ment, ooiuprcMiiog tli« 
]H*08tatic urethra from above. TlfiH muscle and the pubo-proBt«tia tibrea 
lirobably asnst in th« t<jnciiliktioii uf semen. 

4 £Kiripod miUGular librvu — the tracev«raus perinei prufimdun miutclo 
— Iviug immediately )>6hiiid tlio anterior layer of the triangular ligament 
BUa enolosiag the menibrnnoiihi urethi'a and Covrpor's gland. 

6. Stripoa circular fibres (coulduuouti with the liul named) flurrouuding 
th« m«tnbnuioiu nntbra. 

All llicMKi muaoles (excluding the internal ^hinoter) are oolleotirely 
termed by UjTtl the compressor urothnu ; tliey oanstitute tbo cztenml 
apbittcter of the blmlder. 

6. Tlic bulbo-cnvvrnoitus, which arises from the ouutral ti-ndon of the 
pAiiaouni, fineloiws thn bulb of the urethra, pmues forward on either Ride 
of the penis, aurrounda the corpora cavernosa, and terminates in a mem- 
bnmoua expansiuu oa tlieir uppor surface. TUis muscJo is a jtowcrful 
OOmpTMSor of llio uretlira, whose a«tiuu is witaeHHod Ui the jotting oscpul- 
fiioa of tlie laat drops of urine ; it ns^sts m the ttrevtJou of the penia by 
QOninreitsiDg the dorsal vein luid tlic orectile bodie.iL 

7. The corpus B)iougio8UTU ia riclily piovided with unstriped ciivular 
fibre* throughotit iV* H-bule lungth ; imlvird Stilling deucribcs tho ajwugy 
body ts ft " muscle tlirough wliieli tho urethra nins," 

Irregular coutractioti of one or more of the urethral muaclea ia n not 
infroquout occurrence in individuals who have sufferod from disease of the 
urethra or eroii of the rectum. In (sases of catarrh of the bladder neck 
followiug goDoiThivo, and of exliau.Hliou from sexual <ixoc»im:s, maoturlMt- 
tion, Ktiicture, etc.. there is often some irregularity in urination; the 
p&tient feela a frequent desire to empty the bWlder, but aecomplisbea the 
not with difficulty i be may be coinptdlcd to wait tor some miautes before 
be can void tho urine, notwithstamlint' tlie fiict that he experioQCWi an 
urgent dAsirv and makes every effort by ooiitriuUiou of the nlxloniinal 
muaclea m> to da In other iusUuicca the stream is small and oDcasiouolly 
intorrupted ; Ibero may be a <lribbliug uf urlue imuiodiately or Bunie 
uuititee afl^r tbo cohcIukiuu of tlm voluntary not. 

Irritation in the rectum may occasion simihu- irregularity of the ure* 



2S 



DI5UA.flS8 OP niK UUlNAUr ORGANS. 



tbral mnBcleB ; opemtionii upon the asuH or rectum are treqneatlj followoci 
b.v com]>lol« rct«iiLiua of uriDe ovring to the ruflvx epanu of tho urethral 
inusclcH. 

Simple nervous excitement or exhaustion mav arouse 8uoh xpasmodio 
contmction of the uretUnU comprpssora tu to render uriaiitioij temporsjily 
impossible. In Kuch ciuies the iutrtxltiction of tlie catheter rcn'oau a de- 
ddoiL obstacle to its piissoj^e — a tipAsmodic iitricturo. 

llio ]>oBBibility of npasniodii! Ktrioture is practicaUv deniodbj Sir HeDcy 
TTionipnuu. Of it he aajs : " It is an axoeodiuglv uM^ful exouee fen- tho tau- 
tire of inittruinentH. It ia n refuge for inoompetence. Spasm may prevent 
the uriue from going outwuvl ; I do not know thn.t it m-cr prevente the 
instnuneDt from going in." Notwithstaadiiig Sir Henrj-'s soepUcinu thcro 
cau be uu doubt Outt ^aHnodio oontractioa of the urethral muadea m^ 
attaiu Huuli ii degree aa to oppose and even temponuily prevent the en- 
trance of a catheter. Surgeons who certainly undcrstnud tho introduction 
of the catiieter. and who need no " refuge for i&compot«nco," hnro placed 
upon rvc^ird histtiuces of apiutmodia stricture. Thus Dittel hae aeeit it na 
the result of isitnple ncidity of tho urine and in cases of diabetes mellitiu. 
irritiiliou of the anus by wormB, fiseiUTB, etc ; and he narrates Bereral 
coses in which no otlicr cauitu tlimi uiuutul fxcitcmont could bo ocsigned. 
A VieuuM pliysiciiiii vnm cidleil to t«te a. lawyer who was iireparing for a 
jciuriicY iiiid HU(l<li<:tly itiifTrreil releiitioii of urine. The phyaician at- 
tempted to introduce a cittheter, but met aa iuEunuflUutablB obstacle in 
the m(3UibmnouB purtiuu. The [jntieut wns txken tu IHttel. who passed a 
No. 25 F. without trouble. Two yi'iuT* liit<T tlw name phpnoni«iion oc- 
curred in the same person. This tLiue Pittel, iu atteuijitiug to introduce a 
catheter, met an obtitniction in the uembranouft portion, which yielded 
only after the catheter had been iinnly pressed against it for fifteen 
luiuiites. 

I wfts once conHiihcd by a nxtdicnl student, who upon tho cvo of an ex- 
amination for which he hnd be«n industriuuid)' prbpmug, suddenly fouod 
himself imable to evHCiialu his bliuUler. By peraiatent straining ho was 
Huccossful ill expelling nnly n vcr^- mnall amount of iirinp, which dribbled 
away iu n stuoU aiul jt-rky »ti-eaiu. Hl- stated thut fur Huvural days pro- 
ceding the occurrence he had cxporicuoed difficulty iu unnntion, being 
often comjielled to wiut^ some minutes before the urine ^^oukl tlow ; and 
he Dometdmes felt sure thitt he Imd not completely evacuated the bladder. 
Ho hnd uever had goaorrhutu nor auy other affection of the uriuniy organs 
pTOTious to t^t lime. After soTcriu uusiicceasful attempts to iutroJuco 
difier^t catheters, I Hucceeded in OTerL^ouiing the rcwistaiiRe, which vast 
looated in the meuibranoua jxirtion, by oontiituoits pressure for severs] 
minutcH with a small couicai metallic inHtriinient Curious to know 
whether or not this was an infitance of s])asuiridic stricture, or merely of 
ray " iucoinpotonce," I (M-mired tho piilienf 8 permission to try itgiua, beveral 
days after lie liad successfully p««si-il the examiuatioii. At this -time I 
found no difficully in iutrodiiciiig difft-rciit cnthctcns into the bhutder. 

That n spasmodic contraction of the iircthi-itl niuncles should exist is 
oei'tainl}' not remarkabh'. AniuialogoiissgiAHm of the spliinrter aiiL 18 afre- 
<luentplicDi>m<tuon in cfiseb of ulceration of the rectum or fissuif of the anus; 
indeed, in these conditionn n sposruodic cx)ntractioD of the sphincter of the 
bladder, catuting complete t-etention of urine, isnot infrcciuent. Th»^ sphincter 
of the vagina exhibits a amihu spasmodic condition iu oases of Tacinismua. 

It bos been atssertcil that spasmodic contraction of tho uretbim muscles 
may exist for Jem's, cuusiug all the s^-mptous of organic stricture, iiud so 



J 



AKATOUIOAL AND FUYaiOLOOIOAI. VONSmEBATlOrfS. 



23 



dofloly Kunulntlng this affection as to deceive the surgeon iuto s^iitcmiitic 
tfeatiQ«Dt by dUatatiou or aretlirotom;. Tuffnell ciU-h a case where a 
diagnosis of organic stricture of tli6 incmbrAHOUs urothm was tamle ; but 
after a tapQ-wurm wliicli thv ijatient harbvred bud beea cxjjL-Uvd, tbo »trict- 
are and itu symptoms viuiisbixi. Dr. Utiti is eqwoiaUy Hiu^'tuiii! iu muiu- 
^mi'ning t|iQ |>oiiRiblfl iiermoueuce of hpasmodic titrieture, wiiiU; m-iirly ilU 
Burgeons coDHider it us nlvrays traonent and temporary. Ho uarmtea 
KTflral «aaes in liia own experience vhieh eertainly corrobomto liiR sinf.^r- 
tiooB, provided ibore has been no error of observation. In these caws 
Uie 8paHno<Uc coalnicliou of tli« conipresBor urelliras has been, according 
to (HiH, tbo result of in-itntiou ciumjii by a Rtridiiro of greater or less 
calibre ia tbo anterior urethra ; bia usual exi»«rieii<:e baa bcva tbat the 
oatheter meets a decided ubstinetion in tbe nienihntnoufl uriitbiii, Home- 
tiinefl yielding to pretKure, but; often pormittiuK oiil,v tbe smuIleHt insLru- 
mentto pass. After dividing llio utricture iu tbe imLorior urt-thra, Low- 
erer, tbe lurji^Gat sonmla are pnssfid into the bladder without obstruction at 
tbo meaibnutouH ui-etbra. 

At a meeting? of the New York ralholoj^ctd Societj, Waich 8, 1KH2, 
Dr. Otis prcMeutod tbo nriniu^ orgnna ol n in/ui who liml for twunty yeai-s 
aubaiKjuciit to a ^norrliu-a eutTt-red couaiiuitly from fi-eiiueut, dilUoulC and 
painful urination. He had beeji under the oiire of many noted surReoAH 
lu Kiirope and America, including Sir Deary Tbompson, Civinle, oiid Van 
Burcu. Keitbcr athoturo nor Yf«ii;id calculus bud ever bceu detL-etod, nor 
van there any solargenxont of tlie protitnte, YnriouHdin^ioHcs haH bdon 
mada Otia discovered a stricture of lai-f^fe cabbre near the meatus and 
diii'idcd it Tbe oporfttion wua followed by iilmoat coiupleto rebcf fioni the 
distreaaing symptome, -ubicb bad been nearly coDNtrutt for many yt^am, but 
tbe patient died ou the ninth dav from ui-ienita. Tbe autopsy rerealed 
hypertrophy of the bladder and dilatation of the uretem and pelves, but 
DO moobauical impediment to tbe evacuatdon of uriDt>. " Dr. Otis tliougbt 
that iu tbo ubsciico ol luiy other oauito, abseuce of ubutruuliou of any kind 
to secounl for the eondition of the urinary orgniiK, vm must be jkr- 
inilteil to flUugest the posaibilitY of all the difficulty having been product^d 
Ijy Bpnsm reflected front irritation at a diHtuut part The ciuse tnui atnclly 
in hno with casM which be had presented to Uie piofesnoD lieforo, owes 
where cystitis, frtxiueut urination, apaam at the Deck of the bhidder had 
continued for a long time, and apparently tbe only difiiculty to which these 
KymptoiuB could be attributed v.a» contrnction cf tbo nicatux uriaariua, not 
greater tluui iu tlio present cnso ; and tlio proof that the supposition was 
correct van found in tlio disappearoQoe of the trouble imniedintcly aitet 
division of the contracted orifioe." ' 

Such coses certainly prove that spasmodic contraction of the Tcsical 
naiWlM. even sufficient to produce hypertrophy of tbe bIa<ldor and conse- 
quent diaeaae of tbe lci<Ine>'8, cau hv- exhibited for ycarx witlioul appai-eut 
and <lirRct cause.. Wliilw vesic4U spawn c«i certainly be produc<;d by a 
urc-tbi-al stntiture, the otlwr jkotMible aourues of irritiitiou — in the urine, 
ri-ctum, constitutional taint, etc. — should not l>o forf^ottcu ; aad at the 
aiilii|>gy a careful examinatiou of the urutbiti uud bliubl^^r nick Hliould be 
mode in lalii, mnce valvular foldit of niui^>uK mviubraue ctut bt^ obliUiruLvd 
during the removal of tbe organ from tho body. 



24 



DISEABIB OP THE UBUTAKY OBOAVS. 



GeS«UL SiMPTOIBJiTOIjOOT, 

• Each of the morbid ckuigoR to wliicJi tlie urinnry organs are Bubject ia 
aeeompamod with certain delnite gpajitoma gcnutvAly recognized aa char- 
ftc1«ru<tic of the nffectiou. Tbeae will b« mentioned in duMtuwiinit thew 
coiKlitioDR milh-idually. It Ih to be retncmlwrod t^t tlie patieiitH intmt 
nroitiiiieut eubJectiTe ^vmptoms ofi^n direct nttentioD to boiu^ other thai) 
the diseased orgau* oud iioucc iniidc&d tho pLjsiciau into tut erroneous 
diA^osia. 

llto d^^nptoni which crf-iiti^s Um gr<<nt:(-Ht iiiijircKniuii iiginn Hit jnitictit, 
and to which he al^itvyn asHi^na prominent position in relating hifl rn»e, is 
pain. Now there are two points to which pain is referred in nearly all afTec- 
lioD8 of the urinfii'y as wvU t\n of the ^ i^Dital orgnns : thoRO arc ti«! nccli of 
the bladder nnd the cud uf tho ]>Gui8. Pniu at oue or both of tliCHf i)oii)ta 
itt a Hjitiptoni of tlui iri<»<t lUvoree diaordem ; it in fnlt not only iu nfiii^ctions 
of the bladder, jirostate. and uiethra, but alao in most in£aniniaton' coudi- 
tiuoH of Die ureter and of tlie renal pelvis; iullHinmatiou of tlie kithior 
itwlf, cKjx'ciiiny Hint whiih nriseii liy oxtenrioa from the |M'hin, itiuv be 
a«ioinxis»ieil l>y i»«iii nt the uei-k of the bladder, though the region of the 
l;idney ia entirely fiee fnim pain and from tenderness on preasure. In 
females, afTcx^ioitH of the iitenw and of the porinterinii tissucM arc fre- 
quently ai;<!OmpiiJiiud with paiu fuid irritabihty at the DPck of tb& bladder ; 
indc<:i!, a cei-t&iu auif>uni of dyHiiria is a re^iitiu: a^comjHUiiiueiit of men* 
atruntion iu many ironien. Initntioo of the anus and rectum, if severe, 
EtriGture, pliimosia, contTHi>ted meatus, ndheuion of the prep\ice to the 
glana^ and even nn aooumulution of stoeguia iindi^-r tlic prc|nic«, may bo 
respoQKiblo for unea^ sensations at the vesical neck. 

unusual ponoentration and acidity of the urine mar produ™ not only 
a smarting HcuHation in the foMUi nnviciiUriri, biit nUo n hen\-y burning pnin 
behiitd the qnuphjos and fretpient piiiiiful m-iuation. llic Hurgt'ou is 
aometiines oonsiiltoa by youn^ men -who tan fimdy l■on^'in(-4^d tliat Ui(-y 
hnve contracted gonorrlirca, bec4iu»e tliey fee! a anioi'ting pain in the 
urethra and at the vesiL'^l ueck during the freiiiient oets of micturition, 
following a night of dehuucli iuehiduig impure intarcoiurse. The symp- 
tonis are caused by the extreme acidity of the urine. 

Dull pnin felt at the netk of the bladder wiUi or without frequent 
denre to lu-innte occurs in cnses in which no locnJ ori(^ for the diffi- 
culty ran be found either in the urinary or in the adjacent pelvic orgiina 
In ftnme of the^e eases the symptoms are evidently due to mnlnrial, 
sypbiUtic, rheumatic, or gouty taint, since they are relieved by general 
treatment addreHsed to the removnl of this conHtituUoual taint. In still 
other caaos similar eyniptoms nppenr as one of the DuniernuM nianifoHtn- 
tions of ueuraathcnia, t-illur gen<;nd or sexual; junt as attacks of severe 
nenralsrift of tha slnnjaeh ocnnr from thn same cause. A lady patient of 
lume, m appiivently robust health, siifl'ei'ed for eeveiiil months fiom oo- 
casioniJ attacks of severe pain in the atomivcb. for which I coijd find no 
other explanation thim general exhaustion from mental exertion nnd 
nnTiuty. Tl^ese painful aensatiuue of the Ntomuch tniddeulv eitaHcd, but 
were followed at intervals (independent of the ment^trual function) by 
severe paina at the neck of tlie bladder, accompanied by painful and 
fretjuent urinatian. Similar iittBcltB arc HomctiwcH witncKscd in cases of 
hyeterio, for which do rooBOD other than the general coudiliou cou be as- 
signed. 



J 



ANATOMICAL AND PHYSIOLOGICAL COHSIDEBA'nONS. 



'/U 



Pnin referred to Uio TC^on of tlit! kidney is mroly caused b; di!ienii» in 
the par«Dclivmft of tlie orcan itseU, but is otten produced by nfl'octionH of 
the perincpimtic tiaaueii, 3io pciTiB, and tli« ureter. For the kidney iteelf 
^peois to h« dOTO)!.! of eousory norvoH, which ore, however, diBtributcd to 
its capsule aud the Barrouiiding tia&ue nud to the pelns. The chronic 
foraiB of renal iQtlamuia.tion rarely catme pain iu the Iddney iliielf, though 
froqiiently inducing abuui-mnl senwitionx iit tbv u«cic of tliu blnilder. 
Acute cuut^cittiuri of tUu kidiii;y, diAteudiu); its uipsulo; uuiliguont 
grovrttg; tho oxcretiou of highly ooiicontratwi and arid urioo; periiio- 
phritic inflani niation, pyelitiH, disorders of tlie ^uital orgaiia, sexual or 
SMMsal exhauiition, are i-esiionaibic for the imiu in nearly itll cases in which 
ads is referred to the kiduey. In any of theHo oonditiotiH the pain may bo 
felt along the course of tito urvt«r, in tlto groiu, on tlie iiuivr Hurfix^o of ilie 
thiffhfi, and acroRs tiie abdomen, evoa more acutely than in tho lunihnr 
region. On the other hand, cast-a are reoowled in which these various 
couditioiu (oxi;oi>tinf^ iwrhapH [icriuophritia iiiflnninmtiua) luk\a occurred 
vithout causiag onoiign pnin to consiituts n promiiioiit Hyuiptom of tho 
afl^ction. 

Dtttcaaca of the pclvia and ureter are umially acconijNituod by pain, 
though this is oft«a roferrod to tho blailder, gonitds, socnim, or hyiKHmon- 
driuni, and not perceived iu tl;6 loia or groin. This in cRpeuiaUy often tb« 
case during the paHsiige of renal Htonea. 

Iu some instances ]iniu is Celt in the course of the ureter, though no 
noKl cidouli coq bu dieco^'crvd cvou nt tiic autopsy. Iu ir'uiu of those tiio 
post-mortem exBiiii nation hax hIiovpIi intlaminfttion ami even iilocration of 
the ureter, Thus ToilJ uliiierved a case in which tlie patient hod aeTem 
uttncks of ahnrj) pain, felt in the right Inin and accompanied by obstinate 
tomiting. ThC'^io attacks liutcd for days or vreeks at a tintc, after which 
he reaioined freu truni tlieni for a viu-iuhle period, the luiigeKt liaving been 
{oor yean. The nrine contained pun, but ueither blood nor cryKtalline 
fbrnos were discovered to confirm the diagnotus of renal calculus. At the 
autopsy it vraa fouud tlmt the right urct«r n-us thickened bhroughuut tht> 
groaier part of it« Icoigtb aud its muoous mombmne ulcomtod at seveml 
points ; no calculus was dieoovereti 

There nro caae^ prolmhly more nnmfiroiu than we ore aocufitomed to 
think, in which psmstciit and sovcro pitiii Lb exp«risn««d la the region of 
tho kidney, indepeiidcnL of luiy morbid condition of thia organ or ita ȣ>- 
pendages. If there chance to be alight, perbapa trnnHieiil, albiuniiiuria {as 
so often hap]>ena without reiml disease), tlio phyHiciiiii may he deluded 
tiiti> a diiiguiMiiN it( rcunl calcidi or evnu " Bright'ii <lini^nKc. " In such cases 
the pnin may be duo to soma consUtutioiul nBWtioii independent of tho 
kidney ; a history of malaria or syjiltiliiii, of gout or rheuinatisui oau be 
cBcitMt or a state of Denroua or sosunl exhaustion be recognized. ^Ulbut 
montionfl suv^rot cases in which occasionul attacks of abdominal pain simu- 
lating reiud oolic Memod to \h> flopcndont upon vnlvtdar cartbsu ditwiuw 
with hypertrophy, or aortic aaeurisiu. The depeadence of iiain in the 
back upon sexuaJ exceaaea. usually aactibed by uie alarmed patient to a 
Uciduey affwitiou, is quite geucrally rocoi^izod by the prafmnuon ; but tlte 
ngency of the various coiiHtitutiomU tiutita euuinerAted in prodadng pain 
Ba the region of tlie kidneyx itt, im it iteema to me. sc-arcely appreciuteiL 
pnasmnoh aa a verdict of Uright's disease in so terrifying to the juktient, 
and if mistukou so disustruus to the ph^'sician, the possibility of these 
cm iaew for pain ovtr the kidneys, cvcm whr.n ni-cuni]>unied by albuminuria, 
■hioatd be remembered oud investigated before a dia^ooia in made. 



I 



S6 



DISEASES OF TUB URIXABY OBGAirs. 



Da Coiita relatcH Uie following cabo n» fthowinff Llmt tho A^rmptoma of 
renal difticulty cau be closely tdtnimted by mttlaiiiu infectioii : 

*' A soldier, twenty-four \-ean d aee, oj fair eompIeiioD, and evidentlr 
of ttroog coufttitution, wok iic-ixcd rath<;r •niiMriily mtli pmin OTC>r the left 
kidncT. Tlie loin uras siensitin-e to the towch, wiA ftriiieart-d aoiiifwliat red 
anJ ftwoUeii, The akin was bot ; tie pulae 100. Tie uritji? van not finuid 
to bo nbuormiU, though coutniuiuj^ n reddish coloring;; matter. Tlte pain 
contiouetl for Bererul duyt^ b(jcuuiiu>( mori> HuverE-. iiutwitluituiditig tbftf, 
by Dr. Wort'n direction, under whoso cliRrgo tlio iniin wna and with vrhom 
Imvt hitu, six ounces of blood 'w«r6 dniwu fruin uenr thu offectcil port. 
On the fourtli <lEiy of the diBorder the patient wim njH<nile>l n-itb uxcmciBt- 
ing pftin along the course of the ureter, attended with the roiding, at abort 
intervnla, of a high-colored uriiic. The attack ksled from oix o'cJook in 
the evening until Uro o'nloclc tlie next morning, lenving tlio patient mnch 
exhausted, tlie only relief throughout it« dunitiou beiii^' ohtaiaed from 
the inhalatiou of clilorofurm. At six o'clock in the evening another setzore 
of eqaol Tiolrnco net in, niid after the Inpeo of iiveDty-four hours again 
a»otJii.-r. Heeiu^ tbu recii rrciice of thu piuroxyHiiiu ut iihuut the siuue tiino 
of eaflh d«y, and Ifaniinp from the patient tJiat a few iiiniiths Iioforo ho 
had bad a remittent ferpr, which had left heliinil an uregiiW intermittent, 
tvu resolved upon thu iidniiuiMlnitiuii uf Inr^^ duseit of sidpluite of quinia 
in the iutcrrol between tiie parnxysmB. The scizuro did not take ploeo 
ihnt night ; hut the rctueity being a day or two aflei'ward su^Ksdwl, the 
fourth night was atpiin a ni^ht of anguislL The antiperiodic was resumed 
and continued in lcsson<Hl doses for three weeks. The patient remained, 
for about nix weekn after the lost attack, under Dr. 'Wetft's obaurvation, 
gradiuilly reeovpriiif; his health and ii])irits. 'Whpn he was lost night of 
there was still a dull pain in the left lumbar region, with inability to stand 
enwt, but no return of tho cxcrueiutiiig intcnnittt-ut neuralgic jMiinB." 

A 6«rman medionic, t]iirty-two year* of age and of robust npiKarance, 
consulted me, saying tliat bo was a sufferer fnnii Bright's disease. For 
Kevemt months he had conipliiined of a constant dull pain in tlie Ioihr, 
occosionnlly aggm^-nted by sltnrp lancinating pains, which cAtendot] into 
tbe groius, csiiuciaUy on the right side. His ui-tno hud iMon found hy a 
physiciiui to contain nniiimcu. 

Diligent inqouy into his history failed to reveal any features of renal 
diseoB^ except tliat about two yeju's prenoiisly ho liad hiul ftviT, bead- 
ach*. Mid some swelling of tlis feet, these syniptoinH lasting about a week. 
During LhiN time he had not heen eonfined to his bed, bub had had paina 
in difierent parts of the body. c>ipecuiUy in tbe loins. A careful examine- 
tioD of the patient failed to discover any ^mptoin of ronol disGom ; Uiere 
ims no dropsy, no cordiuo hypertrophy nor increfksed arterial tension, no 
polyuria, etc. Tlio urine contiiine<l a trace of nlbmnen ; in all other re- 
spects the secretion woa noiimiL 

Induration of the inguinal glanda inspired questionit regarding Yencreol 
difloase, which resulted in the information that the febrile attack, already 
deecribftd as Laving in'tnirrtrd two ycjint previouiJy, had been preceded by 
u. venereal sore aud followed by a Hkin eruption. ;Vsauniiug that the puin 
in tbe louis wiis probably att evidenee of syphilis, atid that the febrile At- 
tack ibruB years prenously bad indicated the outbreak of lliu dieease, I 
administered the amol aiJLisyphililic reuiedits, nud in tlie coui-se of a 
month bad tlie saUAfiiction of curing ttie " Bright 'a disease," so far as tbe 
pain io the loins vc&a concerned. Intermittent albuminuria i>eituat«d for 
Kouic months. 



ANATOMIOAI, AND PHT8I0I.OOICAI, CONSIDKKATIONS. 



37 



A young farmer csjno lo too in the flprin^ of 1888 for the purpose oC 
ascertaininr; whether or not hu had Bright'u diaeaso. Ho bnd boea work- 
ing ?«rj" haril for n year, hjul lost nonsideralilo flesh, his appetite was ini- 
pamd, Rut] hift rest much distui'bed by pftin is the back of the head and 
in the loini). A phymcian bad truntcd him for Boino time without marked 
benefit, had finally oificorercd albumen in tho UTtDO. (tnd hod ciproRsed att 
opinioD that tho pntiont wnti a victim of Bright's diaeose. Of sevtrU otlwt 
pIlj'BifiiaDB who were suhHequentiy consulted, some hnd con&rmed wbile 
otlutrtt n-jitctod this diagnosis, according as thoy had or had aot found 
nlbuiuinuriiL 

Upon proHtiiitiiit; himself io m«, tho chief oubjer^vR syinptom wu tbft 
{MUD in tlic loiit.s, usiinlly of a dull acbin^ character, but aometimaa tiggn^ 
prated into n a)iiiri> pain, radiating from Uto hack into tho groin and testi- 
>cle. Thf. otlii^r aymptoms indiotted general neurasthenia. Ilio patient 
bad never hnd venerool disease, bad lived in a luulariol region, but had 
only on<!« eufTered from intarmitteut ferer. The urine, examined on three 
diflor^nt occasious, ahowod abaoluUly uo abnormality except a Hoiuewhat 
bigh apecilic grarity. He v/a£ adriaed to take certain hyicneuic and medi- 
cinal measures at^Idruaaed to the geaertl health. Ten munthi; later I huw 
biuL n^in in aii]>areDtly perfect health. 

I>iiKir<kr» of various of the genito-urinai? organs xaa^ be maiufest«d 
tlor a lonp time only by symptoma exhibited by other ana diBtant organs 

ftoms whoiro <IcpcDd<-iico upon the gciiil'O-HriDHry aflectioa is obscote. 
])tmuo»i)i can be tb« vAiute uf piirc^KlM of the lower eitremitibit, and 
even of curvutiiri*H of tliu Kjtiiic, hiui \xu-n nnfu'.viad by Sitym and Otis ; that 
eexual exhaustion is responsible for numerous and most diverse aerroua 
symptoBU hiui been eBpeciiilly illualrated and emphasizetl by Beard. 
Among the<w nr<? ilj-xpttpsln, constipatiou, ]>alpitn.tiou of the bonrt, dynpnoui, 
r inipoiniieDtB of viBion, uumhaees of Uie extromitice oud filamminfiHR of the 
pfcanda 

In tho uriQaiy apparatus proper, diseases of the Hdn^^ are especially 
prone to fniiite alTectaons of distant orgaofl, whose origin may b« lon^ over- 
looked. Indeed we are hq wedded to tlie nntioii that diaeaac of tho j^iducy 
is DMeeearily accompanied with albuminuria, and so negligent iu the «x- 
aminatiOD of the urine, tJiat the abBenco of albumt-n. even if but oue e«uu- 
inotioD bo made, is often rv(^rd<.'<tl am uouchuivo endouce in excluding renal 
disease ; and it but too often happens that onlees th«ro be s^iecial reasons 
for Buspeotlni; kiduey disomy, uo examination of the urine is ma<1(>. 

Symptom» of tho most divcroe nature uad afTectlng nearly all of the 
pbodily ninctions, nre known to result from chronic rcDol duJcasc. Tho 
mosaibiUty of renal origiii ahouhl bo n-tnomljcrcd in casus of disordered 
Ketioti of the heart, canliac dilatation and h^'pertropliy, increased arterial 
heitsiou, asthma and chroniu bronchitia, dyspepsia luid cbrniuc i^astritia, 
WuoBiu or fr(!(juc»Uy recurring dinrrhocFi, persistent headache, eWplu»s- 
Beee, cerebral oxot«:uent, coryot, the impuuiuout of viHiuii, R-curriug iu- 
BBanimationB of Rerons meoLbriuiefl ; for any of tht^^o may exit^t for a con- 
niderablo fimo without otber ^mptoma directing eq^ecial attention to tho 
nriDor}' organa Now among tbo huurtuus caustis uf n-nal iliBcaso are 
nboormaUtiea, congenital or acquired, of tho lowrr jwrtion of the urinary 
Pbnct. The deiK-mloiice of pyiloutphritiM. hydroncphloeiB, and un«mia 
npoD mich anomaJics us pliimuitiK, contracted meatus, congenital stricture, 
Mte., is demonstrated ; in fact, so intuuate are tho anufomiod and physio- 
■ogiol relations among the different organs of the genito-uriuary tract« ho 
puviaaohiog and diTerse the disorders originating iu these organs, that no 



fSS DI3EASKS OF THR VRUTAKT OBOANS. 

exaininAtion is complete or sntisfactoty, whtttever the BU])p(M«<3 ailment of 

tbo patient, -vihidt (loc« Dot iucluJe ui inquiry into tbo perfonuance of ^it 

ccDital tknd uriuaiy fuDRtionx. The ilegreo to which tliiti ittquirr Bhftll b« 

iiislituUiil must of course depend lar^I/ upon oireumstaiicot. It is unde- 

sintble tn attempt a complete esaniiaiition without special roasuuti for it, 

: and it is practically incoiiTeuiout or cvoii itupoflsible to make a criticul ox- 

UUBBinntkOQ of ttio outire unaarj tract luid of the \mue in every case bi a 

P^fe pr&ctice. At present, bovevtr, errors of omiMiion to investiRate are 

t oertainlj laort! fr«(]ui!nt Among g«u<!nd pmctitiouont than miHtakcA uf com- 

; miBBiOD l)y overinvf'3tigalion. PXery phyBician who makes a pntctic« of 

esaminiuc the urine aud the contliUon of the genito-urinarj* organs •ven 

in vnscs irhich present no KjtafiiotnH indiciiting disorders of tbeeo OTgma, 

niuitt hav6 bcl-u iustanceB in which the neglect so to do uiitfht Larc or actr 

nollj ha» uiLsled into aa crroDOoua Utaguoais. 



CHAPTER n. 
METHODS OF EXAMINATION". 

Whz!! tUseafio of the gemto-nimiuy organs in suspected, a more or Um 
CtJticRl muQination into tli«ir ouiulition is uecessiu^. The nionus t-mplo^ed 
in maldng Kucb exominatioD will of vourae vary according to tlte luituro 
aad ]ocfttion of the supposed abnonnnlity ; a snspect^ij diseAse of tlie proA- 
Into rec|uire8 other metlioda of exploratioD tluui n !n.ij>po«cd ilisordei' of the 
Iddiiey. Yet siufo au affiictiou involvinR one portiou of Iho urinarj tract 
Ireqiifntly lendH Booiicr or Int(>r to tlufordvr* in otlmr orgiuia, n critiail cx- 
amiuatioL of tbo uutirc uriiiiiry aud eveu k'euital Inict in often required. 

Such exaniinitlioii may require seTeraT or all of the following methods 
of fliciting inforniatioQ ; 

1. QuL^stiuuH oddroHand to tho patients 

2. I'alpntioii, porhnps inspection of tbo abdomen, tho groiDO, tfa« peri- 
neum and exteruiil urgtuin. 

IL The introiluctiou of tho finger Into tho rectum (iuto tbo vagina in 
tli« female). 

■i. The iutroducUou of tho hulbous sound for esploriag tbo urethra ; 
tac the cyliodricid sound or catlieter into the bladder. 

6. G^cJunination of the unne. 

Tlie informiktion ncqiured by these methoda is usunlly nmplo for the 
determinfttion of the nature of n ffiven case. TLere are, iiowcvcr, udditional 
means of oxpluratioii whioh ore lesB fretjuenUy required, but which tinmt 
be employe^l in certaiji cases where the OKUnary meuoa are iusutficieiit. 
Among these are : 

0. Coujuiuod muuipubitiou, the sound in the bladder and tho finger in 
the rectum or nvor tlie syraphyaiR 

7. Inapectiou of the urethra through the endoecope. 

8. Dotcnniontioo of the urutUral calibro by tho Drethtomoter. 

0. The digital oxftiiiinntion of the bLiulder. Tliis is accumpUahed in 
the female by Kiiuphi JilaUitJou of tho urethra ; in tbo mahs by urvthrotomy 
in tbe membmiious portion. 

10. Tbe introduction of two fingers or even the hand into tbe rectum, 

11. Tbi- iutrwluctioa of a catboter or wund into Uio lurcter (proctJcable 
as yet iu the feniala only). 



QtmsTIOSB TO THE PaTJI^JT. 

These should bo addroHsed not only to tbe condition of tbo urinary and 
genital function, but also to tbe general condition of tho pali^nt ; for ccr- 
imiu affec-tiuus nf didtiuit orgauH ufteu direct etqiecial attention to i>os8ibIfl 
abuonnjLl conditions of the genito-urinary ortians. The queotiona directed 
Uy tbo et&te of the urinary limction may well embrace the four inquiries 



ao 



DISEASES OF TOE OBIKABT OBQAHS. 



vtiich Sir Hm^ Tbonipaon ftdvisos na n unifona cyBtcin in exauiiung pa- 
tients suspaotetl of uriniiry difflculticti. Tlwste rdfor to four eymptouiij aud 
, idgnfl eoininoiilj oVyaerved in such cases — fre()u«n<?y of uruiatioii ; yatin in 
' micturition ; abnormality in the chnractor of the uriae ; the addition of 
blood to Die mine. 

fVcjiimci/ i>J uTtnation is a x^ptom, inore or Ictw proDOUticed, in moat 
affections of the urinary trict,exoeptingoDlycertiuii dmeasea of the Icidce}'. 
It mnv he due either to au exoeamve secretion of uHno in coDaec|u«QCQ of 
[ vbich the bladder ts fillod and muut licDW be erncuAted at uousunlly short 
I iDtertiils, or the frequGutiy of uriuiilioii may depend upon excesslTe sensi- 
\ bilitv at tlia ncck of Ui« ijloddcr or in the prostatic QrotLra, with or with- 
out anatomical lesion in tbeete pai-ta. 

Frequenoy of urination from increased secretion of tirin« ia an a rale 
pwiarww i from irritiibilitj of th« bladder it ia usually accompauied by a 
paiBful aensatiou during the acL There are, however, eiceptiuna to botli 
of Uieae rulctt : fiXM^iuDit niiriiiritiun de^teudent u^ion hystvriii, for example, 
is often accompanied with decided paiu, and the bame symptom may bo 
obHened in cases of polymia with pyDlilia; frefjueut imtiation from pros- 
tatio hypt'ilrophy or urotbiiJ stricture, on the other hnnd, may be quite 
painless. 

Freqitenny of urination, with or without painful senaationn, may be 
induced by (Sections of adjacent orgnns, especially the rectum ana the 
utenu, wmle the urinary tj'act itaeU remains perfecUy uormnL 

It Mhoidd bo fMnvrtmood wlioUior an «bi**r\ud frcijuvncy of micturitioD 
ia as pronounced at oigbt as by day. If it persist at uigbt, causing the 
[patient to rifie several times to void the uriue, the fact constitutes pre- 
sumptive evidence against the presence of coJculus in the bhidder, iind di- 
ruclH atU-ution especially tu the condition of the probtute luid urcUira ; for 
prostatic hyperlropliy, chronic proslntitia, and urethral stricture are often 
productive of tbii symptom. It ia also notewortliy that the polyuria at- 
tending ciiThosis of tlie kidiieya is oft«u more prouuiuictd ut night than 
by duy ; tlie pnlient actujilly Hecretes more urine dining tho hours of re- 
pose Uian in Uie widdug condition, and itt compelled to empty the bladder 
at shorter intervnlH by night tlian by day. 

Another imiwrtant subject for inquiry ia whether or not fhe deitirc to 
tthjiotc iKvrtrii suddenly a» woU oh froqueutly, A patient often stalcfi spon- 
taneously, a« ft prominent feature of hi* dinonler. Hint ho cxperiencea sud- 
denly an urgent deidro to empty the bladder, ao iuperioua as to brook no 
delay. This is es]Ktc.iaiIy cliaracteriatic of prostatic affections vm (liBtin> 
fished from tloue of the kidney ; it Is also witnessed lu functional din- 
orders — from mioiturbutioii or Trcaifreal excess — of the genital organs, as 
well OS in cnHcs of irritability of the bladder from atTectiona of the femsle 
genitals or of the retitum. 

I'ain upon micturilion is a symptom of various affections of the uriiiai^ 
06 well as of other orfpina. It idiould be ascertainoj.1, if pain Ite expen- 
enced, in wliat part of the nrinarj' tract an well an at what period of the act 
of micturition it ia felt ; also whether it exist between the actn 

A smttrting, burning seiiaation may be felt at the neck of the bladdOT 
and along the eatire coui'se of the ui'ethra, from Btricture, chronic proa- 
tatitia, or in conwqueuoe of extieme acidity or eouociitration of the urine. 
The same sensation, tixuidly l(»a (irououiioed, in a s^Tuptom in diabetes 
and hysturiiu Attention has been already cdled to the fact that severe 
pain may 1>g csperieuced over the Uduey, alonp; the coiirno of the ure- 
ter, in the groin, itud around the neck of tbe bladder, in cases where iio 



J 



METHODS OF EXA3UNAT10N. 



31 



id lemon can be r1etect«d in tmy of th(»»e orifniiR, in tbo gonitnl organs 
or in tL« rectum. In such cases the noaaibility of a coustituttonal taint 
from tnulona, ti3-plului, rboumutiiuu, onu gout sliould bo iniiuired iuto. 

In numy affectionti of tho kJilney, pclns. and unter, pmn ia felt ultnost 
exclusivolj in tbe bladder and uretlua, e\en tliougb no locul U-xioii rxixt 
in tiiese ports. In these casca the pain Li not e^ciaU; nggrevsted dur- 
ing iiriiiQiioii. 

Pain which is felt only at the end of micturitioQ is uaiutUy caused 
either by chronic itroataLilis, f3-stitiB, v^cal catctiluit, or tumor ; it may 
(ilao Im; jjrfxhicoj by strirtiim in tlio iHJst«rior urethra. Tho pain of 
chronic prostatitis is felt chiefly bohimi the eymphyHia imd in the peri- 
neum, ofton extending alon^ the urethra ; tlie pain cniiiu'il by n ittoue iti 
felt chiefly at tho neck of Hie bladder and tit thi^ eud of the ponis. In 
femalaa s burning pain buhind the syniphyaia in often due to disphicementti 
and ili^Hnktie of the uterus. 

Fain felt around the neck of the bladder before and during mieturiUoa 
is a common symptom of acute and »ubncute cvfititis. 

Pain folt at eomo spot in tho ui-otbm ^uring micturition is oft«n occa- 
sioned by a stricture, the urvtlira bcHud ^t> ob*itructiuu being diluted hy 
tJie urine ; even a slight conlrantion of tho clumncl mny produce it In 
cases of bladder tumors, the pain (if any be felt) is usually aggravated 
during and after micturition, but often exists also in tbo inti^-n'ols twtncen 
tlio nota. 

Fain felt e^ecinlly in the perineum ia caused by irritation of the pros- 
tate or of the bladder neck hy inflammation, calculus, tuiuor, etc. 

The vondilion <•/ the wnWninybo modotlio subject of iniiuirj- ; whotlior 
or not habitual turbidity, lii^h color, peculiar odor, or other characteristic 
have been noticed, and whotlier there Ims been at any time a pronounced 
sediment. 

TVie admixiure of blood with the tiriuo eonstituttis an importaui feature 
of the case. The natiant's statcmenta in rrtgai-d to thia point are often in- 
correct ; for a small quantity of blood is not recognized by tlie nolied eye, 
and on the other Land he may mistake for blood an intense ciAor ob»ervi>d 
in higl Jy coacentrat«d urino, or tbo briglit md hiidwhirli in comnmiti<;ati>d 
to al£aline urine by oertnin vegetable articles used for food and medicine, 
notably rhubarb. If ho have notioed vhat ho regards ns blood in the 
lu-ioo. it should be ascertained whether the blood preceded, accompanit-d, 
or (oUonod the stream. The nppoar&aco of a fuw ilru)>H of blood itt tho 
end of urination in in tho majorir y of cases duo to proxtatitig ; it iiuiy occur 
in the oourae of a •jouoiThiua from simple congestjou of tbo mucous mem- 
brane of the pemlulouH urethra, without involving the pi-ostatw ; it may 
also bo producud by a polyp or urethral stricturo. In cn»cs of vesical 
calculus or uooplasiu tho blood Mouctimcs appcnn low-anl tbo cod of uri- 
nation only, but is uniinlly mixod witli tho stroam. lUood wliich had been 
intimately mixed with urine for some time before voiding — as happens 
when it vttcapcs from the kidney or the pelvis — frequently pws to Uio 
orine a dark brown or black color, which*iB not recognized by tlie patient 
as due to the prenuuoo of blood. 

The maimer if urination often furnishes information of value ; it may 
be desirable to liave the iMitient urinate in the physician'a presence. It 
may be noticed that he lumdlcs the irxtlu caiufully. perhaps Hut he keeps 
tho p'riaoum enveloped in oxtni clothing — features c^r«i.tlly channtor- 
istdc of prostatic diaeoae. The promptness vith which thi^ bladder obex's 
tb* impulse to evacuate tho urine, the cluuactcr of the stretun, a possible 



S3 



DISEASES OF TUS UBINABT OBOAITS, 



\erij irregularity of nrinatioD, and mon> or l«6s dribbUu); at tho cad, 
fidiould be notiowL Muij patienU, espedally, though not oicl««iveJy, 
tkaae affti-t«d mtii genitnl tJisonli^rs, find nnunial diffiirulty in imimtiiig in 
Iku })rutL-iice of n Kcuoiul ixtruuu ; ticuos wq mtt eouetlmoB comppJled to 
rely upon their Btateinfiiit» i\r to tho mnntior of urinntion. 

All irregular, jerky stieam, appeai'iiig eomewLat tarJily in response to 
ttie Yoluntuy impulHc to urinate, in often Beau iu ner^-ous young men. es- 
peciiil!^ those who hnv« heen tulili6t«d to iiKuturbntiou. Iu tliese cnhcs 
there is frequently some dribbling ut tbo cud of uriuatioii or even some 
minutes after the ttct in npxiaroiitly coDiplotcd ; the KtrKaiu in uHually ttmnlL 
ThviM) ph<>noini;nu npjXMtr to be due to H^NUdiioitii: oontmctioii of tit« tiro- 
Uiral miisrleii, they nre also caused bj Btricture of the urethra, 

A full stream wliinh folia abruptly from the nieatua ia often seen in 
cflBCH nf proatatic hy[>rrtropi)y, and may be nn iiuporliLnt jKiint in diiigno- 
BB ill tliotte coseti in wlilch th« Lyp«rtropby »ffecta ouh' the 8CH9ilk>il mlcl- 

uUa lobe and is not |ii<r<r('pl.ilil*i Uinnii^'b tlii' ructuiu ; tho 8auie pheiioinenoa 

MDSy be caused by n iiti'Icture of large calibre ia the posterior urethr& 
Some authors a»iert that the eiisteiice luid luL'titioii of a stricture ciiu be 
vciTiiewhut (Icrtnitciy rwofpiiwd bv chancteristics of the etreniu. Thus 
Dittel says that if ihe strfnin bt; tliiu mid dRippiiii; theie ia usually a nar- 
row stricture in the posterior portion of ttie urethra ; if thin, \rith abort 
bow and coDBidemblo spee<l, the trtrictare is narrow, forward, and rather 
loiig ; if the stream be brukcii. the upeuiug ia not ceutral. 

Disease of the goaitiol oi-gniia alno may induce tlie munt diverse S}*mp- 
ioms — disturbances of the cerebral functions, epecial senses, stouacn, 

f iMttrt, periphend uer\-es. as well m of the »ei.uRl and urliwu^- futictioDS. 
Wliile it W'>uUl be iu tunny i-imcn iudvUont'O and impcd.iiitiiit to inquire 
minutely into the state of the sexual or^ia, yet a general (juefition con- 
cerning them is rarely out of ploee ; and it oflen happuiia that the patient 
is anxioualy wiuting and hoping that tho phyHiriiiii will bn-idt tliv iec U]K)n 
this subject. If some obscuni afTectiou of tlie urethra, bladder, or nervous 

' ^atem seem to exitil, the patient should be discreetly tgueBtioned as to his 
Hpxiinl habits and functions; the extent of his reaei-onl indulgonco, pant 
and pi-wii'Ut, his virility, etc. Many patients aro esidi-ntly much relieved 
when an cipjMirtunity for discussing the subject is thrust upon them by the 
physiciaji*s (luestiou ; for, while f>ome men, alanned by frequent pollutions 
or other gentliil abuorroulity, apontaueously direct the pbj-siciau's atten- 
lioD to Much i^inptoms, many olhers, oven though behuviug or suspecting 
that their present Rjnaptonia are produced by sesnal sins, are reao-ained 
by pride and shame from mentioning the cmbarraHang eubjeet ; and tmlees 
encouraged and du-ectly questioned, they omit entirely or merely hint at 
those 8yuiptoin«. however important in their own minds, which they 
believe to be ruwooiat^id with sexual nbuscit. Other patients are really 
ignorant that the annoying headache, affection of the eye. palpitation of 
Iho heart, or indigestion of which they may comphiin. are intimately asso- 
ciated with boxuoI exceBsea, etc, and Uierefora nmke no reference to these 
haljits. 

The manner of eja^^dation ia occaaionally a proper subject for inquiry ; 
it hi precipitate and often feeble in consequence of venereal csceJtses ; it is 
sonietiini^it painful in caaeH of chronic prostatitis or urethral stricture (of 
which it nirty be one of tlie earliest syuptoms) ; and it is sometimea lack- 
ing. An Gxaminatioa of the aeueu with the luicioscope ia often abuolutelj 
Qecessary, 



)IBTllOt>9 OF EXAJIIIfATIOM. 



58 



Tbo eye and tbo Imml furotah important infomiatioii, poaitire or nef^ 
tiv6, M to the imtiire of a (liffimiJty in tbo ariniuy or genital m'^iu. Tlw 
meiitua arinarius. the ginne. (ind tlio prepuce should bo CArefuUv oxumin«d ; 
n coiitrncted pr pouting taontuK, an el<m^t«d jti'fpuce, n tight pliiiiioms, 
the ftccuiuiihitioii of RitieRiiui behind the coi-ona glaiidis, amy coiintitHte 
the t«y to ft nerimia Llifficuttj-. and m-e especially to bo looked for in cases 
of oeurofies of tlio urinarv or ^i-uilnl urgiuis, Mueb u« iiTitability of tba 
hlikldei*, ptiiu ai-oimd tlio pixwttAto, ct*'. TliP iiitiuciico of fiiieh fn'oton in 
proloa^nS thufn (■i>ui))ltiiiiL'i is espteialiy j^-dat iu iixotu; who Iihtc smffured 
or lUe Riitleiiii^ fniiii tfonorilui'^. In <;aAea of acute goiioriiuea, the dlvi- 
•toa i)f a narrow mc-atua is offectnal in Hboi-teniu)> the diu'ation of tlie ilia- 
cbarge a^ vrcll nH in diiii)Ttiithing th^i KiiRvnn^K of thv ptti<'nl. Bometitiic^ 
a thin fold of iniicoiu ineinbraue cniieeali« a ))ock«t jtist Ix'hind the lo\i(^r 
oomniiniui-n, llie dlriaiou of wliicJi, lil<» thtt divinioii of a uiirrow tnculun, 
uuiy relieve obscure eyu)>toinH referred to bladder and uratlira. 

The (^ouititiuii of thu scrolniii and iu^^iiicil cauixl t>hoiild he olmerred, 
the possiWo pn-st-iiiMi of viu-ii-ot'iil«, liy<lnioph'. haitIiic»H and thiolcouing of 
the eiiididymis and of tho aiwriuntic cord he noted. The spasmotlio nctiT* 
ity of the eremaatem. aa aliowD in the constant roovcoienta of tlio testielea, 
is espccinlly fi'c<]iieiit in tho mibjectfl of fuiictional or neurotic diHicnlties 
of tuv ^'i^iiitAl and iiriiinry ori^nuit. By hoiiio (Icnuan Hur>^fOu« this con- 
stnnt iiioTi-iuoiit or " liDdeitlitiix " in re^uxh-d an (■iiariictt.-ristii; uf hubituiil 
maatui'bation. Th« coutttnot presence of uioistuio at the meatiia the 
"weepiDR penis," oulduosji of the poniH, c'lamminiMH of lb«> acrotuui. am 
occttnowil Kyiiipti>Rii4 in cwott of Hitnitar oni;iu. A slight ^l<-cty diKrhar^tt 
may proofed from stricture (most frwuieul), fi-om chronic prostatitis, or 
eiuiple proetatie hypertrophy ; or it may ba seminal fiuid (true Hpermntor- 
rhu;a iMtioi^ moro fniqtiout tliun in ^enondly HUp]>oi4cd). 

Gxce«dTu itiiuturbHtioii froqunutly, though by no mciuia im-ariably, pro- 
du(.-4?a certAiu changes iu tho ){uuital organs rocogiiixnhln by UiH vyc I'bo 
penis appeal's eloDjfated ; the glaus is disproportionately lari^e ; the mucous 
mvwbraao coveriu^r it imj the i>oist-coroQal furrow ia thickened, reKemhliu^ 
tho cutaneous surfnue ; thv voiim uf tho orf^au become enlaifr«d »ii<l tortti- 
ous; sometimes the oi'gwt Rppcani iiiiiiatumlly cold, and tlio liiM of th« 
meatuH are constantly wet. The serotum i« eloiigatmi, tlio testiples often 
t«ndor iitiil sntiii^titiioit rcninrliably small and soft. Tbe veins of the spox- 
tuatic cunl am freiiueiitly vnricosi'. 

In the ft>ntale eIou;{atioii »F tho diloria and of th« labia minora, Iiyper- 
troplty and wrinkling of tlie prepuoe, ars found as the retult of maslurl>a- 
tion ; tli« nnia>u»t membruue of tbe va^a ia exti-emely hard and retdstinf;, 
and the calibre of the caual frequently diniini<flied in girls who imiclioo 
this liabit ; na increased reilu«w and secretion at tho vugiiial oritice may 
also be found. 

If an inspsction of the fcmitle geoitala he made, the urethral orifioo 
should bo cart-fully obMirviil. HuiilII, but wry piuiiful %iL»cidttr poly)M are 
Bometimea dete^t^d : tbo folliclen nt tho lowor border of Mi>^ lucatua some* 
times rumiHh a clu'onio semi-punUent discharge!, whioli is presumed to 
{uroceed from some other source; aluu-ply-defined uk-ers jiist within the 
urethral orifice u-o oft«n found iu awes of tuberculosis of tlio uriuwy or 
genital organs- 
Tile (•lands iu the groins should be examined ; their enlargement may 
3 



DtSZASEB OY TOE UBINABT OBGAKS. 



I a da* to Kma obacum dtitonlnr. The |)0!«il>lo doprndence of iiri- 
umj ajs^itoou D|>bD faffmorrhoidfi, fiiunrrea or ulceraliOD of the aaua MnA 
**»^— . ammtidoi, tie,, aboulil b« remembered an<t invetdignted. lu the 
Itadl B vagiiu) muoiiuition taa; reveal such a comlition of tho uterus 
and of the pcrim&trilic tisBuo as suffices to expluiu BjiaptomB referred to 
ill* uiituu^ urgauK. 



Examination pxni ItBcrtTM. 

Tlift introduction of the flng«r into the rectum oflcD affords Etifonna- 
tuni which can be acquired in no other way. By lueAus of it thu nicm- 
bnnout ixirtion of the urethra, the protitiite aiid nitck of the blndder and 
tha «*i»iiuil nnaples nr« rotiilcrxxl ncocunbln to tJiv iiiigcr. 

For Uiis exauiinatiou Die patient 13 pUced iiifun tlie btick ; the trousers 
aliould be slipped down to the ktie«B, a small cuahion placed under tli« 
mertiia, the Knees drawn up aud the thighs separated. In epecial csse« it 
luay be detrinble U> luive tGe jxitifiit lid ii]>ou hiH aide, tlje kneeii dmwn 
up tftwnni the nliiloiiiDn ami tiiv litittorlcrt projecting over thv edge of th« 
table or bed. Otis adopts n di(l«rei)t poeitioa. He aaya ; "This exaiuiuatioB 
will be most convenienUv and efficieutlj made, not in the ordinan- nny by 
placing tha patient on his hnck nnd iiitwrtin^ tfao tinker bclvTccn Inn thighe, 
but seated in a chair %-uti direct him to ttlaiid WLiuaruly with Lis bnck pre- 
sauting; hare biin drop Iiui nantaloona and drawcint, luid nitli Iur knocs 
atzatgfat bend forirard at a riglit angle." Aside ixam Uie indelicacy- of this 
pDiittOci it is open to the aune objection us the position upon the side, 
Tmauiy, that it docs not permit Uio itimultmiooiis exaiuinntion with tbe 
eoutid which is so often neceasart'. Tlte patient's mxisciUar coutraotious 
neonaaary to maintain this poiiitiari are idm a disadTau1nt;e. 

After the patient hoe tissuuied tLe {ic«itioD described — ^upon Ins ba<^ 
vitfa the hips vlo^'atod upon 11 cuHbiuu (an important item) — Ihe forvfiugcr 
of the appropriate hand, well oilivil, is ycntly intrndnccd. Tliis itro*-!!*!!!!* 
is decidedly unpleosaul to tlie patient atid ia apt to be resisteil by sjxts- 
iiiudic coDtractioa of the anal sjihinctem ; genlleuess of mnnipiiltilioii ocair 
ainnn the least reatsbmoe and ofTers the surest uiOAns of ovcrtvMning it. Jf 
the e:i;>loriug linger enoscs estreino pain or violent ttptii^m of the sphincter, 
the anus should bo inqxicted to determine the potnible presence of le- 
siona. 

Jiist ■within the sphincter the finger distinKwisbcs on the outeiiOT watt 
of the rod.iiiu a cord about on inch lout*, the ineiulimnous urethra ; some> 
times the [xwUirior miifiii-c of I.lic buU> alno can be detected. In cases of 
Btnoture at thin portion of ihe ni'ellira, a thiekening oft«n of iii-cguJar 
Bhi{M but sometimes in the form o( a rin^; can be roco^iizod. 

At the inner extrrntity of tliv ineinbnuious urethra tliere is felt the 
apex of the pmstatA glaud, i-spidily videninfi aa the Bnger follows it up 
tlie rectutu. The groove in the iuid<Ue line. correspondinfT to the iiretlira, 
is uHiudly felt distinctly ; and even in am* of prostatic hypertrophy the 
point of the catheter can be felt through this groove. The upper border 
of the proiitate, when tbiei is of normal size, can be readily reached by tho 
■poial of the finger of oitluinry length ; sometimeti, inde«d. tlic htst phulanx 
eao b« flcxc<l around the proMtnte. The aoiind iutiodncad into the bladder 
is met by tbe finger above and behind the prostate. In those cnses in 
vliieb there occurs enhirgement of the middle Inbe only (which alwnvs liea 
po8t*nor to and projecting above the \-esiclo orifice of the uretlirn) its ex- 



I 



MCTnODS OF EXAinNATION. 



as 



k 



I 



iBfence can be ofteu suraiiH^tl l>y the f«c-Iing t1»t Boinethin^ Tinii<niftl is in- 
t«q)UKCi1 Ixitwecii llio (tu^tr in tite rectuiu nnil tb« ttouiiil in tlie lilndiler. 
Id a few tjiwh it has been found possible lo delect with coniddemble cer* 
taint}' a globuW projection front this part of the prOBtat*. 

Tbfl QoruuU prostAt<: in of lirm CDUviatcucc, uuooUi uid HyinmotxicaL 
At either superior nnglo tiip liugpr can foel nnd foUov tbo Honiinnl V4>«ic]o 
whicb fttretclieH up^^ui-J along tlie poatei'ior aiirfoce of tlio bluUler. 

Abnormalitiex of the pi-oabiUi iiro iudicutticl by deviations iu its size, 
smoothnesa, symnaotry, and seusibilJt; 

A iIocTDOMo in tin; aix of tbo orgiui, ntropby, i« not infrwicont Jn rA- 
TTWictd age and occni-s in earlier life an the lesiilt of gonorrhrea and con* 
oeciueut |>rostatic intlammatioD. Etdurt^emeut of the Kland mny be tb« 
result t>f inllaiamatigii or of nimpW bj-p«rtropby ; in oitber wuw tborc in 
uguuily ft Hyinniotricnl incroiuo ia siiu), tbo ^iirfiuso remaining siuoolb. Tbo 
licute itilbiiuumtory tfiiliu^uietit is indicated by extreme beat and tender- 
ue98 and by the projection of the prostate dowiiirard over tlie mctubnvtious 
urethra and bttckwiuil fueroavbina; upon the rectum. In casw of sunple 
bypnrtrophj Uie upiwr bonier of tlie glniid i« otlan hbyouil Umj roaclt of 
tije fiuger ; in other insbuices thitt border can be detected ou either side 
but ia prolou[;ed iu the median line into an indefinable projection, often 
indicAtuig au caUr^omcut of tbo luiddlo lobe. Finn jiresdure ii|>ou the 
ftbdomiiial wnll above the KyuipbyuH luny, by fort^iu^; the neck of the 
blaiUler lumewhat lower iu llie pelvifi, luako tbo prottlute more nnrnim'blri 
to the fioffsr io the rectuto. 

A Uuii t^ aymmetry in tlie prostftt© may depend upon enhuTjement of 
(MM IoIm or atrophy of the other ; Uio htttc-r condition is found ikf tcr gonor- 
riKBa and prostatitis. Enlargement of one lobe occurs in cases of tuber- 
enloaiB, as well aa in Bimple hypertrophy, 

'At! wntisteiux of tlie rIiukI TftricB in different coiiditionfi. In caooa of 
fURiple Ii>']>ertrQphy the prostatic tissue is luiiisually Rrm ; enlargement 
from chroule infUiunmtiou is softer ; ui acute iutlauimation it boa a aoft, 
doughy feeling. In cases of abscen fluctuation cau often be detcctod : in 
BOiue mstaucoB pi-ostalic voncretions, lyin^ iu the disteuded prostatic fol- 
HotwcJoM to the ret-tuin, liiive beeu recogniKed. 

The tmoolKnew of the surface is nino to be noted. Tlie presence of 
amall hard nodules nuaed above the t^tjuerol surface is eHpeoiflUy frequent 
in ctWM of tubcrculowa of the gland \ thry are also found in tluit rare con- 
dition, maliguaut disease of the prmUite. 

The genaHivene^ of the prostate is much increnseil in all inflammatory 
oODditKHW, including the tuoercuJouB ; pressure from the rectum, like the 
uoesago of the sound tbi-uugh the pi-uiitutic uretUrii. ut'c-iUilouK extr^^me piiiu 
ID casea of chronic prosiatitis, of liubitual muKturbaUou, uud of aeiual 
Bxceaa. 

The examination of the gland per r«etum is oft^n followed by the ap- 
pearance nt the meatus of a luillsy or glairy fluid, vrhiofa should be at once 
iiwpected thmugh the microMcope. It may be urethral or prostatic sercre- 
lloD, gleet, or semen, and Kboidil nover be dismiamd aa siiuple " prnstat- 
orrhoia." If there be no history of goiiorrhaja, and no proatatic byper- 
trofifay, this fluid usually indicates hahiluid miLstiirbation or excessire 
venery. 

The exj^oration of the seminoi vestcks in hmited to ou cxaniiualiou na to 
their Btze, consist^'uce, anil sonKitivpnosa. In cnsea of ehronio prostatitis 
tliOM ^aods are often quite sensitive and disteuded lu eon8e(|U«uc« of the 
occluaion of tbo ejaculatory ducts by the HwelUng of the prostate ; u aimi* 




or 




ImMImI <MiudtoJiilfftaee(<.g..wM<wwKi); tftnck] 
miiy «f thwihiioB «MMr memUi dkUoboti el ll» 
NM^MMMMOMtiimi, ftritabUllr of tb* bl«kle>; Bkd DDctanl 
III HMW IwrtaiieM tha •jaenUtofy daot » obrtrvetod li^ c 
HoflilMl III fl,<i w iiilual Tttnd* ; tbcrg wnlt»a <Twr < m lii» rfflntt w ie l t: 

riaiMi.f iiifi tuijucDDipnMtolic. OmtkpnantrairiibtlMfiiigcrio^j-sena'' 
' iliit iHiiiiliiBl oaneKtiauuM] nopm thfldoct fatoiM«*Mi»-, 
{Of.- I, .. ^.xiii liri,v fWo j-Mmokl, the right IoIm of tho prostate '«aa madi 
MilMfK*!'). |'>"J">'tiii(; Ix'tli into Uie rtKituut oud the bWldir ; tbi tmnor wtm 
rtHlli* loii'l' I I ' '> )iniNHiiru, J''riMjiieiit luvd pautful uriuation, th* |imi 
lixliiff full 'I iv t'lwnni tlin rlune of the act ; thir amieaniioe of a few 

iU ' ■ I „] lliu trill] of imotiiritiou ; dull pain in lti« p«riaeDin. altea 

fi, I ,; llio iiritllini Ui tlin iiit-Atiw ; all IIh-m: ft^'niptoiiis token in 

MNfttf'.UMit Milli lliK ciiiiiilitioii nt iho prostate, led ton dugnosLSof tuber-. 
fiiflimlM of Itid kImixI AI II ■iil)M'i|U6tit e iam i n ft ti an. prcMure upon tbe i 
IniHt'A |iii'hU|i> Iii'Iw«<ii tlii' llitger in th« ivctam and a eound in tbe 
lit.'Mii, I'liiiatiil II itiinli of wliiti»li nutter fiom the lOMtos tn which snail 
I ' I > lit imiilr it['|KMrHiicv wen? aeen ; the fluid oontainud fippmiatozoa. 
1 1-. Jiiiiiiii ii( lliu iinMlatsaud all ths unp ie ai nt BpnptouiB uumodiately 



CHAPTER nr. 



I 



THE SOnND AXD CATHETER, 

Tira inlroiluction of instniments into the urethra mnv bo nn<1ertak«ii 
for ttie purpose of exploriufj tie urctUni ouly. or the bliulder also ; in the 
former case, the instrument tOionKI not bo hkhIo to ont«r the hladdsr nor 
alwa^ tho prostatic uretlira. Tho habit of tmiuinj;^ a toiinil quite into the 
bUdder. ev«u ihuu^tU the urethra only is the subject of cii>loratiou, is 
not onlj- uMl^wws but may be jirmluclive of hanu. 

Tfa« exploration of tho urethra aims to detect chiefly two possible ah- 
nonaolitiea — a (ynMrivtion of its calibre, luid hyjXTceaheaia, local nrftenewU. 
Tho nninl naterior to the tnaii^^uliur liguincat {membrnnoua jiortioiiy should 
be explored vcUh an acorn or bulbous eQunU (Fig- 1) ; since for obvious ret^ 




7io. 1- — BalbaiH &jiii]f]«. 

6008 the with«Iraw«] of siieh n bulb couKdtutes a fnr mors (^clieitte ineantt 
for det4?ctint,' and localizing a stricture (eapeoially whea slifiht) than the 
iutroductioti of an onlinaiy conical or cyhndricsu soimd. The Utter lu- 
atnoneilt often vnnbhM tho vurgcoii to A^nu that a jiiiticul Aid » atrieturn ; 
t( nreti/, if ever, jmtijiet him in n»*vrtin</ tlie entire ahsenex nf strirturcs. If 
a No. Englixb ti»uii<I meeta a decided obstacle at hoiuo point in the j)Bn- 
diiloua uretlira of an adult, there can lie uu doubt foscluuing Uio proscucu 
of (oreiin) bodiea. fiiliie [huikiki-ii. ^tc.). that tho lu^tiim is fttrictured at tluit 
pniiit ; but tho pnwuigf, without [n-onoiinced reautniico, of a 9, 12, l!j, or 
even 18 Eiiglixh sound ilot^s not prove the nbgence of A nrethrnl conNtric- 
tiou which may lie Miifllciont to miLintnin n ^lont or other tuorbiil condition 
of the urinary or genital functiona, for the normal tii'etliral calibre in ibo 
aiiull in rai-t'ly less and iimiaJly more than 17 EnRlisb (SO Freucht ; hence 
rwn a <^>n-'«d<n»hlo constriction mivy oppoee no rcBLStanc© tn « No. 12 or 
16 sound. MorcoTcr, a stricture may m ho distensible and elastic (re* 
silieot) as to ulmit, without nim'ke<1 i>p]>nsition, a eonical Bouud wIioho 
diainetoT exceeds ita own ; yet upon the i\ith<h-an-nl of the «omid it con- 
tjactn again, TiVhilc such ulricturcs ore found with eapeclnl frequency in 
old men. they are by no means liniitod to ttuch pntiouts ; and they may 
Mcope detection entirely by the ordinary sound, and if detected cannot bo 
dafinitely located. By the' bulb, on the other kuid, they ore eodly racog^ 
nuMcl Olid loaitviL 



M 



l}ldKAS>:3 OF THE URINART OBGANS. 



Tlie following uni<]uo oom iUustrnles, witli unusunl forec, tlie uaelea»- 




following lii« thiiil attack uf goiioriLtea. He Lftd l«een under treatment 
nliuoat conatantlj- hy injw^ticmx an J BouiitlH. To mv i>ro^!«ition to exploro 
llif urutbm for ntricture, lie rejilied tLat tliis would be uiuiec«6«ar>- ; that 
liu Lad onco Imd a ntrictura wliicli Lad be«ii dilatetl to No. 'i4 ; and that 
lio w«» now paaeiDg oveiy week a No. 24 HOiiud. Supposing i h^n to !•« & 
No. 24 Freucli (13 Eu^^lMi), I prodactd the iiiBtruiut-iit. remarking that 
ilB poBGftgo did not prow tlie klwcuce of rfriiHiirc. To my nstonifthm^nt 
lut replicnl tlial hia No. 24 was " about five times as big an tLat." Hariiig- 
uo 24 English nt baud I produced a Na 22 and found that it pawM>d into 
the bladder Mrithoat auv serious renistniice. I then introduce-d a Sfl French 
bulb, th<j witbdiawal of which was opposed quita dMidcdly at two points 
two aitd nite-lialf and throe and on(>-qiiait«r iiinhrH from the meatus, a »■- 
fiiatau4.-« ijuite peice]>til>Ie to the patient. With the uivtliroineter I found 
that the cnlibro of tlic uruthm at theoo potntK was oidy thirty-three and 
tbtrty-c>n«. Hn^-ing AHOortminod hv tbo eaaowxnw tlmt (ho mucous tnem- 
liraiie behind a»d between the Btnotureit, tbougli congested, was free trota 
large granuhttions, I adviBed dilatin;; urethrotomy for tbe cure of the 
giMt As the [>atieut demurred to thi» I inad« daily applications with Iba 
endoscope for a week, without jiciccptibly dlmiDisliuig uiodisohargv. He 
tUon left town on bu.sLnci«ti, but returaod six weeks Inter and espr*8fied lita 
consent to tlie opeialion. It was performed without an»«thetie, an in- 
cision two inchcalimg bcinK niado ku as to iiidudo tlic tissues in front and 
hphind as well &s betwiM<ii thi' two sli-ti-tun-s ; th« tissues were dind«d to 
42 French, uo diviaiou of the tneatua bciug ret^uired. A No. 24 (ISnglldi) 
was passed dnily until tlie sixth day. when the patient n^iu left tlie citr, 
tlif' '(isebarge b^ing then a mixturo of merum and blood. TwoinontLa 
later he chIIihI U> smy thiit since tliu Leiitli day nfti-r Ui^ iiiHtntiou Uicr« had 
been alitioiutely no di-iieliarge— fur tlie tirat time in ueariy two yeaiK 

While I have repeatedly cured a y'eet by the di^-iaion of atrictujoa «d- 
tnittinf; <imd lieuce undetected by) fiouiuls or largo iia 14, 16, and in one 
case 17 of tbe Eiigha)) soak', a Htrielurc iidmittiiit! a No. 22 En-^llsh is. in 
my eiperience, wholly unique : it sugyests a topic for rt-Ueclion to tliOKO 
who luie iu the habit of asserting tlie absence of Btaictiire if tbe urethra 
will ndmit a 15. 14, or eren 12 Kngiiah sound. 

Tbei-u are two reasoue why bo many etrictiu-es arc o^'orlookod ; indeed, 
only the pronounced ones (those of xinnll caliljre) are recognized by iLe 
ordiuar)' method. First the cyliiidriod sounds fail to detect a alight or n 
roaiUcot atricturc ; second, the nientua, when of fail' size, ia tacitly re- 
garded as the measure of tbe urethral calibre ; for allliougb Ibtu ralutiun 
of the uieatuH to tbe ui-ethrol calibre is not formnlntod lut u dixticict ]iix>p- 
osition, yet it ia beld in practioe bj nearly all siuveouB who use only the 
ordinary soimda. For tliey rarely deem it neoeBaiirj' to eidarfte a (air-Mzed 
menttis in "sounding for stricture." though just why the mentuw is re- 
garded &8 an iiid«3C to tbe dtmeusioux of the ui-ethra. dues nut appear : in- 
deed, we wiiulil exiH!(ti tluit thi? nH-ntiiM, ]ik» the mouth of cvi*ry otlicr 
pi{>e detdgiied by nature or art to throw a xtream, would be smaller tlian 
tbo ch&uuel behind it ; and this is found tu he true by actual meiuure- 
mentsL 

Many excellent surgeons deoline to regard as a etricture aiiytliinfr 
which which will admit a No. 12 English sound ; and in this they foUov 



I 



THR 80CKD AND CATHETER. 



39 



no kSB an authority tliau Sir Henry Thomiwon. ' who finya : " If No. 10 or 

11 o( om- Bcalo goes onail^- — i»lM>ve (ill, if it m witlulniwii nithout b<iiig 

held and itUOctt out with iKrfect fanllitj, toke my woitl for it be hns no 

8trtctui-o." Ue invci^lia ui^nst the idea that the areraga urethral oaUhre 

■bould be gi'cater than No. 11 or 12 of th« Eoglisli scale, luid r«g«i-da cy- 

liudrlcal bougitta as advquiite instiniiii outs for tho d«tecti<9u of stricture. 

k jt will be raniembcrc'] that thiH iliHliu^uiKljcd siirg€i>u Iiom idwavs bo9D 

IsTcrse to the iiitruiluctiou of large iaatruiucuta u)t>> the urctlmt ; ittrM 

only ftfttr louf^ 011(1 l)itt«r oppoHitiuii that be mlmittfid (very reluctantly) 

that tho MVfira^ urethra is eufficieutly cApiiciouB to i-et-eive th* loi-ge evac- 

Lnatiiig catheter {iG tu 30 Fn-iich), by tho uao of nbich Uigclow nccom- 

mlished Hthotrity A.t ono tiitting. Th«8« gADtlemcn do tiot deny the 6x- 

^^tone* ol urotUral ootitntctiouH larj^r thiiii tlio iiieiitux or than A Na 11 

Hoand ; but merely nwert that Kuc-h coutrnctions are of no iirnctical conse- 

quetioe, booause devoid of morbid influeDce. Tlie teat luust consist in 

the remrval of eut^h stricturcM in couwit of gloet, urethral hiwhqi, ncu- 

rsl{^ etc., whoro no nthcr ajiiinrcnt cause can be found ; luid this test, 

■ 4iujido by iiuincroua coiupt^teut surgeons, luui shonn lluit idiglit Htricturea 

brhicli admit n No. 11, I'i. 15. or OT«n lu^rger houikIs, are aometimea HufK- 

Eftient to waintaiu a sloot or vosical ueurah;n% which cea&eti upon the r*- 

nxtval of tbu itn^thrtd ooutttrietioii. It iturifuoDa who dcuy or i^^orv tliis 

Bould be i)entuiul«d tu inuJie this t«Ht in ])rQper ca»e8, their oiiiiiioiia would 

|{be entitled to greater coniiide ration. 

The detecttoa of u idi;;ht iitrictmi) in onv item ; the iatcrprvtutinu of its 
morbid iuflueiuio ih aiiot.lt«r. Tliti fjict tbnt tuouy itn obstiuntJ:^ and intmct- 
■bla gleet ha« beeu promptly rm-ed by the dtvisiou of blight strictur«a has 
led certain entbuslnatic fiurgconii into a Imbit of HKcribiug ueaily ail ob- 
scure and obstinate g^tnito-ui-inaTy compkiiit)) to such Htrictiiros ; aa a con- 
MMjuMiCO thurw lio-t bfioii a HOuivwhut [i 1*0111 lm;uouh tiJiJ uflcii iujtuUcioitx 
penonnuice of uretlirotomy. Tlie nunierou!< biuret) to relieve by thia 
■BMthod moi'bid coudiLions produceil by other caunea, lias brouf:rht uauier- 
■{ted discredit and dietruet upon tUu whok subject £tou a gloat which i» 
Suually (tboMgb not nlwHya, as Otis iuststi)) dqj«udeut upou Btrioture, may 
pemictt aflei- the removal of all urethnii coutraotioiin, bowet-er Hlight, aud 
yield only to local nnpliiratioiis. 

Tho iiao of tbt! buihoiiH uound in detecting strictures hi restricted by 
the taut that thu nieatun id iMually anaaller tlioii tho genond iirelliml duui- 
nel ; hence many slight coL^itrictituiH (larger tliau the ineatua) are not 
recoguixed. This reetrictiou cotild of uourau l>o remoi-ttd by division of the 
DMtutUM ; but this motumro, to hank nnd often unjustiliabic, ia never ncc«it- 
■pary — tluuiks to Dr. Otis' iugonuity in denaiug the urethromi>t(>r. Thin 
Ematrututiiit ix pntotii^Uly a dilatable bulboua souud which can bo intro- 
duceil closed through even a narrow meatus, and theu expauded to any 
dodred diaiuetei' in the more capacious urethra. 

For detecting oontxnctious of the cavernous urethra, therefore, bidlxiun 
Bounds (or tbe ureUiroraeter) should alwaj-s be employed. The lai^est 
which can oaaily paaa Ibo memtuM is firat iiitroduor«l ; if this meet a de- 
uided impeiliueDt, smaller bulbu ore subBtitutcd until tho obstacle is 
biMad ; uu withdx-awiug the instrument thn abrupt Khoulder ia tirst ar- 
Beated by, ilihI th«ii, upon slight traction, jiiiu])s over tho strictiinv emu- 
bauoicating thereby a distinct nctiaatiou to jmticnt ns wt^ll an surgeon. The 
Hnsp of a spasmodic ooiitniction of tho urothrnl uium-Ioh (which is inure 

K ■ DiwiBea of tbe Uriuur OmiiM, iSSl. j*. 19. 



40 



DISEASES 01' TUE UltlNARr ORGANS. 



I 



» 



» 



r 



frequently nroiueil by s bnlboas tlmo br a orlindrionl iionnil) is contiuuoua 
for aarenl auuafceo. uul gives an cntir^ didbrBOt seosation. 

Byv^nealhttimot Um urethn, whetlier gmend or looKlizod in spots, is 
fttn mulilT itvtectad by tlie bulbous wand ; but aoce thia inBtrument 
nuif cause some pein even in a DomiAl iiretbra. the diacoven- tif 6«i»itive 
flpoCs riMMild be confirmed by the intrtMluction of u o-lindrical wuud : tlie 
bnlb thoald, moMover. ntvor be introduced into di« i>rostatic ui-etjirn, 
bwHiMe tiua poftioa ot th* channel is tiormally vety ecntitire, and is prai»- 
tkaUy nlmyv &M from itrictureo. Eren the menibroooue ur^tlim uliuiUd 
not tw invMHl by • ktge halh i tor to panng tba tiiangtiliir tigiiun-iit Ui« 
UHtmineat onau'maam pain and blMduig ; and it may be tigtiSy i>i-n£i>ed 
■ad Aiu^ bead bdnna ih^UgUMM. 

Tb» ■e l awtiaa ol lb* iaatewMSt fcr nploring Qm Uaddcr is natui-ally 
iIH^wiIimI npaa ttw ii ipowa eoocfitkin uf the parts to bs explored, and 
iqM tbe obfKi to he allnnod. Tims iu ol<1 incn irith prostaUc hfytr- 
tnipl^ tb* ank o< lb* bladder ii cktatevl and the jiroelntic urethra lon^ i 
battc* a oatbatar, to na^ tbo bladder, must be loiif^ir than unud. and 
|>i^**>** an iihumli km;; rtatc In diiidrcn, too, thv iit-rk of tlio blnil- 
W v> biitbar tbao m ailultA. nad the beak of the inntmnii'nt imiAt be 
■uaila rotTf ai xtadinrfy inng. For the rxplomtion of the bhidder. where 
BO byi^rtn^^v o(um ftvNtale exida^ an iustrumont vrith an abrupt curve 
aad «bon baalL cafaUa of beiag ixttidcd iu the blnddf r. is required. 

3'*^>Uw UMtruaaeala da^^pied for introduction into Ibe hiaddei- oliould, 
■***'*Hy wnaliM. ba nada to ntoform to the nnlurtd camhir« of the 
iMa hoimm perSoB ef tba nratJira, the aib-pubic curT«. Thiii mxre ol 
Ibe matbn^ tnwail ak«£ tla u|i|nr WaU, btgina juet in front of t)i<' i>ubic 
I W W al ttw inaactiott of tba wnaptairpiy ligaueut of the peots, rnthcrniorc 
ibHil •■ iarb anlertor lo the bulb ; thrnoo it d^'accnds (when th« btxly i» 
«nrtb attalniiif; ita ktweat [xunl nt ttte aut«ior Inyer of the trinngtdiir li^a- 
■HMtl ; it Iban HMomda thmuiHi the uicnibnuiouit uud ptoetal i<- ])ortion. 
<jV >-"*-rw» «iKl ho« aonifwhal higher than the nntr-rior. This curve 
c>' > lUw MV (if a dr^o throe and n quarter inches in diameter 

fi4n-i..i— ill ; tint flhml of tlie tuv tuns lUmost jierpendiculir to th«iLxi»ol 
ibe <Of>"(\K\wi^ b»it U iui-hncd iJightly upward frtoij brfoiv backwiud. 

vtt* unUuik u attaclwd at three ')xiiutt> iu lhi» cunt — ihe &TU|>en90t7 
KKailMB^ Un triiuijpikr ligunent, nntf tlio imbo-proFtatic )if;Bni«ent : these 
kicnuiV u*x«4rUi«Ua^ a rcititin amount of Muiatiou in the cunuturp of the 
(iivil^i'v ««< ibM rven a atmight inatrunicnt cnn be iotnxlnred itito the 
to Vd\-iuit,i^i, i> t»kou of tliia fact in flio ix.nKtruction of soiiiida, 

\\\ x'U\ ^ >i„„.t (Ujrupt ciuve fiwUiUttK lit* eulrance of the in- 

•inMtiviit iia» Ihw lilttdder, after whioh it ran l>e iiualieU ou until tho eutire 
\m-^l I. ....M»»iirt.,l tit Uie cavitr of thia orjjan, the utnught iJtiilt DCtuiiyiug 
|l. ,,t Imlt^i ^a iUBlniuwut whicb ba» no tune, but iestinight 

11... A.... ,ki it* I'liliiv Ui\fii\u ctax be by earefnl niaiiipulatiou introducwl 
(iiti* tlw UUdW wiUmiuI iuiurv. 

'n» \A\hm\\ uwlalUd oathatan aud aounds ahould bo consli-ucted bo 
«a Im ivhIuihiNo iW eurw of the urcthm M measmrd by 'llioiupacMi, 
i»< ' I t,|H (<Mn« ooiwlitutas tbo arc of n circle whose radius is one 

»«'* .1,. i,„.i^ Uia dKxd ot tba uv meaauring two and tbit-e- 

«|it«ait (>..'tit«i 'IV rathatar abonld bare a curt« ct>n'«8pondiiig lo one- 
ftMiilt, t'n' .ln!i.„,mi tJ thi» dwiUBiferwMa ; U*o aouud iihoidd be ahorter, 
«>. , i„,.l„v,Uh a om-iaUirw eovering about 60 deprees of (liiB 

•"' -.. ivm-r Wheu lb«' lonRor of these two instrumeuta u used. 

Mw iwuttt nnH\«« til thv i«\»«l«tK' muu« when the shaft nssU »t au angle of 



THB SOUND AND CATHETER. 



41 



* 



I 



16 dftgwes with tlio hmiyon (the putient lying upoD hii* back) ; Uia \mat 
ot tlie iiliortei- iuatruiueiit rests in the membrasoua urethra when its shaft 
18 inolined at the sauib ajigle. 

The soLiads ftud <%thct«i'8 in gcn&rnl nw an oft«n of tuvHty ciu-vfttm-e, 
CHjicciiiUy at tL& extremity ; this is too long or too straight, iluiiy of tlto 
<lttlioti1tici of cathet«rizatiou arise entirely from these iiistnitnental rleff-cU 
£Ki'ej>t iu especial cnsvs nlreiKly ruentioueJ, tlie catheter should not com- 
prise more thfin oiiu-fwiirtli of the oin:uiiiIert:uue ; indeed, u sliorttr instru- 
ment is oft^n prcfornblo. But iu any cnno. tlic «ad o( tho cnthetor should 
bo so curved thiit the asia of ita ©itremity foruis a right angle with tho 
axis of the sliaft ; in miiny iiistruuitTita it will bo noticed tliat the angle 
formed by tLea« two ase« i« dwidodly actitA. The point of the instra- 
mout should be not trior« than one ntid three-<]U<irt(!r inch from the axi* 
of the Kbaft ; nnd if it be only one and one-half or even one and ooe-fonrtli 
inch, it is more easily mann^ed. (md oft«ii quite as serriceahle. The 
sound is made with u Hhurttir bual: so that tiiu entire cunxd portion uuu 
be intKxluood nnd i-ovolvwi within tho hlnddor. 

77m; ititrudiidion of the catheter should he undertaken onlj wlten tho 
patient ORcupies the rocumbunt posture. The clothing is removed suffi- 
ciently to afford the surgeon free Mcesa to the perin«um and external 
grnitnli*, and to p«nuit t.he necesaAiy depression of the whaft bi'twteit Ihu 
thighs. The operator ordinarily Htan<U upon tl]e left side of the luitient, 
thoujjh he must be able to cnthoterize fixim cither side. Since a rectal 
exploration is often ue^'ussarr whilv the iu-ftrtuuint ixsts in the bliulder. it 
is coDveutout to have the patient's hips flevatfld upon a HRiall i-iiitluon Ijo- 
fore iutroduving the entheler, 

The instmiuput, previously vmmiod and oili-d, is held lightly between 
the thunih and linst two fin^rfri* o( the right Iianil. its shnft placed liorizon- 
tally over the left grotu. Tlie left baud grasps the [>cuis, tJie thuutb and 
forefinger applied no as to retract the )irepnce. The organ ia raised above 
tbe groin, toe poiitt of tho entlieter is then introduced into the wethni, 
and the outiru iuotruiuent ia e<l£d bodily dowumu-d (tovrard the kuecti), tho 
shaft still retaiiLing the honzontal position. Meanwhile the peuia is drawn 
over the instrument with the left hand. "S\'h«D the point has penetrated 
to the Hiutuonsory li;;am<,'iit — about ns bu* ils it will enter ivithout force — 
th« shaft IS carried from tlio groin to tho iiicdinn lino over tho abdomou ; 
then, while the BCrotum ia giaaped ami derated toward the puhes, tlio 
upper end of the catheter is RentJy raised imtil the shaft atimiinea the vcr- 
tieal position, a movement which eJiould bo readily ncoomplished without 
foroc by n single finger. The forefinger of th« right band is now placed 
over tlie o|)eu end of the catheter, whioli is then carried downu'nrd into 
th« space between the thighs ; during this movement alight pressui-e may 
bo mndv, so as to cuuhv the point of the iiuttruuient to progrcsts. 

If thi're be uo abuorniALitv of tlio urethra, the inti-odiiclion of the 
catheter ia usually elTtKitinl in this way without any diflh^ulty ; the impedi- 
inentit which an esperionccd hand mcet» are often <lue to his own ouxiuty, 
which induces him to grasp the instTiinifint tirmly and employ force in its 
introduction. No (or«j in re<|uircd or pi.TiniU<id ; skill in catheterization 
is exhibited not in overcoming hut in avoiding obstacles: 

8il6ce» will be favored by ttelectin^ a l.irge instrument, cot less than 
No. 9 or 10 English, unless somv abuunuol impodimcmtt sucti as a stricture, 
exists. Since the mfiatns is usually thtt mu-rowost pait of tho canal, the 
soTgecm vriU rarely make a inistake iu selecting the lai;gest iustrumeut ad- 
mired b; the urifi<:e. 



49 



DISEASES OF TUE CBIITART OROAKa. 



7%« tilatttelm uAicA may oppose Uu eitirmee of the caOteier into th« nor- 
tnal ut-cUiTH ar« tbe foUowiog : 

1 . Umlrat'ted iuetttu& 

2. Th« lorg* follicle sittutod on Uia upper wall of the uratLra au kcli 
or man from tbe ueatua; known m Um " laciuui auigiut" Tbia cooaes no 
dUBoult y if A large catheter be ujwhI as directed, though in the introdooljoik 
of ttnutll eooical OBtbel«n and boupes, it ia to be avoided by k«epinf( tlio 
iMtut of the imtrumeot on tbo Sovr of the untluu (or aixmt two iooli^s 
hnaa t^OMAtua. 

3. Tbe qvpl^jrais unpodM tbe jmpvea of th« cAtbetcr in coee ite point 
I u peimiUid to m^ad upvard too bdoil This ia aiit to bappen -niieii the 

ab^ of llie eaiMlsr is iwvolnd to the median line over the iLhdom«u iu 
earpokttt pOTww ; to btcM it tbe point is ilepressed. 

1. nMauMM rf'Ifctf bmA ocwiorti tbe Ix-vnimei- more difficulty tbna all 
tW otber wonmi intpedimaols to^^thcr. Fur since th« urx.-t)m> is bora 
much laifier tlwn io liw nambnDOua portion oiljoinine it:, nml in morn- 
onr ommIt itwrtimfiW* tlMl* oeents a nooular dilatntion of the door of the 
ttmhn jw* aBlerior to tbe triai^pUar liaunent. The pobit of the catheter 
il nil to Mtov Ibe ioor ot thi< canal and Im stuppod by the hg&ment. Jn 
^ vAxt to uvereonM tbia obatraetian, tbe point is sometiuoa forced 
tttntwh Um wall of tfat urvtbn^ vhiob is bare uDusually tU'licate and eoailv 
I iMamtad Ilk* JUMfflhj at thui poiut itt overcouio by keepiu;,' the iKiliit of 

[ OHlar vxlNMi^ n ^ attbeler, thereby the jMiut is raised and guided 
f i«to Ike iiiiealnff in Ibe tJinunenl which uontuius tlio nuimbianoua orethra. 
Tb* oboMCW of aniidint; this obetaob ore increased by gi^iule tracUoii of 
Um twii^ wberwby lli« nacvulor eahufccnient of the builwus urcthi-a is 
,i.bJiii-t«t«>l by lb« iitr*t<'biii(i of its floor. It is sometiiuee necoiwary to 
iiIbiv n •:■■■—'':•» 1)k> |<rhiic'um or in the reotum, and thus elevate tbe catb^ 
[ ^teriu>" 1 1 ihmiitlh Ibo l.rimiKular ligament 

A, ^|M>.Tii.'.li>' i-«>titnkHiau of tbe raembnuioiiB urethra oocaaionally op- 

uOMa Ibv ell 1 1*1 II-*' of tbo oathvtor. It tit usually OTorcutnc without difficulty 

rvaltwlr ItTMDUro nilli tlio point of tlie iuatruinout for a fev minutes. It 

1« aoUVrtllHOe diAb-idl (u determiuc whether the obstruction at this point 

i«a a|MUUiw«ilion>iitri>i't>oii. an ui'^^iuuid HthcturB) or the triangular U<;amciiL 

Ih lbi> bklloi' i'«k«' iImi ))»iiit of tlio iuxtniiuent is freely monble in any «x- 

ci^ilil lliu outwMxl (lirwtiou ; wbilo if tlte iustnuueut be engnged in a stric- 

Min, )<illit>r tvHiutle or a]HMJuodic it is perceptibly Rrasped and retained. 

'fit*' K"^"!' "' " KiiiMMitir t<oiilni(.-tion is often plainly dutuiguiahed from 

lliat \*i 'ttt »r>r<")i^' "li'i^'tiiru ; yet it i« oortain tint tbe two are aonietimna 

mMt^<Ull>tt«l. iiil4niulin(l tbo HuiytHin into a i.lin};uo»is of ufyamo stricture 

whfiv iittllilii|f tuit a epaaui uf tbo luonibranuna ur«tbr» uxiHtit. Di-. Otia 

lltdilia 111'*) tliiH oftou Dcoura i lie a^ys: "I>e0potgasio urethral strioturo is 

n .itiiilNltxl by muaoular auutn. The gnial proportion ofcoMtt treated 

i>W i/iiuMfiOH, am tnabtdfor ilurp »triclui\t kAk-A doet not esutt." 

. . Kwi in nbioh H>'ateuuttw dilntatiou of ii spaanodtc stricture 

yf^„ , lI.hii ill lltu lK<li«r tliAt it WW an orgauto conKtrictjoii — bus not 

ImDi'm ttixU't my oluM>rimti»ii. Vet I rtxM'ulIy saw a case in which esteiuul 

iiii<tltii>l>>i<i^ w>tH piMikiHtl for Ibo rolit'f of a t)up])oae<l or^ranio Gtricture. 

'I'bt* I*mM(-iiJ Vivi» » i»*» »' f"i'^*'< who tt])pUeil to n pi-oiuioent local surgeon 

nl ti iiiilibii ttUitio (or rollcf fnnu fretiueuoy and poiu iu uriuatiou. He 

»l.t(.-*l lb»< h..badhn<lnt.'oiiorTbiMlhiafintat(nok)nxmoBtbeprenoU8]y: 

lUnt II iibxil li*! )Hiiiw>t<sl until within a mouth ; be had need injeaiona 

and hud tUuillv Hm'^HHvlnl in alopiuog tbo ditsoharge. Since tbo cessation 



i 



n 




TB£ SOUND i.sn> CATaETZR. 



43 



of tbe ^lc«t tirinnUon had been frcquonl, ootupcUing faim to riae aereml 
tiiui38 during the oi^ht, aikI hod been accompanied nith much pain. Tlie 
eiirgciiii, auMjiectiuK striottire, Attempted to iutroduco n lftrg« et«el souuil ; 
tbiti wot) ikn'cHted iu Lhii bulbuus purliun. Succv^ttivuly limiilicT iiiittruuieats 
ft-ere iiitroiliR-ed. until doaliy filiform bougifls wei-o Piuployeii. All were 
ttTrt'«U'd lit itWut the eame poiut; the tiae of the bougies occaaioued the 
patieut iniicti pn,in, and una folluwud by tlio appennuicv of houk; bluud at 
the ineattia. A diii^iiuHiu of tigLt tiilhi-tun.' wu mado, niid tlic pnticnt ibl- 
vi8«<l thnt nil o))oi-ii.tion would girobablj' be ueoeasory. A ftw lioui-ft Inlor 
liH sippliod to luf. 1 found tliat a No. 12 Englisli niw lureHted at the 
Wlho'Tiicmbtiuious jiiuotiou. Suspoctinf a spasmodic eti-icture, I d&sisted 
from furtkor eSbrte, and lulviwd tlio puiivnt to peimit no further incu'liAui- 
cal iutorfbrouw for three days, iii order to allow tbe gwelling aud irritatiun 
to subudv. At the end of the time specified he called again ; a No. 1'2 
was again arrested at tbe same point, but eutered the bladder upon tbe 
exertion of (;cntle proasure, Aa the patient happened to bav© a large 
mmituit, I tntroducod ritill luxcr nouud.-* and found no difficulty in jxuMing 
A No. 17 EugUsb into the bladder. 

6. The ])roatati« urethra in its normal titate ir^ontAius no obHtaclea to the 
entrance of the catheter, tliou;^h the piis8ap;e of the instrument through it 
ofti'u oL'Cindunti thi> jiiitiunt sumu puiu. A lilifuna Ijou^o has oocaaioually 
ftiiti'-ivd till) oritice i>1 the »iuus puciilnns, In abnurinid conditionit of the 
prostate, however, this imrtion of the urt'thm may occaiuon the surgeon 
([reat ditfiaulty aud per]>lexily in tlie attempt to introdui^e the mtheter. In 
prOfltAtic h\-poi-tiophy tbe coiitoiaod urethra may bo much increoMid in 
leogtli. flo tWt the ordinal^ catheter ia too idiort to reach the bladder ; or 
it may deviate &om ita usual eourse, to one side or tbe other, forward or 
bockwani. If the middle lobe be enlarifcd the uretbi-a may acqtnre an 
additiousd currature before euturing the bladder. Moxt uf thittw coiiditiona 
can he ut lituiit KUMpected by i:\ue uiiirttion [ht rvctutu ; hut tiome of them, 
especially those dependent u)}i>n eLlai'u;eueut of the middle lobe, may es- 
cape detection by ructal explumtioii. and be Husiiected ouly from the diffi- 
culty exporiouood in the intrwiuc-tion df tlio cEith»tc<r. tt w lUwt U> Iw re- 
t»emtK<red that the pro»tatif urethm imiy be no dilated as to contnin OOD- 
Bidetable mine ; the escape of thiii uriiif- may dcccivo tlie Horgeon into the 
belief that Ida iiuitriimcDt liiwi ivachod the bUidd«r. 

7. If the ])eDitt be not stretched ov«>r tbo c.>itliet«r, the poiut of the in- 
strument nuy be arrested by a projecting fold uf mucous membrane any 
where to the peadulouH portion. 

'Wltenever tlie point of the catheter meets an obatruotbu the instrument 
idioul<) bo witlulrawn hidf nn luuh or more and advoncod of^a witli ita 
point in » slightly dilTerent direcUou. lu (.'um; tliere ia a probability that 
a falto jiuissa^^e existt^ the> point of tbn in.>4ti'ninont nUonld ho guided along 
one or the otiior side of the urethra, since the false ]>a8»i^o ia probably on 
the opper or lower 8iu-facu. It is well to bear iu mind also the ISust thai an 
organic atrii^ture may (^xiitt oven thoni^h tb<<rc he uu hiatoiTi- of gononrfacBa 
or injury- ; since it may rettull trout masturbation or congenital formation. 



D*.MJEB3 OF CaTHETKRISM. 

Theoe ore but few and iuniguiticaut if Uie imnary ai>panitua be normal, 
bui arc oumeroiM and perilous if abnormal condiUouN of the uretlint or 
hladiler exist Prinmry diaease of tJie kidneys constitutes no objection to 
the use of the catheter ; it is ouly iu tliose leuol afiectioiiB which result 



44 



DtSEASKB OP THE DBIHABT OEOANS, 



1 Ute lover portion of tb« oriiiar; duomel tliat dwaater to 
Hilts from oLtliet«mti]. 
fitCun introdocmg a cntbotcr it is important to mosrtain, ns definitely 
m |«9Hibic, the otmdition of the uretlin, tfae prostate, uid the bladdin'. 
~ A» axiataBoe of a Htri(rturt> or of a false pasBBge fram preTious in- 
I exsnuastaoni! ; h}-]K'i:iTx>pIi^ of tLa pnmtate ; pweeia, atoDv, or 
of tbe blivUkr : ouiittttctioo of the meatta and phimosis, 
< th« mbjiy^t oi inrjuirr, for if nose of tfacM taaiA. the d«xteiN- 
lalrodnetiOB of tbe catlieter cau scarc^l^' occasiou nur ^\il i while ia 
' pimtaust of DBS or more of tliese coudiUooti, eren skiiful catheterism 
_ ' oooasioa ascioiM rMaltx. 

'Tbe fnJttriMi irliicl) mnir follow tbc imssa^^e of the catheter are either 
^iract or titiliroct The foi-mor nro oontprittcfl xlmost eDtiroljr in possible 
' I'ul iujui^ to tlie uretlira, and occur onlv when an undue amount 
It iimmI, Tbey are tberoforo expedallr frecjuent in thos^ casns in 
Uis entrtnes of the instrument is oppoft«d by n etricUir^, bj ea- 
it In • Use pwsirnffit. or hy awkwon) tuimipulation lu tho bulbous 

„, Hiifh injury is iodieatod iD)m«diatdy by imin and lifmonlinge, 

su4 subso(|ii«iitly jmrbapK by a chill and fever. Tb«ae si>Tnptoms. caused 
' IsflemtioB ot toe urstlira, usu&llj occur within three to five bouri after 
) Inlndaotion of the iwftnimoiit 

!%» iwlirvoi iiijitry wliich mar be caused hy tlie inhoduction of tho 

J^Mitu-tfr wvim wbcu akilfully performed, occurs eHpedally when the blsd- 

lublii (osvaeuato itself n^mpletely. Tliis is usitnlly th« rctniltof 

>i> ..-- iMtiiical impcdiniciut in tho iiriiiar)' cltnnne'l, |)artic:iUai-ly proatatio 

|t)j'IiurtrT)p)iy or utriuliire ; li«nce it is esp«dal]y in pntieiitu nftiicteil with 

\tnM or tlw uth«r of tliem conditioua thnt the u»e of tlie instrument is at- 

[ti-iidnil with mrioas cunsequLiuccs. lu itomc few cases iiunluess and even 

rhonm liAvo been known to follou' tlio iiitroiluctioti of u cntheter into tin 

outnly iliaUiii(l«d bladder, tbe dtateiitjon rettuliiug dimply from voliuitary 

fvstoiition of urine. In tbe srentcr nuuibei' of niars, howercr, tlif disustroua 

jJtn lit cnthoteriattiou Wvo occurred in iudiriduale Biiffemg fmm «trict- 

l<tuw, pnialntin (lypurlroplij-, or oUii'r uit-cliiuiicid iuipcdim^nl, t-aumuj* an 

bsbituid dii<t«nlinn of Uie lilitdtlei- in conseoiieiire of its inability' entirely 

to ovwreome the esi»^iiug impediment. Aii luquiry iuto such cfUi«8 shonv 

ttut tli«ro liiu loui{ txistt'U couttidirablc difficulty in uritiatiou ; tbftt ia 

[«ofiMr|ueQoe of esoeaws in etiling or drinking, Gxpoi^ire to cold or eiu 

{ofir;oil voluntary retention of urine, there baa occurred such an inability 

Vi ettujuato tbe bladder rut has n-quired tlie aerrices of a physiuixui. 'Xbo 

catJwlar is introchioed, usnnUy without (^eut difliculty : a liu-ge amount of 

urine n wttbdrami ; tbe patient cxjienviiRitt no ill re&ulta until two or 

(brea days hare pamed. when the first syniptonia of a condition reeenibUng 

typhoid foTcr exnibit theniHelves. 

In tbeoQ eaaea dio raiult of cnthoUrizatiou is nttributiible iin( to any 

K^ianiral injury of the urethra, nor to nuy bypoth^ticnl retle\ nervous 

lolluSDOe, etc.. but simply to the removal of an Mi-omttomed pressure fi-om 

tbe waUs of tho bUdder, ureters, pelves, and urinary tubules. For tbc 

k. impediment n-hich bns re8Ult«d in thL> iuiibility of Ute bliuUUr to evacuate 

litMilf — tilt) stricture or prostatio Iiyjivrtropliy, for iiistiuice — Las residted 

An»t, ill the habitual retention of more or less luine, and aeoond, in a 

hypi-rtmphv of tho muscular Bbrea of tbe bUdder which Rive to tbftt or- 

^gau tuore tiirui itn aormnl finunces. If tbe impediment have long existecl, 

s Mmilor dihitation will be found to have affecrted the iu^t«r^ the {wtvea of 

111* kidoiiya, and even the uriuaiy tubules. Tlic iutruductiou of the cathe- 



J 



TUB 80UKD AND CATlIKXKi:. 



40 



ter, hy withdrawing entii'elj the urine Labitualiy i-etained in tho bliulilcr 
(ami pertiapH urctfrs imd jwlvcs), cuuauM fstrcnio renuuB congestion of tbe 
tuucoim monibmiio Jii tho blnddcr n.t lonst, and iu those other portioiis of 
tbi: uiiuLirv tiiurt which have beeit dlst«iid«<1. Id tuauy ohm tuJs 00DgM> 
tioii ftftoet^ not onlj tlie sujierflcinl blootl-vessels of the nmcoUB niombrniio 
hut iil.io thrt&e l.ving in the {lai'enchyuiii of the bladder. The r«au!t of tliis 
GongeBtion — which thu QuiniuDa adl U\/{n:nvmia r-x oacuo, or iioKative 
preasare— depeiidu upon its (Ict^oe. that i«, ii^ion tho niuoiint of rosidurd 
iiritic liiibitiiAlly pri'suiil in tlje bhulder an well oa uyiMi tlio degree of 
liypetiropby, ftiid hence iutlexibilitv, wliich tlio muMMiIai' wnlls of tlie 
oti;tm have attaiiie<l. lu those casea in wtiich the bUdder luis suffered but 
Utile change, tlie hyperemia ifl twiiallj of xlij^bt <l«grfo iiud tempormy dii- 
ration ; th« piitieiit biu u chill, suine fever and nit eticniie of bloud u-itli the 
urine — tbe bittvr duo n«>t to mechanical injury of the luuooiu intimbnuou 
but simply to the «xtmYn»atioD of bloud from the congested TeB8eI& In 
severer (^siaea thin congestion is the prelude to an inlUnuuatioD, whioii 
may nflV'Ct only tbe niucnUH meiiibraiic, but often iiivulrc^ Ibo entiix) tissue 
of the blftdiler, resultiiit{ in nri at-iiti^ pnretkcliymatoiui cyHtiliii and even 
pericystitis ; the bliuldtrr-wuU benomea Kwnllen ami iu>ft«ii<Hl luid i>3di;l>its( 
miliary abscessea ; suppui'atiou may uccuv also iu the connective tissue 
aivuiid thu bhidder and rei>tum. TIiu urine uftei] Inui a fectd odor. 

la wvcrcr ciwom, ihom: iti which tbo iu-cUts and tlio kidneys have suf- 
fered trom the habitual roteiitiuu of iiriuL', thv ;>liLiuoiui-uft of vesical irri* 
tatiun and itiSamniatiun atB often moaked undfu* tlin more nlarmins; sigiiH 
of rvnal diwttn'bnnoe. Am already meutiouod, hemorrhage into the tubules 
of the kidney treipieully fr>llowH tbo iutruductiou of tlie uitheter iu th« 
daas of CAiiEiR under diRcunaioii ; tliis hemorrhage, liko that from the TOximl 
raucous membrane, is the result of the inteoM ooogestion consequent upon 
th« suddeu removal uf the urine whii^h liabitualljraistenda the tubules. A 
high (legruc i>f tbi>f <rnngoKbi(in, produced in cases of great disteotion and 
hypertrophy of the bLiilder, ouunaioita coiupkte uniirifl. 

The oiperieuce of every surgeon furniMbea iratiincea in which the 
BTDple Hkilful introduction of a catheter lins been followed by more or losa 
uupleniMiit re«ull!i. rouging in suverily fmm slii^ht fliill iinil fever, to a 
general infiammntion of Uio uritiarv tmet — ej-stiti*, pwlitis, nepliriti^t — or 
to fatal anurin. The literature of this elfi»9 of diseaaen aboundu iu ainiihu' 
instnucM which have bH|>pened even to tlie moat distinguished aud skilful uf 
inodeni Murgecjiit ; and in warnings om to tho possible rhsa«t«i-« t-ousetjiieDt 
apon the introtiuctiou of an im^rutnent into tho bladder. Yet but few if 
any of our standard text-booka Hjran the suhjoet mnko a very clonr and de- 
cisive <1i>rt4nction between those cases which may be catheterized without 
danger, luid those iu which disrwtvr may be apprehcudcd. Iu nearly nil 
cases the danger id tutrribcd to tho infrr^iudton of the inttrument, mther 
thna to the nvacucUion of tvtadual urtriif — t)je real element of i>eril. Tlius 
CouhMu Bays.' "cystitiii of aaerere and even fatal kind baa Wn kuowu 
to follow thfi paxHuge of a catheter or «ouinl. It in only mattonablo to 
■aeitme that in tlie mnjority of fflich oases on undue amount of violeuoo 
«u tile oauae of the miHPhief." Again '• it seems probable that by rellex 
■olioa the pnssage of an iiistrument along the urethi-a indiiccN, imilnr cer- 
tniu circumtttuncGs, » dinturbiinco iu thu circulation of thb kidney, or iq- 
terferes in sonic ouumer with ibt function." iju- Ucury Thotn]iaou ' in 



■ 



■ DboMM of Ilia Bladdnr miul Pro*tAt« Glam), taxWi odilion, IS9I, p. d7. 
* OUidettl LootuTM on Disuuci of lliv Urinvj- Orsiuu, \^'i, ji. Stt. 




4B 



DISEASE* OF TffS CRISaRY 0R0AX9. 



ApenJiing cif the iiifroJuotion of Ui« ciitk«ter in th« treattDent of rase* of 
prostatic hypertrophy, refers to the iitiplewtBot coiixcquvDcos often esperi- 
eti^-ip(I, aud KUggctiU, )ioiue»'b»t vaguely, a plan for nvoiiling Uiem, witliout 
hinting at ttio vxpliuiiitioti. Ue saya : " I revert to a &ct alraadj' itDiulecl 
to, which is one of conaiilerable iraportanoe, that olthouKli the urioe iu»y 
Lave heen quit« clear befora the I'utheter was employed, yet in Home in- 
MtADCoa, after ttii bnbttuol tuo iuin Lven utinLinued fur ft Hbort tH>riod, the 
BecretioQ becomes cloudy and the patient is fevdri&h an<l uuwelL &. BtaR« 
of lionstitutionAl deiaDgement, more or leas marked, )xa& floiactimoi to be 
passed by thoee penons who, bnving long t^xiwriciipod difficTilty, Buddeuly 
change from their usual modo of Tuicturitioii to tlio HrtillciiU ooe. Sir 
Benjaniiti Hnnlin wiut the tirxt tu remark it, aiid in hiH raliiiiblo lectures 
cdltid atteuLiou to the circuiustauce that pntieuts mi^ht even souiotiines 
gi-ailuiilly BUPL'umb witli Byniptoms of low or irritative fever a few weeks 
aft«r bp-;^uniDg to ui>e iiiD cHthctor." As to the cnuiw of these pheuomenft 
he merely taiym : " If the putieiit has been in the habit of retainiu^' perhaps 
a pist of urino or ctoh more after ho has made water, it is a serioiis cluuige 
for the bUdder to be suddeidy and completely empti<<d two or thi'ee times 
a day ; the organ boom becomes irritable, the uriue ia charged with pna, 
and tlie patient loses appetite, becomOM feverish, and there is BometiiQes 
considerable dauber to life." 

A knowledge not only of the clinical fact but ul»o of the anatomical 
COnditioDs which expliun it, ia extiemcly imporlnnt, for without it the 
Hurgi'on who iutroduccs thu ciithutin* i» gropiut; in the dark uiid liable to 
be overtaken in any torn by a diaastc^r whieh he Li unable to cx]>|jun or 
avert. Now these casen of prostatic bji>ertrophy, Btricture, and other tm- 
pediiueuta to Die evacuation of urine. coQHtitute a Iiu'ge proportion of the 
coses in which the catheter is required in trvtitiiig the iidiilt mole. Hence 
tho importaucv of Oiieertaiiiiiig iu avery eniie in advance the preseuM or 
absoiice of ruoIi impetlimtintH antl of the dihitation aud hypertrophy of tlie 
bladder coiiBec|Ueut upon them. 

A compruhcmdou of Ihvtsa anatomical relations suggests also the pre- 
cautions to be adopted in treatment, nrecautionn which are quite an noecs- 
sary iu evacuating the bladder for sudden retention rb in cases of Imbitiml 
natuetcniim. Sinee tho ill cliccta hi-o traceabk- Iti a "hypenemia ex 
vacuo," » congestion in eoosciiuenee nf tho rfrmoval of the accustomed 
pressure cati^d by resiiUml mine, the liret re^juisite in preveuling these 
Uk is, of (^urse, precaution to avoid this couKestiou, tliat is. care not to 
empty the bhiildor completely. Sir Ilcnry TlioiiJi>«ou, spwdcing of tho use 
of the uttiiuItT iu prOHtutic hypcrti-ophy iuiya, " it i» undchirable to vmpty 
the fohidder completely on every occasion of catlieterinin <luring the first 
few daja" It is, indeed, estreuiely desirable and abBolutely essential for 
the patifufa welfare Ujut the bladder should not (m emptied compieteiy at 
aU during the first few days. AVithoiit fui-thcr discusRion of this it«m of 
treatment here, it will suffice to say that whenever the catlieter ia to be ia> 
traduced in cajtes of retention of urine iu individuals who have stricture, 
ttalarged prostate or other im|K>ihmeat which muy be reasonably assumed 
to have caused dilatutiou of tho bladder, caj-e shoidd bo tokcu tu ovacuato 
not more than half of tlie urine, whoftC quantity can be ejdimated by pal* 
pation over the pubes and through the i-ecfiim, by uerciiasiou of the abdo- 
moa. etc. If this rule wuro gcncndly observed, tho introduction of the 
.catheter wowld not Ijc held roMjxinsiblc for nearly so many inexplicable 
and unforeseen diHaalei-h as is now the case ; and instances of " urethral 
fever" would be lei>« nunierouij. 



: 



J 



TUB SOUSD AND CATlIETEit 



47 



» 



I 



Tbe erii effecte cQD9equ«nt upon the BuJ<3«n iui4 complete evacuation 
of ua hatntually diluted bladder am uot conliDed to tlie dbg of tlic catheter 
and aovaid aloae. Upomtiont) in tlio drop urcthm or iu the l>ljKi<i[pr, wlierfl- 
by long-ntoudiu;; iiupodiineutit to tlit; tlow of uriuu arc HiiddiMily I'emovvd, 
ftro ftl8« (ortilo in pnninriiig cn-tfa of cystitin, ])ye)itiR, and iiepliritin. Tho 
reiuoi.'al of a tight stiictiiTd iu the poflterior urethra by either cutting or 
niptiire, the opcmUou of lithotomy in elderly meii. i» mon.' or Ichu danger- 
ous Inr^C'ly nccordtag to the ooaclitios of the blodclcr. I<iUiotoiiiy in noto- 
hounty tar siifcr iu <wldren tbau iu odultit, otlier thiu^ 1>eiii^ ctgiuU ; tbo 
grcnu'r itftfi'ty licfi evidently not in the operatioii itHtdf^ — for the hom prnxiut- 
ity iit tilt? child of purta to be nvoided iucreiuteB the danger o( Bccid«nt from 
toe knife— uor is it to be sought in the removnl of tlje stouu, fur there is 
greater prohiibility of bruialn" nnd rrugliitig the piirts iii iJie child tliaa 
in thoiKlulL T)io rcamDii fortliirt greater aafety lies largely iu tlie fnot Uiat 
the ctuld'» bladiler in free frnm other abnortnaJities than thoHC cnuKcd by 
lb« presentee of the §t4>iie itself : th^re is no prostAtic hypertrophy, prob- 
ably no <hlatatiou aiiil Ini^crtropby of tlif^ blndJnr, no ililittAliuii of Uiu 
pelvjfi nnd urinary lubuldB, coiuliliniiH wliioh we rcHpoiisible for so much 
of the mortality (ollowiiifc lithotomy in tlie adult. For it is well knowu 
that this moitality ariaes not from tUfi iniuiy inrtictfid by tho kuif u iu enter- 
ing, nor by the stone in leaving the bkcider, but from the cvsliti«, [WPicys- 
titifi, jiyeliitH, and nophntiH whi<-h cb-vctlnp in the course of a week or two 
after liie operation. HiirgeoiiH are in the habit of gnuKint; the probnbiti- 
tiea of ftucceaa after lithotomy in. an old mau by the " condition of the kid- 
ney* ; " the fact is that tho condition* of the kidney ix, wo far «m it affvctii 
Uie r««iilt of lh« op^rfttioa, dependuut u)x>n abnormality in the bhulder or 
urethra ; a jiriniary ditt^ase of the kidney dot^t not predutpoeie to inflamtiiii- 
tory reaction after litholonij-, providotl the bladder is free from dilutation 
And liypprtrophy. 

Anotlxir ]>09iNiI>le fUaser in the u»o of th« cailietor in the introdutrtioa 
of materials into the bladder which may excite cvstitia. WiUiont discus- 
sins the nature of such materiala. whether they lie organized or unorgan- 
ized Rabstnnotw, it ri-iniunH an mtsiired fact tliut OMett of cy>«tiliii linvp boMi 
deflnitdy tnced to the use of uncl«au Instruments. Mor \» thiK surprimg 
vben we obaerve the alutoat uuiverwU prai-Lice of cleauMiig a catheter by 
simply n-iping it on a towel or permitting a atreaui of water to run through 
and over it. That iiialruniEfutH liliould be renden'd sunjutiJiy tileiui is in 
theae hittor <hiyM nxtotnniic ; the heat meiios to thi« end i» iiiidouhtcdiy iui- 
menion in a weak (one part to 5,000) eolutJoa of corroeive sublimate in 
Tmter. Corholiwd oU or vaaeUne, frequently employed by eurgeouit, lias 
absolutely no raluo f'tr thiH purpose. As metaUic instruments nro rapidly 
corrotled by the aiililiiimte, tlicy may be healed iu uu alcohol Ilaitie. 

However dosarablfi iw ii rouliiio practice the elonn«ing of cAthctera and 
ftOHiuIs by antiseptic ageuta may be, the neglect to do eo is followed by se- 
rious results iu couipariLtively rara caaes ; and theM? are caeen iu which tho 
bladder habitually fails to expol ita contents, ihkI Utcrnforc always mmtaiuii 
roadool urine. The reason for this lit-s tuniply in the fact, esi>eninentallr 
as well aa cbnieally demonstrated, that septio matoriala. or^^iizcd aa well 
aa imorgaiikM^il, guin no foothold on the mucous mombinno of n budthy 
bladder. Putri<l fluidfi, swanuiufr witJi the biict«riu of [lutiefaction. have 
been repeatedly injncU-d into the bhulilrrs of do^^x without oauning the 
leart observable patbologiciil eOect. For the bladder at its next ooutntc> 
two ezpela aucb duida entirely, and until iuiured in noma way affordK no 
opportunity fur the origin or development of n soptiu procviut. U is <|uite 




48 



DISBASS8 OF THK UmNAI£Y UltOANS. 



^Otb«rwise, liovever, if, aft«r the iDJection of the putrid flniclB, the bkdtler 
< pcsTCDtod from Hnipt>-inK ittielf, by tyiuc a ligsttire arotiud Hie |)euu fur 

' *xauiple. Id thiscoaei while tho oiucoiiit iuciubnui»it«^ nObnlH iio opnor* 
tuiiit V for wptic proceeaes. xhc retained urJna furDiahes ample tDateiiaf for 
feruieDtntion ; mi a reoiilt, tho urine uu<U>rKue8 the ainnoniacal cbanffe 
on1inai-il;r esliibitetl outside of the h(y\y, niid cf-Ktitis follt^ns. \ pirciselj 
KWlogoiu prooBHi occui-s us the resiill of Ibo iiilnKlucUoiiof au (siiivirnlly) 
ttncloan OWtoter into a human bladtlcr which habituAlly rotains moi-o or 
lees ttrine. \Ylii)«, therefore, such a catheter ma; be used vnth ituiuuiity 
ill the i^'Rt luiijorily of indiridiiaU, its euiuloyment in casea of Hlncture. 
|NroMiitic byjK-r trophy, pnresis. uod atony of the bliulder, mdiI oilier coudi- 
liooa iu mhicl] n-wduol uiiue » prcMUt, is often productive of cvstitis. 

Nor tloAH tliit (UmMige rest with % Biiuple inflatuniation of the blaclder. 
Wir, ill Uie cJiuB of onaoB referretl to, the tiu{>edime»t which cnutMM first the 
dihitatiOQ of the bladder mid linbitoal i-eteiittoii of urine in its cnvity, oiay 
{iriKhifo. sootier or Iat«r, an ejrteiudoQ of thie eonditioii to tlie ureteni tOM 
wi\n\ \K-\nnt, wbiob then cootalu % certain aniouut of residual urinr. Am- 
Biouim'Al fenneDtfttian, orisin"t«cl in llie blw^dcr \iy an uucleun calhvter. 
•Slouds of eouFM to th« uriuo ocmtainnl in the uretem and ]>clv<-x In tnich 
aim |)>vlitiB hihI mi{i|HU«liva aiphlilia MVn ntiMdIy upon the cvblitis. 
t^finluiijintttii in au OfifllriniTl imh)! of tho iiitntibiclinn of tbe vatbeter, 
nitvly idtvr tbi> I i»[inj[ ot tit* iualnunvtil only » few- tiine«, but fmineutlj- 
oortirnuu KHiuer ur Utvr in lluiao i-aura iu nliicb tho habitual use of tlie 
Vfttbalvr t* nuuleretl tim><<MMry l>y (irtkulalie difficolty. 

d('H(i> (•iv4<itf«ii> Ihw hi « few i»»l«ue«e been occasioiied hy the iatro- 

llU«U\4) fit OUlllVtvl* lUul MUtt^U. 



CHAPTEU rV. 



CRETHRAL FEVER. 

Tiru teem has been used to deuignatd tlie various mnrhid phAnnmpntL 
wliicli fio ofl«n occur uft4ir opt^nttirtax iipoii tho iiretbm nnd bladdef. The 
nnme exprmiMa th« funeral umlenttaiKlint; of surgwons with nfj^d to it — 
that it ii* a reflex Or imrt'iiua phenomeuou clue to cotiUuit of inMtriinicitta 
iritL the «xtieiuely eeasitivo miico\i8 mi'mbrane of the uretlun. Tii« fact 
tliat these sytDptoiUD otwur without mochaiiii'iil itijtiry to the miiroutt tui>iii- 
hmne, iiiaT«veQ fuHow tins nkilfui ami uiio])]hik('i1 introiliKrt.ion of the ratli- 
et«r. biu given rise to the hjpath«sia thnttJif iit^thmiscuilowed with kouiu 
[M>«uliAr acnHibiUty not poaseRsed by other muc-oun mfruliranofi. which mn 
bo callfid into action b]r ample contAct of a smooth and soft «athet«r ; aiid 
u'biob. thus aruiued, exerts au iaduenco not ouly upon the ort^as in its 
imtiiftliAt*' TJcinitj-, but ubio u{iou the oitcuLiti<i» through tlio kidneyfl nnd 
tvea upon the lieart iteeU. 

TbuH CiviAlfi, quoted hy Otis, sayn: " Independent of its local aenidtiTe* 
n«aa. tho urethra pofttemoti imotbor kind whiuli luny Ixi termed sympntbetie. 
Whi-n thi» aeiimtiveoess is aogravated it niny awnken Bympnthetio roHpoDM 
in«TMrorganaodluBotiOBoithebo(ly." QroHa'BavH: "The urethniHecmii 
to poooeao some peculiar morbid xympathios, through which the introduc- 
tion of the oatheter is Homt!lii[i6.t foHowod by uuplviuuirtt effeclK, lui portisl 
sjncop^ shock, <!jiilij|)lifi)nii {-onvubiitiDa, lUid ovttn dcAih. Tlicsc orciir- 
lenoes an roost common iu persoivi of a nervous, imtnble tcin{>t-nui]cnt, 
orivbo have suffered ironi intermittent fever or lived in liot clinmtps ; an<l 
cannot always bo pievtintcd, however cautiously tho npenition may be per- 
formed. Tho setisibiJily of the urethra la very {;ront, aud beiio« it is not 
Rurprising tfaut tho cont/wt of n houf^e, hoveviir tdight, idiotUd ocoaainnally 
be loUowed by great pain in the parf«, nervous proatrstioa, and other dis- 
■gteeUe effects. Otis ' remurka : " In pontons of hi^rhly ucn'ous tempera- 
ment the prodiflpoBition to urctliral fever is tho rule, and any flight me- 
obanicjd iulerference niay giro rise to it." Coiilsoa ' sara : " Tht* cau«o of 
the symptoms of urethrsil fever is very obscure, but it seemti j>robablfi that 
by reAex cuttion tiio piuvuige of an inntrument along the uretiitn induced 
under certaiu circunitttauuea a di^turliniin.' iu tho cirt-ulution of the kidney 
or interference in some mnnnor wilJi its finiclion. It wiw fnmKiriy sup- 
poaod that the symptomii wer« due to absorption of urine from u wound 
or csoorialioii iu tliu urinurr juutuigce. but on tho one hand the riRur often 
occurs Iwforfi any urirK^ is poMMul, nnd on the otlu^r it in not found tlmt 
rigors iuTari(»bly follow lilUotoiny or internal or extenuU urethrotomy, 
after all of wlticn opemtionn urine is more or less frequently to coataet 
witb a wounde4 surface of the urethra." 



*INSM*e* of tlie ITrtnw/ OrjSDS, TiUnI Bdltloii. p. 1S7. 
*Loa alt. p- Vit. 'L<»v. dL, p. 




DIdK\S£3 OP THE UBINAKr ORQAJtS. 

Bir Henry Thompiion ' nnyM : " \MMt tH uminllr tcrm^ fever " (nfter 
litlioLrity) " in • wrim of pbeDomeua which denot« a (wculiar disturbanca 
of (Jin iifltTOUH iiyiitvm, llw piodact of luedLonic-al uit4)rf«r«ii«« with Uia 
imvlo tiraUirft. 'niiin^a atigbt OTur-tliUtnUon of the canal with a bougie^ 
•iiil Mlill mora tlio occunvuco there of eoiue oonsiilemble UaioD. ma; pn>- 
tduoft n (oUtiln ntlock." 

Nviu-lj' aU itiitlitin OflVM with those quoted in aacribiog urethral ferer 
larudl.v lu ati oxtrKiiie MnmbUily of thu urcUint, in coDsequence of whioh, 
■■iiii|>I« con tact— which ought ho luLrml4NM in tbo case of oth«r mucous 
liii'iiitinUMM — tunjr nnxiMi ouurtitutioaftl teoctiou. 

Klitiiy writon omjiluxmy'O ihn ni!ceB8itj for nn exniQination into the wii- 
dlllni) of Uio IcMne;" l>oforo uuilertaHnf; any ojieratiou U|kmi llm tircthra 
or iilmliltir, m n prouautJon attniiiRt Huriou8 "urethral fever." They msfn- 
plitM> lh«< (iw-t tluil ronal dliieiuie ia often Aggntnted by eupIi mauipuliktioa^ 
[liiil offfr iio l»ltor cxpUnntion than rellex action or tli» rontnct of anne 
I*Hli III! ni'rrulwl Kiirfaon. Tlnui OtiJi,' in diacuwiinK nrettiral fevor. aiTS : "I 
llliilil tliat in o»>"'H of long-*il«nding uretJiral trouble aud in all dderly per- 
■Miiin llm |«Mnuu ■>( any iuBtrumeut tbroug^li tbo ui«thra into the bbddtr 
Hli»tild iti<%-iii- be atlfltii'pU'il witimut n prehminaiy eXAmlnation of tJie |mi- 
tttiirH mill" to tUtenninn tbu stale of the bladder and kiihiojiL It is not 
Iroiii tiiK fiift llial itmthral fvvt-r in sucb cmes is more likelr to occur utd 
mIiIi piHHubl^ KToaUr MToritj than in henlthr persons that uiis predispon- 
Itnii la iiiiinirtaiili but bucauiia when it does occur the dan^^rof the redex 
liriliilliiH nib»i<liii|| to the iireti-ni ami kiduejiiand induring a siipprewdon 
or tirhtt', U Kr«atlT inrrcAaod, and that siipprMnoD so induced in frajuciiUjr 
anil rai'ldly tnUii Vwii Uur«ii and Keyea* eay: " Thnt all tbero disonlera 
•Ititiibl iltiiM'itil »]"»> <-l>o "iiiiple absorption of unoe through an abraded 
ttill'rtutli tw III iJi" liltfbMit dc(,'reo improbnble. Other forces are nt work, and 
lllMw am |)iiilNibIjr sliuck aud roilux actiuu, mupctiding the fuuctiou of the 
hblMM/, >*r(<-ii rtlniiulf tliMtoaeil. Tho oonditiou of the urine also has ranoh 
In do with III" oHh'I' of urothnd fever. It uroduce* do H!ect in contact 
Mllli a wiiuiidiiil m\irtnr*\ when it is nortnaL When in ainmouiacal fermen- 
laUitN U k utuUMMmily capable. If Bb8orbe<l. of occasioning aeptitfamie and 

Enht pltsnomnn luid uofortunately in bljuldcr and urethral diMase the 
I li Tiiry tiflnri niiirn or Irtw decoitiixieed. Tbo extent of tlie injiuy 
I ta tw liidi'i (if Iho utiKiiutt of fever Uiut will follow, Tbu gentle pas- 
INi((» iif H Niit«i>l)i Miiind nm,v ciiuho sjieedy death, while exteDeive wouutia I 
Mill) Uotirnltolii "f till! ciLDft] iir« uttou absolutely innocuous, and that^ toes ' 
mhPtf Mix lirilMi I" ■IronRly nllcAlim-." 

il la KVldiiiil, frofii a raimi deration of the rases recorded, that the terra 
HtfiHiml Ifffr iviMij>ris4)B M'wral distinct patliologicol proMSMa; and it is 
»"|iiNilr I'Xdwtl, frwiii tho oiiinioiis wlvmnood by experienced surgeons, that 
lUi> liiHiiKito riiitiim of Lliniii ppK^eiMi's in (.'^^ueroJly unknown. Indeed Van 
|hii«ii Hiid Kn^c* fniiikly wty (]!. 4')) "the uncortAinty which Hiirronnds 
tliNi ('(iiidllloii kiiiiwn w iin'tlunl fuvvr htiu not yet been «utire]y clt:ar6d 
ti|«." Il lit Muerallj' awuniod that them itt n rottex nervoua nction, origi- 
t|«t#>i| Uf Im<at4nn of tbo turethra and reflected upon the renal circulation. 
'I'lila lu "' ' P')!^ Iiyitothms; there is io many ciuos no c^-idcuoe of 

iirfdidil , wIUIp ill iiiuny othora in iriiieb exleneivo locorntion oo- 

<.>itia, nil itruiliral fever or other orideitoe of rvfivs lU'tiou followx. More- 
ftibf III MiiMB bistuow ia Wblub Ui RggTavatiQn of reoiU disease fallows the 



l« It., p. HP. *Im. elt., p. 40Z 

' (iMilto-Urini^ DtatatM, p. 46. 






M 



CErrSRAL F£VSR. 



51 



introductton of iiutnuiients into the nretiira, ther? is no proof tlint the 
mcwbid cbangeii obserred in the kidue^- can be traced to the irritntioo, real 
or hypotlicticjil, ii> Uj« uretlirn. 

It the cliuical history and the poBt-mortem appenrooces be carefully in- 
vwtigBtsd, it will be found that tmse cuaea may be divided iuto two |^u> 
etal nlnwinn ; Qrat, thoso iu %t-hic)i tho use of instrutiMiTit* him oftciutioncd 
demonstrable oud direct lesiuiis auiBctent to explaui the sj'iuptoniH on 
MUktomicai groundii ; find oecnnd, those in tdiich no lesiona are dtncorera- 
bl«, and which are therefore explained by a h^-pothetical reflex norvoua io- 
lluence. The latter elaaa is gvuendly xuppOHet^l to iuclude by fitr the irreater 
number of raues of urethnu fvrcr, but a careful oonmdvmtjon of Ui« tui- 
Atoiuiunl relations of the different organs compoaing the unnarj tntot, 
materinlly reduces thn number of cnseti nbicli ciuinot be explained upon 
auatomimd grounde. 

Lexions of the xirtihra or bladder, oauaed by tJie iutroductioD of instru- 
mftnts, ftjre hoM rcitponsibto for miin; oiuea of urethral fever. In Rome of 
theee cases tlio wouud undoubtedly becomes the slartinp-point (or abeoeBB 
formHtion, phlebitis, and pjiemia ; but in most iusUuicett the lesion tH alight 
is inclicftted only by ths cswipo of bIt>od (n>in the iirctfara, mid in iioverUie- 
loM followed bv the Htiverer OH well as by the luUder forma of urethral fenn 
Id uuiy of thesn ojiHes there is no reaiion ior nsmbinR tlie eonstitutional 
effbctto the iusi^ificani injury, cmi)l that no other r-rplanaiion ia to he found. 
All BUrgoonH iwi'^xma the uttor disprupurtion between Much aligbt letiio<iia 
ftnd tho sevoro ftyniptflmn which follow, and many attempt to explain ths 
eoiiueation between the two by assuming that the passage of the urine over 
the laeerate'j surface, and not the laceration ibinlf, causeH tbe nervotia reac- 
tion. Thifl hy|)othesis is exploded by tlie simple fact that the chill and fever 
often occur tx-foro any aiiae has paaeed over the wounded surface. The 
gug^eiition that amnioniacal urine may, by «mpl« contact with the abraded 
tissue, cause the chill and fever is opposed by the fact just nentioDed, tliat 
thifl reaction oceunt before contact with the urine Iiah taken place ; more- 
over, tho anno is in nianv of thme canes not animoniacal ; furthrmioro, 
Buoh oontaet is in many oilier instances not followed l>y urethral fever. 

The aggraoatioit of pre'erittiny injlaminatinn of the vrinari/ orgaia ia 
nippOMd to be induced by r^Hex action from the in-itated uretlu-a Cyetiti«. 
pvelttis, and 8Uppumtivi.< ut-phrilis ai-e fre<|ucutly found post mortem tvtter 
t£e introduction of a catlieter or sound into tlio hliuMor, but that tliey are 
produced by reflex irritatiou has not been deuoBistratetl. 

Allowing the griuitcst pomihlc latitude to those anatamical disturbancea 
)□ tho expliuintjoa of tlie abnominl phenomena which follow tLo ialnxlue- 
tion of the calheter or sound, as well im o]NrmtionH u|x>n the deep urethra 
or Unddcr. there remain nnmerous cnseit, conntituting the majority- of those 
obsorriy], which lie beyond the pale of such explanation ; cases in whicli 
there k no evidenee, during life or aft«r dc»tli, of laccmtion of tho urixuuj 
paangea, or of pre-existinp diaeaite of the kidney. Tlii-ne CAsen comprine : 

L Instances in which cliill, fever, and other sitj'us of coiislitutioiial dis- 
turbance aro exhibited for a few boura or days after the passago of uo iu- 
atnioient in individually who»e urinary orgnutt, including tho ktdneyii. ant 
apparently liealthy. 

2. Those iu which the patient has long had an impodiment in the cmo- 
oatioD of the nrine — usually a stricture or prostatic enlargement— <bat no 
evidence of n-nal iliwaw. Mnny of tbciie canes k-rminnte fatally, and the 
report of the autopsy records noiiual kidneys, exwjA IhM Ihet/ ore intemviy 
eoagesled. 



DISEASES 0¥ TUK UIUHAK7 0K0AK8. 

*■ nK»e CMM in whicli njmcopo, ooUitpae, and e\ett death (&Uow im- 
_^*r upon Ui« cviitaation of an over-dintewif-d bladder. 
—^•Mp^witionfi offoml for these obmu haw bean clu«^ : (I) sbnct ; 
• ?'""* P**'"'"""'^ ; (3) reflex aotioa tbrougb the nervous eystcm tuis- 
"JBTOD kraal irritiiUon 1^ the preeance of the inwtrument in tli« uruuay 



li Ui« term sliodi can be properly apulied to any of Ibcse castti. il miirt 
«rt*»nly be reHtriotea to thow> in whieli tlw sodden etjwimtion of nn otci^ 
AlBfflded bUilder — wbetJicr tJir diatcntion bo iicuto or chronic — is followej 
na«di«ic-]y by »iicb failure of tit heart bb to cause (uintnesi or even 
d«iui. Tlw w^ll.know^l eatte quoted by Sir Hnniy Tlionipson is an illiis- 
tf*tion ; in tl)ia inHtuiic-u " the old mao was placed upright o^fouist a wall, 
tb* catheter introduced, mid ttix pint*i ot urine were withdrawn in fiiU 
•tlWin ; but the Mai^r liiul no Moutiur ooiimiiI to (low thaii the [latient fell 
dead at the mjrgeon'B feet, I-'ntal Byncope hml lakcu pbicc, doubtltw in 
OODMqusaw of llip r&pid removal of no Inr^ a body whipli had pn-vionstjr 
prMSed on the alHlomiiinl veins and Tiscera." Since eft'eols prwiBely nin-l 
UAT in kind, if not iii de;^«. 01*0 familinrly knuwii to follow the eranintion 
of larg« quantities of tliiifl fmm tlic ahtloiniuM c«vity with out uny inUir- 
(erenve whatsoen-r with tbe ui-iuory on^aiin — lu in coses of nncitee and 
orariaa orMs^it is fair to luwunie tliat thi> deprensang influence which 
eauaea Uu> ^nioope in such coHen of evacuation of the ovetwlisteiided blad- 
d«r, arines not from any jwciiUarity of ihc uriniiry orf^iiin, but Ktinply from 
the peneml Arterial anvpinia cnuBed by tiio aiuldon intfrsto Mnitroittion of 
the abdoniiuft] t4uim«'1h following Uie rajiid removal of previous ])i'GMture. 

Unrmic poifioninfr cannot be i-^aoonably aHSUincd to explain cuReti of 
Hudden and inmietliate uervoua diKtnrbonee After tho am of tlif oatheter, 
«v*n tboui^h ]>artiul or complete iuiuri» ri'^ults ; for th« intert-nl which 
muKt elapw* Iiefum an at^niuiJiilnLion of urinary in^t^dientH in the ayBtem 
could inauife«t itself oe uiieiuia is for greater Uird lliat which actually 
occurs in thcw caiwu. 

R«fl«x action Uirouffh the nwvous Bj-Btem. oriciuated !»y local irritation 
io the urinary channel, it* the favorite hypotliesia adopted for explaining 
uietbrftl fever in the abaeoce of anatomical nppeanuieei<i. This idea of 
*' reflex itction " Le «» vague and indctinilo, so coiivtniont nnd heretofore a* 
entirdy devoid of exporimeutaJ prvof or disproof, that it has been inaile a 
genend scajie^nat for exciiMnj;; and exnlainiu^r urethral texer and other 
COiopUcations of catheterism which coula not be explained hv direct and 
vUlua aoatoiuical cluin^ti. Indeed, bo siniplc iind Mitiefying im this theoty 
that it has been employed in many casv^H where annioniieol chaugea were 
obvioua. Thus Sir Andrew Clai-k", in his recent paper upon '■ Catheter 
Ferar" before tho Medical Society of London.' lifter dencribiuK n typieull 
eoM of reniitt«iit; fever foUowint; the introduction of the eatheter in n po- 
titrit of lulnuicf^dyeara with prostatic hyjici-tittpby, saya : ■' The patient, aup- 

IKNwd to Ixt healthv, but aufferinK from an affpclion of the bladder, wna a 
ew weeks before my viat enjoined the daily use of the catheter, <lid woll 
fur about u weok, thcti buctune ill fuid fell suddenly into tlit* uoii^Ulioii iu 
which I aaw him. Ho died within a wcolc n( our conKiiltalion. With 
great difllculty permisaioii wiia obtained to make a post-morteni euiniiuii' 
toon, and idthonjjh il wub ihiuIb ivith both cjirc and interest nothiufi defi- 
bitfl was found outside the bLulder. and nothing in it to necciufitale or 
■ocount for duuth. The proatate was enLirgvd, the bladder was dilated 



IJBETUKAi. FEVEK. 



58 



BDil IMckeDeil — viewed front the hanclc it was trahecnlftr nnd ttli^hlly wie- 
cular — the uiucoiifi liuiu<* oont^stetl &u<] in pni't 6riMte<]^ and Gverywhero 
coated with n gmyinli white, dtiiiking inticus, Therv wax nothing to bs 
(leteoted ill Ihu uriUimor kidncjH, liltlnsughllioywero Maiuiiif^d ejirefully.'* 
In Btukinic to «xpluiu the i-emitteut fowr wlii<^!i ufrura eo ofteu, k.4 in tbia 
case, ftt tba commeDcement nf Iiabituivl catheteriiuu, Hit Anrlrew Clark 
Bara : "It probably begins iu the ntirvoiu systefiu : the disturbauce ot the 
oervoufl eyntfim n-ikctn in the fintt iuMtmioc upon tho gcucral mtilikboliKm of 
the hoUy. nml in tite aecnnd iiistsnce u]v>ii the secreloi7 organs, b«giDniiis 
vith tho kuhie.v : that the effect upon the kidney may coneiat oither in 
etractiu'al alterations of the kldnev, or (as wcuis to bo much more prob- 
able) iu ulI«nLlion of tho coiuttitution of the hlood, that dytiamiu cuiitiiLioa 
of it« n>nKtitut:tit.>t in Uiv rciinl vitaiH^hi «!>tt«rtiliitl to tJi» t^lalmraLivt! iiution of 
the secriitory celU th«if<of ; and liiMtlr, tlukt Die coi icuiTQiice of them cnn- 
ilitiotis may ami ofton iu eiifurc^ed by sBptio ri>ub»urplioii into the blouil." 

Tlio raisnH in qiivMtion, jsimilar to that dcHcriboil by Sir Amlrew Churk, 
contaiufA ni> iieresaity lor it lecourse to theories about rellex u^rvoiiii ao* 
tion. «ven if «ach theoriea wer« made for more iulrlli^blc a»d coherent 
than that Hii(;^ixtvd ; for thom cOMffi KTO roacUly explained upon nicchanictd 
priiifipltw alrvaily tdhtiled to, uiuuely, that the Kiidilvii rtituuval uf nriiio 
hnbilually prMttdit in a ohi-oiiicnlly diHtvudftd unJ hyjK-rinipliiud bUidil«r 
oooasioiici an intenae oonK^Btiou of tlie ui-iuary tract which may involve the 
kidiu>78 as well at tba bladder, may even induce Buch euRurgemeul of the 
kidoeyM aw to pi-ixliK^t; cxmiplcti; ntmrin. ThucoMo which Dr. ChLrk ■tol«<;tcd 
08 his text neenis to h.ivtt bpcii a typiml one of this cati't,'ory ; not only 
the eliiiiml Bymptoma. hnt also and especially the post-mortem appenr- 
atUMM— tho colarK«<^ pro8tnto, dil»tod, tliickoned, and trabediliir blntldor, 
the oongeMtioD And eroaiuu of the iiuicodh ni«iiihrani> — ore thoiio n>i^ukrly 
found in oaaea of <Ty»titift iind pyvlitiH oiiimrriuu; in old ni<!n witli proatatio 
hypertronhy iu»d dilated bladtl«i', as the result not of the introduction (^ Ih: 
caUitter. hvl of^ the lumjihfe cwiouu/iyii — by tha aitheter, lithotomy or utbvr- 
inae— <yan habilufil/i/ ilUimiM anil h'j/H-iiroi>hii'ft hlaiiitrr. 

There is. ao fiu' as 1 am aware, no proof, eithnr phyttiolo^cal or nlinicol, 
that a chrouic niid (continuous roflox at'tion. purely ner^-oua ia ever tnnui- 
fostet) an th« n-miit of ii militniTf IniTid irriUiUon such aH tlio introdticUon of 
tbe catheter. It may lie iiHM-rU'd without fear of contradiction, that any 
ehronic and (Hiutinuoun (Unorder of tho urinary organs, InM-cnblo to tha 
introductioi) of a i-mthetcr or sound or other opei-ation in the uiiuai^ chau- 
DsL ia bosed upou niurbiil nnaUiuiical chKu^->i niid is out of merely retloi 
nervouit origin. Thu iutriiduiTtimi uf tli« iiuftrumsut may hi>, it in Li'uv, 
tbe ioitjal step in IhepatliologiaUproceHHi the oatfaetermay empty an habit- 
ually ibHteuded bladder, tho Huuud ni.ay accomplitdi the aame result by 
diluting a ti>;ht Htrictiiit! ; but tliv diNwtn>Tm conHNjuetlces which follow in 
eather «aae ore due, ni^t to tlie coiitAot of the iuHlrumcnt with thfi »u»tiepti- 
ble muoouB membrane, but to the mcchanietd oong««tion in the urinary 
Oinoa, oauttMl by tbe aud^leu removal of a chroiuo impediment aiid tho 
raUef of a cliroiin; <bat«utioii of the bladder, ureters, and Iddueyv. The 
nwiriiid nnAtoitucal f<vitur<» of tho caao m^ be ovorlookod, or may be nn- 
appreoiated. but they are nevertheleHs preaeflt. 

Yet there are doubtleBa canea in which rofloK antion, i>urely nerroao — 
that ia without ])crceptible foundation iu morbid auatonueal condttious 
—can Ix! properly atwuiuiti ns the cauite uf urethral fever. Thexci luv acutu 
oaaes, thoiu> in whicii the- initial itj.nmptoniR avo iiianifeabed immediatt'ly, or 
at least withiu tweuty-four houri after the iutroductiuu of thu iusUruuient ; 



fi-* DlSBASSa OF TttB USUtJUtT OKGANS. 

whuJntWD Uwir m»m inn f«irdkTiat most; kDd termiiuto either in 
twaih (rarely) or in noovery within Uine dsjv. la »1] of tbcM tben ire < 
sviuproiiiB ladiciiting fMlure of the bMrt ; in th* noat proDouocod tliia faU- 
ur« to»y «tt*iii Hicii degree w to ocendon bintaieBi, ■yncope, and even 
.iNith. u«j- bo mdMd temtd "aliock.- In the !<■« «rcr« andusiua caawi i 
nu" S""* ciwnktioo ia iudicatea by ouUUitsw of the extiemitiM 

Fur these ph^nouua then i« r pb>-«iolofpcnl boaia. That c«rt«in o* 
ino |)*i\i(, tQuoow BwmbnuMs art iutanialelv Hiwocmtcd with important 
tivnv wHitPBii k d«ffloi»t>«UKl bj both ctUiitsil niwi Kperimcntal oba*n,i»- 
UOBFi Jlr. Sttvnnr wiMuhiaiwHl tLiK rlinic-nl tact, during tbo tltBcuasioii 
"'"*" V"" J^iwWvr riarV s iwjwr. in the follon-ing words : " Everv surgeon 
T" . tl ™""*'*"*, '"''•» ""■ f""^*, which is confirmed bv phyMttlogj-, that 
i|Uiiii>; tlwt *<lnii«i«tr»lion ot anwstbelics, (ifler tliv ijowtr of reflex 'ftctioii 
luM .t>«.M-,) „i ,j|i „n^f py^ Qf jjjjj i^iy jj ^^g Rtillbe i.n)\T)iwi bv irrita- 
''*'" *•*'»' Un> Vii-iiMu-T cii^tmH. H jnu docapitnte a turtJ« wid ■«iiit for 
•"*"'* '"'"»». ibn |^.w,'r of CTokiag reflex Hctiou dice out part bv jwrl, but 
111*- Im( tvut 11) wliioli Tou t-'au evoke it is th« region of the cloacn."' "I 
«il|>|«iiM> It iiiiut Im ii) the espfricnoe of every sur>;i-oii (but occfwionollv, 
(HVM ui tUv vt'i-y _vniiiij; miil healthy, a fonaderable aniniint of shock is 
imiMMi by tUii liilr(»llicti(tii of tlio instnimfillt I eui>])oae it miut have oc- 
i>tit<4'd to itll tif y»»i to Bee ill Bome caaes, even »(tcr souiidinff cbildren for 
iiltnit". lU'tl a docidi'd aliwlc in produced by the opomUou." It ie tilao in 
\\\tt *>i|Hirl«iiuMt of many Eiirgounit that the intruductimi of an onlioarr 
,tilllttiti» Of Noiiiid, ev<:u aa farns the fuinm DanculariH, has been followed 
liy I'litll ami duriiled pix)Htration of tho patient; imtl it is cotDparadrdT 
Hflihilli tlial a Himtid or catheter can be passed fur the finit titno througu 
llli* l"""Ulir urctlim cveb of a perfectly healthy man n-ithout caiisiug at 
latul Moiiiii iili^ht indtcAtion of nerrous deprMsion. 

'Jill' iirtithrn ta uot tliv only luucotu njeinbTiLiia whoso irritation may 
linTK II duprowinti effect upon the citrulation ; for it is a fact well recu(;- 
iiliMxt \>y N<irf;«oiia, tliut Jiiriiifr operations involving the anus and the rectal 
apliliiHxrH a iiatieut uud<.-r thv iullucacu of an aouatbctic is peculiarly 
|irt'ii" I'l ctliibit failure of thp hfiart or i-cwpiratiniJ. 

'lliuMO rliiii<«I observatioiiB ai-e BupportEKl by the results of an cxpcri- 
Itioiitnl iri<|uiry which I luado in thu laboratory and with the co-opemlion 
,4 l'r<it(mmiT\on B««ch, in Vienna.' Tliis i»r|uiiy was not undert^en 
fw III" nnrposo of aupportiujf any preoouceiveJ bypDlheidit ; iuil«<Hl, the 
Niiitrnl Inct ilvmonatrated, tL^t irritation of a inucoiut membrane may 
Ixi fiillitwrHl by pronounced docrtMUie of blood preaaure, was diacororvd 
wi'ldiintally in punuinK ujiothvi lino ot iuvcstigntioa. I vraa enabled 
h) AKmooKtmle that nii-cliaiiical irritation of tho niuooiu membrane of 
(lia vagina or of tlm rt-ctum near thtu- reBiiectire orificee, or of the anus 
fif nil**, auMoiI ill curari^eil dogH an immetliate and pronoimrcd depres- 
■lofl of tho hlood column and of tho hcart'i; action. ThiH deprt-anon 
»l»'Mtnt«<1 in sniiie instanoea to more than fifty jH^r ceat. of the entire 
t^KMl Milunu — an amount certainly ample to caii»e decidei,] eymptoioi of 
(i«rT<rfM and ctrcnlatory ilrfpreHtuou it induced in the human aiiiiranL 1 
WM fiutb«r «aal)lvd to ascertain that this effoot was pro<luced by a true re- 
Ak anrtltll fanolving oertaio braaehee of the tsocral nerrea, the qnuul cord, 
MIhI (fa* aptaoahnic nerve* ; for tlw circulatory depreattiuu fikiled to appear 

' fnMUlMd In r»ii llulu Reimond'i Arcliiv fllr rhnfologle. 1S8S, pag* 196, «iitltl»d 
''&> Pv^MWVr H'^iwi Ooiicratwl I17 Irriultim ot MucoM HeubvUM." 




URBTESAL F£VBU. 



S5 



attat nieohaiUGA] irritation, if tbe moral nervos on U» onfl falDd, or tLfl 
splanchnio nerves on the otJier wtire divided. 

B. 



s 




Two Bpedmena of the krciognph trnciuf^B ore appended (for otlicra 
me tli6 onfnnol iLrti(^l(>). In 'tb» eaxgftfvxaa the abooiaiia ia nised, to wv* 
spsoe, 20 nuu. in Fi^;. A, luitl 30 ia F!g. B ; tbo vpftoe* b«tv«eo Um tat- 




i 



ce 



DlSEASEe OP THX UttlHABT OUCAKS. 



timl linM on Ibo ftbaoMa indientA tli« inten&ls of time, Mch ^Me lepM- 
seutiDg 20 aeeoods ia f^ A luid 30 aeoooda in Fig. B. i 

Tbe time and duration of the initation in indicnted bj tb« bomonldj 
linw just above the nbseissa ; tlie locality- is dctHignatad hv the accompaof- 
ing letters — )' vihtrt tliu vagina waa irriLitcd, li in the ca^e of Llic Tuctum. 

It 18 tliuB ox]MirininntaUj damoiuitTatml, iw woU as dioicolly obM-rred, 
iliHt a mecliaiiical irritation, without iujur>', of tlie i-ectom nud ot the 
vagina, tnaii' cmise. by le&ex action ; a deciiled clepretudon of tlw Renenl 
blood prt-'Bsure. TUat the twuue powi^r is p onotooo j by t}>r utvtliral uiucoua 
uicmbnuif, I have bcoo vuabkd to Mitikfy myself, tLough vol with tbo 
mathonuitical neeuracjr posiiible in cxpfriDncutit upon aiiimaJf^ in tbo fol- 
lowing way : A fine glaBa tube is doaeti at oue «ud with a doee-fittisg mb> 
ber cap, nud is then fiUcd \nth mei^ury to sncli a h«igbt that tbe weight 
of the metal is miflifietit to sliut off tbe curront iu the ndift] Artery wh«o 
tlio rubbvr »tp rcxtM iipi>ii tltu tomi«L TIiik in Ixdd Id a wooden tnto^ 
irhicl) 18 idso nrmnged m a rest fur tbe wrist. Wben the forearm is 
plaxied in ))oaition in tlie fnune, the tube ia lowered uiiLil tlie nibber can 
reals tiruilv upon the radial artery ; so lone oa tlie blood i» propellctl wilt 
tniDii-teul force tu piuts tbo ubHtruc>liii(! ueigbt of tiicrcury, the surfiu'o of 
the metAl in flio tube exliihitM Uiu unoilliitioiiia of the pubx! ; by gTiuluallj 
lowerint; the lube (by uicaiiB of a ruck aijd pinion) a point ia reached ai 
vrhidi the mercury ceases to oapillntc, antl the iirlf-i^' is fully L-om|ire«w9d. 
A giiuliisted scale attocbcd to the rock tuid jiinion rsbown tbv ])uint to wliich 
th» Kurfaco of the meix-iiry tsiukti at dill«rt>ijt times before tlie arten- ia 
coinprciwed. In this way it roujj:h (tiliniute of the relative force of the 
radial inii^ under different couditiona can l>e made. Tbu« it ia found 
almodt without exception that the puW- ia stroiniw — that ia, reiiulrca a 
greater weight of mercury to comprcex it—in the recumlicut than in tliA 
erect posture. 

In order to obeorve the effect of tbe intivdtiation of an inBtniinent into 
tlie urethra upon the blooil pr«eaure, I linve, after plncing the wrixt of tbo 
iutU^ndual iii {NMatiun luid Hcruniu^ down the coluuni of tiiercuiy until tb« 
oscillatioDs of tliv puW^ were plainly tntii>aiiitt«il. iDlToiluccd a aound into 
the urethra. Tbe r^ult varies somewhat in different pez90D& In some 
rases, in which the urinary orKims vtora apparently ptrifectly bMlUif, the 
contact of the instrument with ilin nix^thrnl miK^oiiK mitmbmne bns not 
prodiioed any decided efl'oct upon th« roluiun of nierrun' ; ia other in- 
■tancas tlio pomogc of the instrumc-ct has been followed nt once by a 
ooruplete oeasation of tlie oBcillationa in tbe tube, indicating that tbe forca 
of the pulse was dimiuiahed; the witJulrawal of the instruuieut was mxhi 
followed by a return of the oiK^iUntions. In otw tn»e of tiftht atriotui-e, the 
introduction of a ciMucal sound until its point was grasped by tbe stricture 
occauotied an amtRt of (he otidllalionii, which were resuineil only after the 
htpoe of several minniea after tbe withth-awal of tbe iniitruinent. 

While thia appanitiu doc« nut funiinh eudi delicate and aocorate refi»- 
tmtion of the changes in l>loo(I prpssuro aa can boMOurod by a eonula iu the 
artery att^tdicd to a kymograpli, yet it afBsrda a demonstration of the fact 
that the introduction of an intitmment into tbe urethra, c-vuii a normal tmo, 
may. in certain caaes. cause n (Icpressioa of tbe genend arieriid prngnirtt. 

Cvndu&ioiw. — A t,'vucral tsurvt-y of the tnibi«ct auggeitA that tbe various 
morbid conditions which may he excitefl by tbe paaaage of Rounds and 
cathetera into the uretlira and bladder — conipiiauig amonf? others the 
somewhat ill-deliiied grou|ni of n^mptotns known lut " urethral fever"— are 
due to TariouH causes, chief among wbidi may be named tbo following : 



I 



UBSTHBAL F£V£K. 



57 



I 



1. liefif-x adion, n purclj ncrvouM pliODOin«DOii without nppreciable 
UAtomiuU leaiou. This ina^' ho aroused even bj the skilfiil iulroduutiou 
uf Ik cutli^itcr ui' Houiit) IqIo the normal metlira am] blatUler; »1bu b^ the 
introduction of aa iDetrauient for tlio dilAtntiou at etricturc, with or with- 
out leaioii to tbti muuoiu luBiubnme. TIki pboiiuuioLA of tbo n'flux Actiou 
mxy Tary in dt^gree Irotu u slight chiU tiiiil gttiicriil iltijiniMKion wttliotit 
fever, to aiiiuin. sjiicoi^, ami collnpHe ; anuria in to be fef\reil wJieu the 
Ici^lneyEi are already chseoaetL But whatever the deprcQ of the sj-mptomfi 
tbey are nlwnrs mauifostod, wbcii duu to redox notion, nitbin a few {'A to 
6) hooni aft«r Uie use of the iastruiueut, and may ev«u bugiu before it in 
vritluJniwn. 

That this predispomtion to .exai^geraled redex effect of oatheteriam 
varies extreniely in (Ulfereut peraons iu wull ucdf^rtitvud ; nor are there any 
ruloa for prodictiiig tliw oiuoimt of diMtiurbiuicu which tuny bo oxvtted in 
any giveu iodividiial whrjiM urinwy organs are iu the uonual fitato ; tho 
preidiBpcMition is <.'«rtainly (p%at«r in caaea of cxiiitia^ chaeose of the 
nmtbni, especitdly DtriotuTR ; and it is iisunlly asserted iJint the reaction — 
of pun-ly nervous ori(^— iti ^itraUir iu purauuH of m-rrowi luiil irritable 
toinpaniii]i;iit, iii llioxti of ik ^uty ur rlitiuriiatio diutbuHiK, iu tli« :nibji^i'-ts ol 
ebroiiic maLu'ial iufeulions, oud (possibly) in tlioae who Lave long jjved iu 
Lot c'lintntea. 

2. JyicvraCioH of the Mucoitv M'-mhmna vf Ih- Jtla<i<tcr or Vrrfhra. — So 
bug M tbcee lU'e of hUghl degree they e^ein to have no Bi)eciul effect ; 
doootlesB in mont oaaes in which a reautiua folloivs a alight le»on to tJio 
mucous membnuie, it is imcwible not to tho wound but to n nervous reflex 
notion Huch OS fruiiuoutly occurs without lavcmtioiL \i any rutt-. o iUif*ht 
injury to tho intinoua membrane in certainly not of itaolf sufficient to 
oroune urethral fever, and in the majority of cases has no aucb effect. 

When, however, the lesiou is more serious. eiUier beoiuse more erten> 
«VQ or b«c(iii>w its !oc.ntion prudixpoHCS to th« ncciti»uliilii>ii and dccompo- 
ailiou of uriuv, nuoh laceratiou uiiv become the startiu^-i^oiut for a pyaMoio 
ofieetion. In tlii» eiMta tbn syiaptoiiis arc not developed in te»H tunn two 
or tbreo da>-a after the iutrotliiclion of tho instnunetit. The patient may 
of ooorw exhibit both phcuoiuenii — it nerrous chill dwt- to rcflox action ana 
occurring within a few hours after r/ilhet/riMn, and an ind^'pendent chill 
due to septio ab«*orptiou, occurring one or mure dayw later. 

3. Coitoettion of the I'nnary 'l^rart, caugeil bi/ tl\f Sudden Evacuation of a 
Habittioihj Disiunded (a'fl Hg\tal!>j Ifi/iferlrophieti) /i/ofWcr. ^Tliin nvuse ia ro~ 
■fponaiblD for the so-oalled uretlu-ul icvfr — wLidi ia really tlio bei^^aaiiig ol 
cystitis, pyelitis, and nephritis — which follows the tise of thn eatlutter iu 
oaaea of prostatic hyi>ertropby ; and is seen with especial frequency at the 
bcginnirij; of hubituiu aitlict^jrism or " tli« commcnctimODt of catheter life *" 
in old moil ; thn Hiinin condition results ftv^ni tho cutting or rapid dilat*. 
tion of stric-tiire iii tJie potrterJor iirutUro, and is ri'Rponaible for tiiucb of 
tbe iUnesa and mortjiUty following oiterations for stone in the bladder. 

4. An ayijraiialion ot' pre-e-eiating ntiutld i>»'aj^' by the sudden re nioval of a 
Labilual impediment to tho cvncoution of tbo urine. This is, of cuiuiw, of 
ennotially tlie ^nie nature as thflcongeetionof the iiriuiiry tmct previously 
mentioned. Sa txr as I aru able to aHcertAiii^ both (riiiii pe-rMonal experience 
and frnm tho ohserratioii of others, the itj^e of the CAthel«r never excites nor 
ng^vates an inflammation of the kidney except ia thoae c^sca in which 
on impedimont to tho uvatiuntion of thu urine ua» loot; existed. In this 

ttiere exista, as has been already cniphasiiced several tiuius iu theaa 
pa^feflt an exoeaaive pressure in the uretera and pelveci, which uiay even ex- 






itoatf atdteui 

^» iitaoJmjbumifai 

tboogli 111* bladder ba 

Mt bgr ^ evaenaiion of re- 

y naoaoa, but smph- bj Uia 

1 ss^^^sxx. SaA TtttBL umrm iubt bo 

n% hmt m aa» fvobafafe if tLe organs bo 

iie^iB'fc tafapd n ctiBo opci iii oiw 

tte bbdda- u ^ttite iioin»l Bod 

BiliBeiB n wueb Uw aw of an 

ia Bol is ila aofual cooditiou luwl 

.^^.. WfaHWibmcsditea babibiali*. 

^ 4v uiMsavv tt* Ui fa wlii ct wp of SGptlO 
bv flB^BQMHflH nODHBIBbOlt Of 

^i|iwi. Ih> triiiinri duUaitioQ 

bat ilw a ike ive*cn utd pel\-e», 

lAiaBHtioB eitotds from 

flf mpywii vg oepbritis 



', ud otJwr coDStitu- 
. Hid there fore ex- 

witttB a very few bouni 

MiB btginning during iU 

enned \rf etmilatoty dw- 

tbe fint fnoiptomfi 

tbe U|iea of aeTenkl 



CHAPTER V. 
PRECAUTIONS TO BE OBSEB\'ED BEFORE CATHETEBISM. 



Thibb conaist ohifnlly in ascerlaining, so fnr as may be, the {veaonoo of 
any disease of tLe blndJ^r or kidup^-x previous to £h« introdnctioa of tli« 
cathetci-, I n'iali tu ctuphiuize the word Uadtter in (Jiis couuocliuti, mnco 
nuinv Kurgionl tcncliers nither ignore entirely tho POBdition of tho l>liuMvr 
or assi^o) to it a very subordiniite placfl, conceatrntiug tiieir atientiou upon 
the oonclition of the kidneya. 

An individunl who hns no strictum, no proetatia hypertrophy, no tight 
phiniotttH or contmctiuti of the meatua, no piLreHia nor atony ot the bWlilcr 
—in Hhort, no inability to cvacuato tlie bladJer completely — cnn 1)« (prop- 
erly) cfttheterized witliout dimg^r, no matter what tiie eontlitiou of the 
kiduc.^ii may bu. The wuntt tbut can be npprelioudi^d in Ditch a cnsii in a pro- 
r-niinflotl iiorvoiiH rojiclioii. This mny be no tmiven- m to occnsion tlw fn«udg 
of the patient iuul-1i alarm for a short time, ami include fever, (Inliriuiii, out) 
eroD convuUiona ; but it is of tsmpomry duration, nnd occasions no pei'- 
mancnt di^oAse. So far ns I can a^'ertftin by ft careful examination of the 
liternturo, the only rowt of dcttUi from " tiliiK'tc " nftc-r cntJtcterixm have 
been in imlividualit flufferiikc frnm dimnic di^efue of tlis bladder or 
urethra, or from »cute over-«bst«ntion of the bladder. 

VariouD uii>diuiniil aK<-'u(it havu b<.'ci) rocommendod had employed (ot the 
purpose of diminishing this hability to norvouH renutioii from mtheterisui ; 
amou^' tUeHO quinine aiid oi^iaui hav^ b«en enpetrijUly liiucbid, but, hke the 
rest, linvD often failod. This tailuro in not Hurprininc when ive remember 
tblt Ibd diiiliiietiou botwecii urbthrnl fever of purely nervouH ori^ ou 
the cue h.ind, ami of luiatomtcal source ou ihu other, ban not alwayit boen 
dearly recos^iized by stirt^eouB. 

The existence of §tricture, prostatic hypertrophy, or other condition 
which xany aiittiruUy induce huUitiiid retention of morv or lom iirino in 
th» bladder, callK foi- the greatest catr id oathet«nMin. In Huch anne* thf t»- 
ttrmnent luied jnwtt be i-liMn — guryicaltif tlt^n — a condition attained by brief 
immersion in u weak solution of corrodve nublimate, and the bladder mtut 
never be ol owf. completdi/ evacuated. Cunmdembis tact uid jud^^inent 
luuat bo excroiaed in CArryin;; out the Inat injunction, tdnce wo are not 
alwayn in n pomtion to know jiigt how much urine in contained in the 
bladder. If tliis or>rfin be diaten<led with urine, as happens in those cases 
bi which tho catheter is required in conwKiuwncc of tJii' iiiubility to void 
the urine, the quantity can be eHtimnt^td by {)iil[mtion and {wrcussion over 
the symphyaia ; in stich ciimch the catheter can be withdiuwn when ouly 
half or two Uiirds of the urine is evacuated 

More fre^iueut and more susceptible of injiu-y are the oaiu^s in which 
there exi))t(f not ni] ttcuto but a chrwnic retention of uriu<-, in constxiuunoe 
of pruatatio hypertrophy or utrictiire of small calibre. In coses of the 



60 



DI&BAHBS OP TUX UBCIABT OKOAVS. 



fomitr citmti the (^tiivtor in SnlrCKlucAd porhnpa not to relieve an arato n't 
LentioD of urine, but ax the commeDcement of the treatiuent iif iuhhiijii 
<luriiig " catheter life." lu eucb casea it U ftU-ituikortant Uiat nt least half 
of the riwitlual urine (if tliitt oicevd one or tvo ounces in quantity) lie al- 
lowed to ramaui in the blAdder. If the qunntitv uf Tftiidu&l urine bo great 
— NX, eight, or ten ouooes — its priMc-noo ■» n-Aililr <h-t4'cUHl by laanual u- 
amiuatioQ ^t«r Ibe patieot has evacuated tbe bladder so &r as be can. It 
ia not aiu!ommou to find inatatiees, ohielly elderly men Tritb {in>«tatic h^tper- 
trcppfaT and tliickvRotl bliiildt^<r, in whoto reetal aad abdomtoal exatuiuatioo 
rBTeuit u tumor o» hrne i^ the flO. after the patient haa, aa be sn)>po8M. 
Toi<It.'t1 the liutt (]ro|) of tirinv. In these caxttn in which we can detect and 
outline tbe still parlly Med bladder, we caii estimate aptmndmatcly the 
amount of r&Hiduiil urine bi'fom iDtrodndnj; the cathHer, and tlwo liavioj* 
permitted not tnuro tlmu Itidf of tbis quantity to escape, withdraw thn in- 
Btmuent. lu uiauy other onaea we numot duttTmine aatiafactorily liow 
mncli, if any, re»idiial urino remoinx after the Tolunlary net of micturition ; 
in such casea the catheter ia introduced oud the size of tlit ntntiua which 
iamea froiu it noted ; if tliiH be full nud stroni;. it is probable that aewnd 
cnmcea of rr<Miiliiid uritie nrc prcHonL In nny case, bowerer, in which th« 
catheter i-ovcuIh n'si'Uial urine ftftcr the pnticut baa exerted bis entire abil- 
ity in rvociuktiut; tlie bladder, not more than one or two ounces of this re* 
Hidunl fluid ehouKl be pei-iiiitt«d to escape at the first use of tbe iiiatrunirnt. 
MortovLT, n Mtttuiutoil iiulutiuii of boracic ucid, equal in volume to one-lial( 
of the rciddual urino rcmovtil. Kliould bo inject«<l and pemiitted to remain. 
Siniiliur pracnulinuM iJiould be observed in introducing the catbbtar ia 
cAfieis of iDUK'Htnniiinp. coiitntcted stricture ; only a portion of the vnuB 
should be removeiL lii tJiiB way. oud thus only, eiui we have an ftstnitanc* 
of aToidinfC the mottt scriuus couiit:qu.«uc«^ nuoh on hn)>pcnod in a oase 
whi<-li came under tljc n-riter'x obscrrntion (nnd contititutcB by no nwaiiB 
an iaiulated or uiiifjuu instance in aargical experience). In tbie caao a man 
wuh Rilmitted to hospital sutTcring trom acute rcteotiuu of urine mused by 
the etTects of n debauch superadded to an oUl and contmcted strictiu^ 
XtU^r viiriouB futilo nttetnpta vritli eliwtic cnthcU-ra, a nninll conical silv«rin- 
fttruinent wax intnuliKTril mto the blatlder, tlie effort oocaMoiung trilliug 
faemorriiafj'e innu llie uiuthra. Nt-arly foiu- ]>iuta of urine were evacuated. 
The catbeter was used three tinieti dally for two da.^-8, at the end of which 
time the patient bad regained the nbility to void lirioe. It had been di^ 
ddiiil to dilnt« the strictiu^, when, tipon tbe third day aftci- admuwioD, the 
patient had a am-ere ohill followed by fever, prostration, and the oaual 
symptoms of the K(M»dlod typhoid condition. Tbe urine became scanty 
oud bloody. At the end of n week be died. I'he autopsy nhuwod no recent 
Iwiuunt tLeacat of stricture, butahypertrophied bladder with weU-msrked 
tralH.'culiD njid a diTerticulum just nt tbo right <^ilgii of the trigonum, 
dilated urcUm and pelves. Tht bLubler indl was soft, swollen, and cOD* 
toiued numerous abucesses from th« ai/e of a pea downwanl ; there was a i 
perivesical itilliituinatini) nud colletHiou of pus between tlie bliuldor and ^H 
rectum. The mucoutt m^mbnuie of IJie bladder wan hwoUgii, Hoft^ injected. H 
and at scvci-al places erodeil The kidneys were engorged with t)loo<l, and 
bbowed under the uia-oscope numerous miliary liemorrhnKes. In short, 
the case was one of c^'stitiH luid pericyHtitis in a habitually distended and 
hyjxirti-opliicd bloddtir. Tin- crtusc of Uio intlamraation was not nervous re- 
flex action nor injury to the uretlim, but tlie inuuedinte evocuntiou of all 
the urine coutaiiied in the bladder, or the use of an unclean ciithetor, or 
both ; a result wliiob might have been avoided Lad the catheter hwu care- 



PBBCACnOHS TO BE OBSERVED EEFOBS OATUETKKI^M. 



61 



fully dacuued befom introductioQ, and wUhdraien uAan half oflhe oontoitt 
of ihs Uaddtr had exaped. 

1\6 erploraiion with the «>tinJ or cfttheUr Attartin cfirbun iafomutiiHi 
OH to tk« couditiou uf tbi- urvUiTH ami bla<l<ler. A narrow atrioUire op- 
pmiBB the progrem of thn iiistmnient ; luid if a ranicnl naand of Kach 
size ba aatia aa permiU ihe e<ntnuic« of ibs point iiito Ui« strictnre, tho in- 
struni<>nt iH olinerved to bv ^rml; groepud b,v the ureUini. TliJa coDilition 
may bo, bouever. 8iit)ulnU>tl 'by Hpasmodio eontrnction of the untbrnl mas* 
clpM in the inwnbranoufl portion ; tbe similnrity is incrensod bj- the fnci 
that tbe adjfu^ent portiona of tho bulbouH and tut-mbnuiuuK urethra are 
wp«ei)tll,v oftea tbe seat of strictwrc. To n pmctisftd hand tbn diflorMieo 
between the gnwp of tliv coitiprcHHor urethne and of a atrictur« is usually 
jqipureiit at once ; if there he any doubts it ciiu bo dccidftd bj* Diaiutainin^ 
a gentl4! prfwrnre xnUi the point of t]ie inBtnim«Dt ngKiDst tbe obstructton. 
A.qKi»ni»dic muscular coutriidioa sooa yiehls and resiiitanc« roiiudiM; 
while a Btrii'ture. Uiuugh dilnlint; xiifliriontly to |>ennit thn pnwuige of Um 
inittniniiMit, kUU n)«intiunM lui nppiY-i-inble prcasure and oppoKitiuii. 

Tht' paKNft^e of the mnind alnii;;; the urethra may also reveal potota of 
extreme aensitiveneaa ; this condition is freqiMot after gonorrhGea, and 
mav bo dae to tbe preMDW of eroded or granubtr areas, a que»ttoa to bo 
deci'li.*! bT the eni1o8(^ope. 

Tilt; |uu(Hftge of thfi jwiiit of thp iiiatnimeot along the prostatic urethra 
is tiinially, even in heultii, ni^cotupaniod with &ti utipluoHiuit, pcrbape poiu- 
ftU Eteuanlioii. In cii»(M4 of proHt^Uitiit, tbe p:iti«tit exiterionceaextreuio pain 
which miiy umount even tu agony, cauiuug him to smvani and atniggle to 
escape the Bound. 

The introduction of the Botrnd or catheter into tlie bladder should ha 
made when this orgiin ctonl^titia c!onM(]fimblt^ iiritin ; if it bo Miiptr, fliiul 
abould be iujectcd, wbenire the fulvantoge of using a catheter mther IhuD a 
■Ound fur i;:(plorin(; the bUdder. By means of the inHtrumeot we ascer- 
tain the sentutiveuess, the conoetoDce, the vmoothovos, and the elwAicity of 
ita walla : ibt- prmence of foreign bodiM or of tnmora ; and an approximatA 
•atiiDatioD of itw normal (-njutf ity. 

bi its normal fitate tho lining membrane of the bladder endurea the 
gentle contact of the im^trumtnt without i^xptrieueiDf; piiin ; it ia uniformly 
RRiooth ; it in mifllicirntJy rhwtiii tu [M^niiit tbi; pi>int uf thci initnitimnt. to 
wirry the wnll of tho bladder at lenst nii ircli beyond its original iMMJUon, 
ami to exi>el the cfttheter to the same extent when tlie preasore La removed. 
The Bhort-beaked inHtruiucot iilmruly rv<^(>iiimcud<.-d cnn ho rotated so that 
its point iiiukM a complete revolution in tbe hlatlder without meeting any 
dcci<Ui) rtHuntano^. 

Ui abnormal states the instmmentoftenreTeala decided dcparlurea from 
theHe chnnirterislics. If the inufoua lueiubnuie be inflamed, or if tliere bo 
ulcerntion or a morbid grrmth jireseot, thi- coiitu^'t of llio (uiitiid (!aiiH«a e<- 
quiaite pain. In {reii<^ral cystitis the mucous membrane is eTeri-whore thua 
■eoaitive ; if there be ulceration from a malignant growth or other cause, 
this sensitiveneaH is uminlly loPAbzcd. 

Hypertrophy of the bhulder wall \i indicated by tho presence of trabo- 
euhf, by{>ertrapluod inutwulnr fibres neparated by de|>reM(iion<«. In thia 
oou'lition the point of the nound can be felt to scrape over the ridgrti tliiis 

Sroduoed. In oasea of muBcular bj^pertropliy, moreover, tbe bladder wall 
oca not yield readily to pri'Mur" with tbv iiiMtnuiti'nt. Tlio preawice of a 
foreign body or of a gmwtli in tlie wall of tlte bladder opposes a looaliied 
reiustaiue to the rotation of the sound. Morbid grawths aa well aa oaloaU 



a 



or THX rxntAKT obsjucs. 




1^ 





• of ike bhader;Md 
I f^H^^ luwMu toe ofpatut motl 

lit ■■■in ill ■ liilili ifiM. if 
tfaTbUder tidmk* iMt 
T[f it! Tin MTiwi^ m int^inilii 
ifa* «iAv ii lonibb' aipcaed. 
the matoam mwiilifMW of th» thdaer ia coaad is 
iflf phn^haHr coacratioM; thcw rin to tbe aploriiv _ 
tmtian mA bmt readdr be — '•*-^-n (or th« ^Iiimi 

J iMKotm czplondoD with the toaai m mifrmltj i 
&• nctaiB or bf ft LuJ over Uie ■jBup t jii a. la tbe 
ftapaiitvfawinrtnuMaiteu bs m^ ilctec«ed bos tlw: 
d (MMfi to fleafay penoBs) ftbon tha sTmiibjM. In ■Twiwiiull 

I bodiw B»J be eo in tii poeei ■• to icermt aucb approii* 
I of the Sneer md the point of the apoDcL Tba* aa vDlMr^iaueat ot 
the naddk lebe «f the praetete nwj extend eo &r towud the fbadne off i 
^bbdder thftt ita upper e<3(!« csnoot be teeched b7 the (b^ fa the mo-^ 
tnm. Morbid ffrowths, whicli un vsaallj sitiuted Dpoa or in the iam*- 
diets viciiutT of tbe trigontim, n»y elen prvvoct such twQtact, end e«ik 
Bonetimcs bv defined between the mmad uid finger. DiTerticuU of the 
Ukkler— protnieioiiii of ite aoeoae memhnne between the muscular fibres 
— em aloD ueiullj fouod near the tri^nuoi, end caa eomatiiDea be rRiuliljr 
dcteeted by conjoiDed examinatiun. In ooe cnoe of pcoetattc bvpertrophy, 
with <»iiaocutiT« thickening of the musculer oo*t of tb* blulder. I was tu- 
ebled to fori iliHtiuctlv theeittnuiceof Owtaouud Into Ute (liTertictilum with 
the huid wliicb held the iitslrumeiit. trhile nith the fintfer in the rectum I 
dlfltin^iuahed its point projecting just to the outer side of the aeniinal 
veeicMk 

lly mtuuix of the »otind in t)io bliuMer nud a hand orcr the sympbnii^ 
a is wiuietiiuea possible to det«<rt a thickening of the anterior w«U such ee 
jmf oooar Irom a morbid growth located in this portion of tlko Uadder. 
OiMMrfcuuUr a podicled ttunor ftttscked to sowo other portion of the 
bladder wsll hna been detected in the eeme irnj. 

A ^imaHuai Kmmutaiioa ^ the bladder hu et tintee great advRntAffU. 
^JM in H«oouipli&bed by |>aaBUig two fingers, or even the entire left band as 
(ta AS the thumb, into tbu roctum, while the right ha&d placed jiurt nbom 
tho iiyiiiphveia exorlit finii prossiuno don-nward and baokwaid towoixl the 
j^tum. 'rliu patittitt must of course be under th« in£ueuc& of an an* 
iBitboUc. In ttiin vrnr the body of tko Uadder is brought between the ap- 
proximated endx of tJi« fint^^ra : and if th« patient bo not too flashy, to* 
onilii can bo exi}V>roi] with cniitddt-mblu delioAny. ToUcraann atatea that 
huiiiUl been otinulud in this way to detect tJi« preitenee of a stnne aa ■null 
IMA bi'Mi. 1I« HilviiMiii flint, in children ettjicciiiUv. the object iu the bladder 
\io iirfeaeil by tlio flugefs in the rectum up a^^iiHt the ahduminal wall, 
wlient it cam be Heixml and uuiliued by (IfprussLii^ the skiu arouLd it. Ho 
lim ttiiia bi'Kii (iiinlili-4] to estimate wiUi itcctintcy the sizu and atiape of a 
oUriiluH, The muthoil it, of oourse, not devoid of (kmgex to both rectum 
4U>) bUildcr. 



CHATTER VI. 

DIGITAL EXAMINATION OP THE BLATDEB. 



Be the roethocls alrcwly deairribed Uie condition of the lilfldder cnn ha 
■aoertainod witli sutBcLcut accuraoj' in most cnna.^ Tbcy ore ospeciidly 
Mtufeoton' in tho female ; for a fiager iu the vn^cn, witit or nitbout Uia 
swuttance of the biuiil OT«r the i^inpbywg, oflbrcts more definite And Bati»- 
Inctoty itifoi-mikliou thaa cui potMibly be obtalDtd by fvcLilI i':xuiuiiuitioii in 
ithomnJc Tho uutiro cnvity of tlifi bladder is tliuH bnnigbt viithin tlio 
ZKDgc- of ixiliHitioQ ; llie trigoDum can be outlineii, and its apiv«s can be, 
with a little prantioo, diotiactly recojfuiuiJ. Tbis is an anatoiuiral point of 
■om« iiu[iortA>ice, Hinoe by lueana of a va^innl exniuiniitioii the onfice« of 
the uroleni, locntvd ut tlio ud^Iuk or bbo trigonum, vau bu locutod unJ re- 
toiniti] iu positioD wlii]o a mthotcr U intn>duc«d ioto them. 

Tltc iiitroiluotioii of a sound ennbles the surgeon to explore tbe vetncal 
wall witli tbis instrument, and to include a coruddemble portioD of it be- 
twaeu tbo fiu^er in tho ragina ftnd tho point of the iustrumenb Ln tha 
LLMldor. Culuuli or othor foix-i^ L>u<livt( itbu liittLT mori; frMiiivutly fuutid 
ill tilt) fi'iitdle titan in tlie ninle bloilder) and ninrbid ^[I'aivtliH cau thus be 
detected luid outliiiod. 

In many inatnnooft it ia cxtromoly dcsirabla to mnke a digital exjuuinn- 
tion of thv interior of tho bifidder. In the f«iuii!o thiti cnn be readily 
ancoiupUnhiMl by •hlittaivm t,f the urethra. Thin jirooitdure, whicli was fimt 
brouKlit proniin<>.iitly )>R(ora tlio profcsttion by Hiiiiou, of Ifci^lelber);, is 
readily executed ; but it hao been, found to coufaiu possibilities of injiuy 
and clangor vrliich woru luirdly Mpprociut^d by tho Ktir)fix>nH v-ha fiiKt em- 
ployed it, luul it shouhl be practiwiil only wLea lent radical niethoda of 
axamiitation fall to furuish the iuformatioD required. 

Simon used, for tbis puriioHu uf rapid dilalatitm of tho urethra, a iierifls 
of diUtur^ niailo of hard rubber. TlioM instnuiientM wen? mvcn in niini- 
ber, uonnti tilting ii ^wluiiUy iiiurfiaMiiig serieii, lh« Btualleitt about oue-tiiinl 
'of nu inch, tbe burKcat nearly an inrh nrni n quart«r in diameter. They 
ir«re introLluc«d ia sucoeesion, each being allowed to remun from one to 
two miuulcM. Tho larifowt biu a circtunffreiico ot[iinl to that of tb<: ordinary 
UirfUniiiir. which can therefore be ii]tro<)uce<l iuto tbe bladder inimedintttly 
aft«r tb« r<mnjviil of thfl largitat dilator. 

ThoHe iustruiuoata of tiimon have b^nn AuiierACHled by dil&lJDg RpeculiL 
II iff «xtremely important tliat a proper inHtrument be uaml. since if tho 
dilalAtion bo «Crv«t«iiI, nit is umially tho cfuw, by meana of Home instrument 
^deaigood for luiolhvr purposu — »iich lu uterine dilators, polypi forcApii. etc 
-lAoeratioa of tliti mucoun luomhrane and iucontincooe of urine ari^ almoet 

ritable. It m important that tbo distending' force of tbe iubtruuivnt 
3Qld be diHtribtited eifUidly around the entii-e cin-umference of tlie urebhni 
and not upon two or tLn)o[M)iDt« only, aa occurs when uterine dilators, etc.. 



64 



DI£ 



TITK URINART oroaits. 



oru eiapli>;ir''(l for tliiH purpoKc TI10 clilfitatiou shoalil be oocttnuous. tini- 

, fonu, oDfl gnvtual ; tlie iuauiuaetit sliould be ao ooostnicted as to pcnaifc 

tbe exereiHe of much or little forc«, Aorording to the reeiiiitanf^e to be over^ 

Com«. Tlie cotubinod dilntor and Bpcciiltim, devised hy Stein, of tiew 

York, is a uiout tuttisfuctory iiiMtruiii«ut for iwcuTiiig tbosc r(.-tniJt«. If this 

be properly employed, 1hi>ro ia but little cliinger of ooriniii; Inforatioii or 

more tlmn U-mixu-ary iiiooQlineue* ; ivith il tbe prelimiuan,' iucbii>i)H of tho 

urethral orilic4.', which Simon was in the habit of njaking, are nnnfcesimrj. 

I Boforo using other iustriiincnte thr<N> iueisious niny be made, tn'o Iat«nil 

^ tmen a t«iith of au iiicJli Oc-op, uiid oiiu at tLu iiifcriui' border of the montui^ 

k qiurter of an incli deep. In iisiiiK HteiiiN dilator, '" the jinticut being ou 

the book or side and ajut^stbetixcd. the iiistriiment is introduced (uid rapidly 

dilated to a point at vrliich eonio resitUuioo ia felt, wlica tlie dilatation ia 

JiropcMlrd witJi more slowly and «nitiously, tli© canal bpinp Btrotched a 
ew millitiietrea at a tiuo, tlio torin^ <'xcrt-<'d being in invcnift proportion 
to the resiiitancn to be OTercome, and n Biifflcient intennl of timti alwnva 
ftllowpd to clapito for the tifisues to relax before further dilatattou IB maae. 
In thin niiumcr tb« instrument i» t^-aduallv expanded to the circumfcrciioo 
of th« index finger, or if iiocd lie to its fullest opacity, wliLcb is sis and ft 
ImW (.Tiitiiiiali-eB." 

DiUitation with tho fingem alone, ho frequently performed, ia pmduc- 
livf of most (liwixtroiint r(inflt?qiU'«*iCM, (ind ia ftlwa;,'H fraught with danRiep. 
I liavL> nt'.c-n [icri Vesical i iilliimmatioii nud abacoftN, aiid vv<^ri fnlnl j)r'nlOQitJ% 
caUHed by ttiis ditiitnl dihitdtioiL 

The degree of dilatntiou permisgible rariea, of oourse, 'witb the &(*e of 
tht' jKitii-Mil iw well nn in ilitlunnit adultsi ; tin- pain amldanf^crof laccratiOB 
are proportionate to tlie ritfldityof the canaJ, whirh in iimially niostpro- 
uouiiced nt the ineatuB, 8imon dir«ct«J tbat in patients under fifteen 
yeara of a^ the urctlim ibould never be dilated more than 1.5 to 1.7 
elm. in diameter ; aiid tliat in the «dult feiufdo Die ciilibre of the cannl 
xliould not bv mndt* to exceed 2 etm. Hiia is a safo rtde ; yet in niuiiy 
iiiHtani^ea the dilatjition has been canied to n much greater deyree witlioufe 
ill rcfliiltjt ; hotb index fingers, or n finger and forceps, have been simulta- 
ii(s>uiily iiilroduued uitu tb<i urethra without vauidng even teuipomr}' in- 
continence.' 

When the forefinger is introduced into the bladder, the middle finger 
of the aaniK hiuid rests in the vacioa. whilt the other band, phiced above 
the symphj-siH, presses the nbdnniinid wall dowiiwanl so as to bring tbo 
ftuidurt of Uje bladder within reath of tlie exploring finger. 

UnleHs every precaution be taken, including anicstheRia of tbo patient^ 
the choice of a proper inittrument, the utmost gentleneiie in manipulatioa 
after tbu inlmduction of thtt liiignr into the bladder as well as dimii|; tlio 
dilatation of the uretlira, thia ojieration ia fraught with danger. In favor- 
able eases there may oiwur nothing worse than inoontinence of urine for a 
few hour? ; in other instances this iucontiaeace hoe perHiBted for wcclat or 
luuiithtt ; in still other cases — probably only when g'rot*! orrorR are coni- 
luitted — ]>ulvic in tlum Illation nud abscveBx, and even ]>entouttis, have (ol- 
lowrecL 

JMgital erplcmHon (/ the maffi biadder can be made throuph a periuc^ 
jncision. a nieihod of exploration rect'iitJy employed and broughl promi- 
nently before tbe profession by Sir Henry Thompson and Mr. \^'hite)iea4l. 
Thi' operation coosista simply in external uretlirotoruy in tbe niembr»- 



■ 



SIOrCAI. ££AUINATIOir OF TIUD BLADDEB. 



es 



R 



I 



aona portioo ; the novelty lies therefore not in the operatioD itself, but in 
ill paifoiiauaoe for the purpose of peruiittiu^ digitid explomtioD of the 
UiMttlor. A i^roovcil sttnlT in iulroilticotl, an iiioisioii miule hi the raphe of 
the perineum to the meiubraTious Hnllim, which is then openeJ soffidratlv' 
to ftduiit the iudes finj-er of the left baml ; tliia is then pushed tim>u^ 
the orethra to thv blnddvr. If the luinisthcsiii is no C'»mplvt« that the ab- 
douiiuul uiUBclen tufi titiilL' reliixed, pro88ure with the ri^^ht liiiud above tha 
|>uIm;s hrini^ nearly vwry jHjrtioii of the surfnoe of thu bli)<l<Icr into con- 
tact with the euil of the tiiirer introduced thnjugli tlie urethra. 

The operator carefully observes the couditiou of the vesical muROUH gur- 
iaca, whether it is everywhere smooth, or roughened in Epota ; thiclieDiug 
of tho mucous membmne, ]m)jec'tiu(^ villi, and utoplosmB niuy be found ; H 
boutlR of mugcular tlbrofl witli intorveiiini; d<^prci»ionH aro distinguished, 
the bladder i» h^i^rlropbied ; in aucb caset) a careful aenroU for ciilculi 
ahuuhl be made, since these may be piutiidly encloseii, or even entirely 
encyidcil in tho cavities between tbu fohK In oiio of Thonipsoo's cases (a 
yroiuan I, tbero wan " found spriugiii;; fram tho cuutn- of tho trigone a firm 
promiiienc*, eTtemnlly (*oii3i8l.ing of some soft atructuro and almost ]K)ly- 
poid ill form ; but on di'awing it forward in the attempt to li^'nture ita 
Dttsi;, this outer luyer vraa first scratched tbrouRli:, whcu u hard calL-ulua, 
about tlio size of ad ocoru, vrm disclosed and enucleated, tho proniiuenod 
diMppeariii);.'' 

utiH,' a(t«r performing* mt^dian lithotomy and aearching the blaflder for 
a foroigii body in vain, waa about to discontintie the exploration when his 
Sag«r graziid a soft, iiemluloua body tu» large as a bean ; tbis was extract«d 
and found to be an euc<yBtj?d cnJnnhis covered with clotted blood. 

Soiuetinies a scale consisting of phosphates, or of n p«eudo-niembrane 
iocruHtcd with urinary saltH. uhm tM.'L-n dctoctt^d uud remoTed by the 
fingernail ; "indosd, it is ditfionlt to wiy nt prcacnt what may not bo 
fouod, as fresli <txperieiic-eit have hrougbt to hpht conditions to some ex- 
tent not heretofore recoRiii/ed " (Tlmmpsoii). Eviu if tio tumor, calculua, 
nor morbid couditiou of the siirfAce be dotected, gmnl btmofit i» oft«a de- 
riveil by tbc- repose Mcuxod t« th« bladder tlirough this openitioii ; a larff* 
rubber cnthett^r intjodnced tbrounh tha wound and permitted to remam 
(or six or eight daya, relieves tho bladder from the necessity for contraction 
(uid has BomotJmos entirely removed tliu morbid wmptoms which led to tha 
operation, by ^ving riso to a auspicion of n loreiga body in the hln^ldcr. 

Digital exploratiou ia justittable and frequently useful, not only in 
Uhhmi cnaea where the exialence of a vesical tumor can be Hufely affiiiDed 
ui>on the symptoms preHOuf, but also in miuiy other instiuicos whero tho 
cause of thu morbid ttymptomK may be ob^^ure and undetected. Yet be- 
fore the surgeon uniU'rtAkt't^ ihU operation, ho ahoidd exhaust all the lem 
MriooB and radical metuin of i^viilunttioii, iurrltidiiig a determinittion of tha 
urctJual cahbi'o by meaas of the uretlir»inctcr, and the inHiwctiuu of the 
ureLlira through the endoscope. For tho^^o inKtriimeuts may reveal in a 
urethral conatruction, lH>l>'p, or graiitilar Hiirface, tlie aource of and uieana 
of rdieviiig symptoms which are referred to tlie bladder — irritability, pain, 
bsmorrhage ; if the morbid iuHuence of ttlt^ltt urethral nbnormalitiett bo 
fov]gaU«n or ifjnored, tho imrfjoon uiny hv b<?l4-nyi.Hl iuli> pvrfunuiiig u uao- 
len and unjustilhible explorntjon of tlte blnilder. I'remiKinff that thea« 
methods of explonition iiave been employed, aiid luive failed to explnin 
luid relieve the morbid condition, w« miiy ucixipt Sir Henry Tliowiwwii's 

1 Loo. olt. , f. 944, 




66 



DISEASES OF TlfZ URIHABT OROAHS. 



coBolunons, Ixisecl upos aii «xp«neDce of thirtv-eigfat coees, as uvlicntions 
for the pcrformiuioe of uretUrotomyin tliemembranouanortioa. Ue«iyH: 

" Ob cnrefulljr nDnlvznig U]«m cnsos there nppnir to m four cliicf forma 
of vesical di»(TU«c, in vihkh tli6 oper&tiou of nijcuing tlie uretbru for Uio 
purpOKc of witiidrawinF; the tirt&e altofrether bv an nrtiticinl roiit^. aiKl so 
auHpendiiig the functioiia botli of the bladder ajwi urethra for a tim«, may 
render ffiod service. Crttidcs tXitMte, titere runaiiu n fiftli cIjih of cases, 
namelr, tboMtv in wliicli tlie oj>cmtion i^ und«rt*k«n colelv with a view of 
expluriiif;, whi-u tliu preseiice of a tiuiioi' mny bo Ktrouiily Hu»}jccl*:d. 

" 1. The tinit class coniiislii of tJiose enseH, not iiiifniquciitly met with. 
ID which all tit© syiiiptoina of chronic cystitis hare existed for a louj^ 
period and in a severe dc^^ruc, nnd which jwrsuit in spite of long-continuea 
luid Appropriutc trpntnidiit ; wliilo at the sanie time it is understood that 
the abnence of matci-i&l cnimo for tliu oytttiti.i, iiuah as stoiie, stiicture, tco- 
cal iiiMinpetence, etr,, have been aacertainefL 

" 2. The Becroiid class of oases includes those examples of prostAtic hypOT- 
trophy And of ntony of tho bliiddi^r in which thiLt orgnii niuMt be emptiMi 
by th« oathelcr indiiy timeB in tltc twdnly-foHr houi-s, and in which painful 
oLronia cystitis is obvioualy aggraxAtt^d u uot maintained by the uec^ssaiy 

f)raoeBB of relicL Tlic-wi ore usually raHcs in whicti the diwnan liM cxintod 
or yonrs, and which have niTivt<d to all apptianmce at tlia Ifttest fttngd, 
unless ooiiiplct« relief can hf affonhd. 

" il. The third rhLsa enibnuTB tliose citse^ leEB rare perhaps than tlicy 
have been supposed to be, in which the existence of impnctod calctdns 
or of wlberitig cudculous niatter may be »iiiipect«d or may be kuowu to he 
present by »oiiudiiij». 

" i. In the foui-lii olafis I plaoed thoae cAses in which painful and Tery 
frequent mictuiition or blccdiuK- separately or combined, may huvo JonR 
Axislcd ; without signs of cystitis, the urine being clear, frre or nearly 
BO from uut^us or piundent deposit ; furtliei-moie the e-auae of these 
Fymptoma has liaffled tlie iiioBt cni-eful iut]uiry. On esploration bciof; 
ma<lo no orf^anic chanf^eie discovered, no Ugbt is obtained on the diagnosis 
of the caae, but thf fiincliotiti of tho bladder and uruthm are nuHpeudejil fur 
a week or so, and tlie [mtieiit pets well more or less completely." (it is in 
thcHG coses especially tlmt the endoscope and the urethrometer — means of 
txplurotiuu which Thompson does not ytt employ — should be used before 
the bladder is op«ned ; corefnl intpiiry is not ba^ed until the uiethrn has 
been naaaaured and inspected, and the urine esaiained : and any abnor^ 
mahticH thus discovered hove been, rcmovcul without rehef to the vcaical 
Kymptoina) "Of tiiia remarliablc history there aro ftis oxninph'S in the 
seriee, of which three l^e^fectly i-ecovered, besidts three oUters in whi^ 
great improvement took plfloe but not complete recovery. The renult of 
operation undertaken in the ciicuuiatances desci-ibed as a last if not almost 
hopehrNt) resource, has been surprising and fraught wtUi great iiiU-retiL I 
am dinpoKfid to tliiuli that tbero are tsouiL' pei*ou« in whom an attack of 
cystitis with extrL-uie freijuftiicy <)f nticLuritiou having been set up. the want 
lo relieve the bladder every half hour or hour, at first natmul und uixcb- 
sary, titill couticucs after the local disease htts pas^^d avmy in ttpitc of IJicir 
efforU to overeomo it, tin thii r<i!«ult of what lanybu regnnli--d at* jjersaalency 
of u morbid habit in certain constitutions. I cannot furl.her elucidate! the 
patholog:ipAl condition in any one of them, having discovered nothing by 
the iuvestigntiou to ovcuunl for the symptotna" 

When we remembt-r that Tlioiiipeon recogmzes no abnorm&lity in the 
urcU:irA which is not revealed by pattiiny a No. 12 sound, we are inclined 



• 



J 



WAMIS-ATtOT 



SLADDT 



er 



to the suspicion that th. i ; bilitiea of dia^osJa were not PThdustM in 
these CWCH by tlic f\]'i i nn of the bladder; taid tbi« xiiApioioii ift 
»treagtbcii«l by the meagre details of liis rA8e« in ■wbich the opemtion 
f&il«(l t<> aflord i-eliof. Iti one of tbeae (nofte 41), the patient was ti man 
Ageil forty-fire "SIoiiTjcars puinful Hyinptoma and trcutmout for uUcgod 
iithctare which does uol t-xiuffV). "During lust tw«lve mooUis givnt 
^MiuoDCj of micturition ; now «'vi-r^ hnlf h»ur night and day. Inatru^ 
ni^iits luiv« beern passed by hiiiiseir mid others up to the neck of the bladder 
ftii'l then ffliled to enter. Examination shows that the neck of the bladder 
is diatiactly tense, ripd on the lower nspect, but the short-betiked xound 
pewoflorer it reiulilv in the bladder ; ubrerthcltisii there is uo stricture, for 
So. 15 (Englislil will enter " (?). 

" ApriL 14, 1884. Exploration. The finger on entering the bhidder 
£noonntcred rugfe and a rouKhetied sur&ure of mucouB membnuie, eHpeci- 
bIIv at up[)rr pnrt of bUdder. T^w n«<rk of the bladder won cxooedinf^ly 
tight, gitupiu^ lite end of the finger like a ring ; I diNiiled tiiis at the 
h>wcr border no tliat the tension ecaaed. I-Vee bleeding foUoweiL A tuba 
ivaa tied in (our or five days. He recovered slowly, and gradually regained 
|)Ower to retjuu bix urine ; the istervalii being from two to three hours ia 
the midiUe of Mny." 

Si]ic« ja other oases the eyinptonjs dencribed have disappeared en- 
tirely after division of a aliglit urethriU constriction, the calibre of this 
cbuiDel should bo carofidly explored in such cases before tho bhiddor 
i> opened ; tbt: ^Hwanye of a No. 15 sound id eerUiuly not conclusive cvi- 
deooe that the urethra is free from abnormalities, luid is thci-efoi-e 
^ight Justification for the operation perfoiTued in this case, which np- 
parently did not reveal nor remove the cauxe of tlie difiicully. aiid ap- 
poiuni lo have fumisln-cl but httlo rcliof. Furtliorinoro, it nrny not he for- 
gotten that organic diaeoae of tlia kidney, oa well aa undue addity of the 
urine, niay be nuuiifeHted solely by symptoms which are refen-cd to the 
bluldor nnd which snggest the extatcuce of vesical enlcuhu or ucoplnsm. 
Otia had the rare opportunity of t-xaniiniug post-mortem a typical cuse of 
thissort.' Frequent nn<! painful urination, pain in the ghin penis, veaical 
catarrh, and an occasional admixture of blood with the urine, had been 
obserrcd for two years ; these- Kjmptums were aggravated by riding iil 
a carl, (!aii.'fiil and rtiponfod soundings bail fniled to detect iiiiytbiug 
abnormal in tiie bladder. A congenital contmction of the ntenlun bod 
been divided and u large iu^drument paaBe<l through tlie urethra with 
but slight benefit, A (ligital exptoration of the bladder through tlio 
perineum revealed no cniLSii for tliu KymptoniK. Evou at the auto]wy no 
explaTintion of the difficulty was dineoven^d in Uto bladder, but " the kid- 
neys were ^od n-ith tuberculous deposits." 

^Vhon therefore all the k-sa direct means of dingnoaia bare been exu- 
ploTi»d in vain ; after Ictdneyii, nriuo, urethra, roctnin. and genitala have 
Men examined and auggostlve ahnoruialities correct«d without relieving 
the vesical aymptoma, tlte digital exjdoration of the bladder may be per- 
formed. It luM occasionally revealed n morbid condition which, whilo 
susceptible to relief, uutst ueoeasarily esciipe recognition by other means 
thui uigitAl contact, llius in one of ThninpAon'R eiuies (a fenialo) who had 
for thrirt' years suffered severely from frequent and painful micturition, 
tho cavity of thu bladder was very small, apparently because the vesical 
waUs noro extconvcly bound together by adhc&tons ; these were readily 



I Loa elt, p. 567. 



68 



or TnE CRIVART OROAl 



overcome bj thp finger. Aft*r the operation micturition was ptunlcss, 
tliwiiyh Htill frtiquoii(. 

This opemtton lias lieen perfornieil more tlmn fifty timen by Tbomp- 
80I1, \Vhit«liead, aud Monia, in cases where the bladder wa« bclit-ved to 
coutRin tumoni or calculi ; in many of these ituttaoccH the suspected objects 
werfi foiiud iwd rcuiovud tlirougli tbi> iiioistou. TLomjieou reccininicnds 
it u «UKy of perfomuuicft, pra^itiL-all^ <l<!void of danger, iukI enpnble of af- 
focding valujible information ; tie reganU renn.1 disease and caucer as con- 
1va-iti£catioDs for its performance. Probably rennl disease (wnalittitcs. 
fjer «P, BO objection excrpt wlioii i( is iH-cimdiirj- to Lnbitunl distention of 
tlie bladder, lu one case of ameer of the bladder in which I iwrformed 
the oi>t-nilion — not m> :iiu<-'1i for purposea of ex|ilorttti«ii, Min'f thf dinguo- 
rIs wae already eHtabliiihed, butasameoue for relieving the patient fmni the 
torture consequent upon his frequent and painful uhuatiou— niHrkcd re- 
lief and decided benefit wore secured. Tlio tutnore Iiithirto rrnioved by 
this metlioi] Imvc lwi.ii chiefly polyps aud UbromntA. There is luidoubt- 
e<Uy a hirge field (or this pro<'e<liirn alfio in the detection and remoTAl of 
c«rt»ia cnLu^^cuicuts of the prostate, particularly those in which the middle 
lobe projects into the bladder so as to impede or even prevent the evacu- 
ation of urine. Such frngnaents of tliL' piOBtnt*' have heeu repciitvdly re- 
moved accidcDtiUly duhug thu perfortuonce of lithotomy, cystotomy, and 
lithotritr, with great bencHt to the imtient ; by the perfornwmce of this 
Bitopler and safer operation the some good results might be achieved. 



CHAPTER VIL 



INSPECTION OF THE URETHRA— ENDOSCOPT. 

Tbe attempt to render the mucous membnmo of the iiretlira and hlad'> 
der accessible to the ey» lirts bc«u th« subject of mtLDV ODdearura witliia 
the liiftt thirty yciu-x. TLint it ■w&i* {Possible to bring limited poiiioiiMof thit 
Teaictil anil ui-etlival iuenibi'aii« nitliiii the range of \iiiiou nos ilemnnstratc^d 
tweiity years a^'o, ami an a result (?xalted ^xpectatioim of conHecjii^Dt ad- 
Tuaces in urethral oiirgcr}- xvvrv. oiil<;rt<uiie(L Tlieut} luitioipntiuutt were, 
however, but iiiejtyri'ly ronlized ; thfi few iadividiuila who expc^ndcd iipou 
lilt) Hubjt^ct till! liuiL- iiiid sLuily ueeeaamy for a proper use of tlia coiupli- 
cmted eodoBCopea tiieu omplnyed, did not Hucceed iu convtDciti<; the pn^ 
fesdon at targe that the iuHtrum^iit i>ossoe3ed a tnugiblo value for praoti* 
<■! purpoBcs. The endoai-npe has been and is generally rt-f^nlwl tuiaa. 
iDterestiDg toy, wliose pi-actical iiaefulueas exista only in the distorted im- 
agination of eutbiiaiaala. This impreaeton, which atill prevaila hu-|;;oly in 
the profcseioD, ia based not upon practical cxpcrionco — for comparatively 
few pnictitiouem have had nu upportuuity to loam its use — but w derived 
J»r(j«-ly from surjjacid writers on ILesG dbH-aiK::!, who |K>iMib1y (ixprf-KH a 
prejuilice mther titan the result of nmple experience. Thus Hit Hcniy 
^omp6oti,iu the last edition of ilia "Clinical Lectures," says (p. 8): "I may 
tell jou at oucc, that if n mivn hit» n good and n tolembly pmctlsod bund, 
vith a fair ahrire of intelligence, I do not think he will ^ain n great deal 
by the eudoacnpe ; aud if Tie ban not, I think it wilt be of no use at nlL" 
" In ninetyiiiue caeeH out of a liuiutrcd you cnn arrive at the necessaiy in* 
ioniiaiiuii without il." A.iid iiotivilbstaudiiig th« repented deniuDHtratiuiia 
to the coiitriLT)', he [KtrKidtM in siL^nng : " I mny iiK^iition tliitl no ono Iioa 
yet been able by it8 mea»» to identify the rern inoutanuni. " 

These eiUitementa, which becauHO emanntiii;; from so hi^h an authority, 
aro g«n«rully re^^dcd an expressing the actual t!tnt« of the case by those 
who hin'e no experience with tliu uiidom'opi\ am based upon the use of the 
comphcatcd instrunienta contriv(-d by DeHormcfiuT and (hiiiiw. And bo 
tiar a» these inatrumente are concerned, the statements doubtteas represent 
Bpproxiinately the actual state of the citse. 

It tsmiit<i (lth<'^^viIK.■, however, wttli the mniple endoflcopo which haa 
been in the Inst few yeant brought pi-omincutlv b«foru the professioD of 
Germany aud AuDtria by Dr. .Josf^f Gi-dnfeld, of Vienna. By his demOQ- 
atralioitit to the Boyal Sotricly of Phyaiciajie in VieDHa, as well as to numor- 
oas pupitH, Orflnfefd hut »hou-n that the endoacopu Iibh in a arluin iimiled 
jfoM the greatest importoneo in tho diagnoeifl and troAtmcnt of urethral 
di a a n a e w. Aa erldence of the appreciation bestowed upon it, may be ad- 
duc«d the fact that Uilli'otb and Ldcke have devote^l to the aubiect oiie 
volume of th«>ir "Deut&cho Chirurpe," which bsH appeared aii " Dio £ti- 
iloakopie dcr Harurohre uud Blaac " by I>r. Orilnfeld. 

It was my privilego some years ago to eujoy the private instruction of 



70 



DISBASBS OP THE UIUKAllY OUOAKS. 



Dr. GrOnfelJ for mtmy mod Uih, m well tm to oT)Sor*-c tLo practice of Pro. 
fcmor Au»pit£, of Vieona. TliTOueti my obsei-vatioii Uiea, as well as jwr- 
Bonal ex])(>rieDcc Btnoe, I lun eonvinceil of tlie value of tie cDdoiKope m 
oiie iniportaut niftaiut in tlie diagnosis uucl tr«atment of urethral disuses. 
WliiV it LH UDJou1>tedl3r true tiiiit tho iiistrtuucut lia« a practical value for 
|Miutivo dia^osifl in comjiai-ntivcly few cases mily, yi-i in tlic*c few cas«a it 
u absolutely imlii'iMiiiMblv, afibrdins iuformatiou which can be acquirod 
in no other war, aiul furui&hiiit; tht< '^ti^y ratiuuiU and siir^ceRsfiil plui of 
tTMtmont, MoreovEir, it \mn lui c:\tcu^i^'u appliciition uji n meaiie of nega- 
ti^ dia^^uosia, that in, of excluding potisihle patliolo^cal coDditionii, and 
tLus arriving at a correct conuliiMiou. Most of tlie standard text-books on, 
this subject iiujiu-t n mii^takcn imjiression ) th«T demoDstrate satisfactoriln 
that the entloscope has a verj' limited field of uaefulucss, bul ignon: itx iiaiii^ 
in that limited Jieid. Even if we admit the neciirapy of Sir Henry Thomp- 
non'K Hwoepinff asscrlioo, that " in Qiuety-aiue ca^v out of u Lundrtd you ' 
can nrriYu at tLo uecesHarj- information without it," it in certain that in the 
r«iuaiuiii(^ ciuH) no dt-fiuitc infctmntiou nor successful treatment is possible 
without it ; aud it in hi^ldy prubublu thnt in tti'vcnil uf the Dinoty-nine 
flSMB actual in»|K-<!tioii of tlio urotlini will ahnw tlmt the " iiecfiftsary " in- 
formation secured without the endoscope ia not aoourafe- Hliat Sir 
Henry's impnnuiianH upon the subject are at least somcwlmt inaccurate, ia 
ahoiTD by his statement that no OQO hna ytA been able to idoDtif}' tlio vera 
moutaiium ; for tliia can bu and Iioa hnvn readily identified by uumuroua 
obserretK In oixler to Kettto all doubt upon the matter, Or'lnfeld intro- 
duced a needle by ueoiis of the endoscope into tlie ui-ellu-al oiilice of tho 
«jaciilatonr iluct in a cwlaver in tho Kudolf HoHpitiil, Vienim ; the urctlua 
wiui then kid oi)>eu by tho prosector. Dr. Chinri, and the ueedle was found 
at llie {MHtit iiidioutod. 

'nie iiiforinatinn which can be derived escIuBively by the endoscoije is 
required in comparatirely few cases : tho instrument, evpu in its simplestU 
and most valuable furm, ik)<-:< not fulfil the cxa^^'crated cxpectatiunit wbichn 
vere eutdttaliied iu the eiulier years of endoscopy ; but an an arcesHoi^' to 
the onnanieut of the aurgeou who deals especially w-ith diseases of tlia 
luiuary orgiuie, it is absolutely csficutinl. Tluii opinioa ie, an already 
8tut«<l. the outf^rowth of porsuunl ohttorvittiou nud esi>erience, and is at 
variiuiro with tliut prevalent iu the profeaetou and endorsed by most of 
our t^tiuidnnl aut-tiorities ; yet it is gratifying to read iu tlie last edition of 
BuuiHti'ud and Taylor (page 108). "It will readily bo seen tbnt, for the 
purposes of diii{jooi»ii«, the endoscoiie provea itwdf to be on iuviJiirible in- 
strumeut in many wwen, 8», for instance, in tJiose of ui-etlu-al polj-pi, or ex- 
OoriiitionK which might otherwiae eticnpe detection. It reveaU also tlio i 
proaeuce and the exact aeat of patchoB of Riouulattuus, spo(« uf herpea,! 
etc. Aud UH u|)plicittioui!i can be made through the tube it euableu us to 
reach these piirtrt dircctJy." 

Endoscopy is now, ho far ae tlio instninieut« and their mauipulation is J 
concerned, one of the simplest and eiuiest modes of examinittiou t'laploye^ j 
in the diaguosis and trentnicnt of (^wMitw-uriniiry disensee. Tliero tire re-J 
quin]<d eudoscopcM or urethral tubes, a head or hand reflector, mid n i 
source of illumiiiatioii. 

'Hie endoscope itaelf is nmply a tube by which the urethral wulls are 
hohl oMunder bo iis to permit tlie )»tg»iige' of light rays. Tho siiuplttst 
lofin, au<l tho oiio wliiuh in capable of the Tiiont gcueml application, ia con- 
glructcd. t'vii'pt as to calibre, like the ordinary cyliudric^ ^ntgiuol 6[>gcU'* 
lam (MO Hg. S). J 



^_U 



INSPECTION OP THE UKETUBA — EXDOSCOPV. 



71 



Th« Ivngfli of tliia — the " simple cndoMopo " of OrQiifelil — rarics from 
6 to 13 ctm., eicliisive of tie «xt«ii]sil fujuiel-liko litu. For tlio t-xiiiuiit-' 
atian of tlio ttutcriur ureLlint uuly, Or>iu(<-KI eummouJj' uh«s an iustniiueut 
10 clto. Iciiig ; for tim posii^nui' urulhni ii IviigtU nf 12 or Hi otm. is l^ 
c|iiin.-i.l. Ill npecifi] cshch an inRtiiiinent Ei to N rtiii. ih BUtUdcntly loug. 
It i» [ii ooiii'se deairable to une the Hliurtest inHtriinieiitH wliieli router tlie 
re(|tiu'«(l length, siuco tbe loe» of light iiicruiuwH nipidly witU the loRgth of 
Uic tube. 

Tho cfilibro of the insti-ninont v«rinft alswi from Ifi to 24 Ohari*iC-K>; tlie 
larger vixoi furuiah, otlier thiuys being equal, u more distitii;t -new l^ecniiKe 
of ^e greater amount of light ])eruiitt«»J to «ut«r aud reiiiia Uirough the 
iustrumeDi. 

For onliuiity purposes four endoscopes suffice, two 12 ctm. lonp each, 
<>om»tTK>niIiug to lH and '2'J Cbnrriore rcHptiotiTel}- ; two uUiolu 10 cUu. 
long, m%'iug the eaido rcs[jcx.'tivu diauictvnb 




fia. S — OrtnUA't ViwthntI SniloMMpa ttlihOonilniitoi. 

For spGciid puqiaaeB other forms arc u»e*l. For the iQHpectioii of the 
mucoiie iiiciitbmiit) of tlio Uoihlor in Iho maitt, tho tubo is aiailo from 13 
to 16 ctm, loiijj, ami ita vesical extremity, cut obliquely, is* closed \riik 
glanH Ko as to prevent the uriue from eatering tlie tube. Another instru- 
incnt itHod for Lli« Hanio purpoiw it xhii^xid like a mide cathet«r with a short 
htok, a purtiuii uf wlioit« couvex curve ia replaced by a pUt« of {^han. 
T1te»e Iwn iiititrum(>nta have hut little TiduQ in practice, ttinco tbo inx])ec- 
liou of the vesical mucous nicmbruuo is objKwod by certain oliataeU'a 
which orti procttudly iDsurmuimtahlc aud wuich aro not mob in the at> 
tompt to Tipw the urothro. 

For practical purpoaes the simple stmight eudoncopo is Iho mont desir- 
able and the niort generally URcfiil ; in fiict all tho iufoniiatioi] of practical 
Tiduo which hna as yet been obtained by means of the endoscope, is secured 
through thin iiuttinimcut ; luid it i» mtUinklly Lhu oidy ouu which ia useful 
in n tuerapotiLii'al niiv, since it nloiiu penniti^ Inoal a|jplicatian8. In the 
following remarks, this form alone is designated, unless it ia otherwise 
Bp6ciilcd. 

TsK nr Tax EifnoscoPB. 

Having aeI«ot«d the instrujuent. short«r or longer and amaller or larger 
in cnlibr« according to thu rc4|iiii'ctQciit« of tJio caite, tlu flmploymeut of it 
includes attenlion to throe mints <)4[woially : 1, Tho])OBitiuuot t)ii> ]intk-ut 
'i. Tho azTougemcnt of illumination. 3. The luaiiipulatiou of thu tul>« 
iifi«U. 



79 



DJSUASES OP TUB TTKINJLliT OBOANS. 



For Uie examination ot tbe anterior urethra, tlie patient may eimply 
iqt ujioii ft chair ; iti orxter to rbiuJi the [xmterii^r xiretlira, tbo giatient must 
assiinie such a. pofdtinn an vrill peiinit aii olititcration of the nntuial niiTes 
of the ui'etbra. He uliould, tlierafore, lie upou a bigb table itucli as is used 
foroperatiiigpuqioBes, lb(! iKirincHin being brought lo the edge of the table 
vbile the feet, widely sepwftW'iJ, are supjiorted by dmirs. ijiy one of the 
gjnwcological cliaii'8 oniiuarily employed in tbis «>uiitry ansvrprH tlie pur- 
pose admirably, since tbo positiou rcquirvd in practicaUy identical with 
that flsmuuDd for the ordiuiiry vu^iuol (•xamiDation, 

Hht iUuniiiiatiou of tlio interior of the urethra is Be^^urei) by mcwia of 
light reflected from a bead-minor, bucU aa is need ordinaiily for»iiTiiiDn- 
tion of the liu-\'nx. Tbe bent light is by all measB direct snnltght; mid 
this sbouM fthvavf) bo omptoyed if it (;an by uuy meaiiM be secured. By 
means of it dilTt'ri^ucE'M in color aud conllgiii-atiou of tLo mir&ice, the jires- 
eucc of diluted hlood-vesseLs clr., lire far more readily (lit«tiufuished than 
l>y any other mode of illuiuiuatiou. In the mnjoritj of cases, however, the 
xise of direct sunlight is inipractieable, and the operator is eompelled to 
fall back upon artiUcinl sourmts of iUiimiiiation. Tli<'- n-lutii^e value of 
theae is delertiiined by their brillinucy ; heuce an electric or magnedau 
light 19 best, though of i^ourRo, rarr-ly procumUle. Except in rare enwa b, 
perfectly satiafitetory illumination is eecui'ed by tlie reflection of light from 
(I j^ax or kerostiie fliuiie furnished with an nrgaiid burner. Whiii mieh 
illuutiiiation ix i-miiloyeil, other nnurces of light should be, aM in ophtLol- 
jDoacopic examinatioua, excluded from the darkeoed rooni. 

Tbe iotxuductioii of tlie itistrutueut varies somewhat aocordinp as a 
metallic or a hard rubber ondoHcope va employed ; the edges of the metal 
instrument are thin nad Hborp aud vould neccsttarily laoemte the mucous 
membrane ; hence it is prorided witii a wooden pluR whieh pimjertR Bone- 
what beyond the edge and terminates hi n rounded exticmity. The hard 
rubber inatrmncut haH thick uud ruimded edgca wMcb require no ptot«ct> 
inp plug for its introduction. 

The opemtor stnnds bet-n-eeu the knees of the patient, grasps the penis 
betnoeu tiie thumb and forefiuKer <tt tb« left hand ajid compreKses it from 
above dow^lwa^d mo as to convert the uutuml vertical slit of the meatus 
into a circuhu- opening. The oiled eudoBcope is held between the first 
aud BEicoud liuRerH of the right band, tiie thumb being placed over the 
end of tho plug so as to prevent its withdrawal Into the naetalUc tube dur- 
ing the introduction, Tho end of tbe tube udvauces reftdily in mont uwioa 
to the posterior extremity of the iosnw nn\Tcularis, where it often meets 
some obsti'Tiction ; tlua can he eaaily overcome by slightly rotating the in- 
si.nuiieut while at tiie same Ume a jiroRTesHive tuovement is given it by 
the tliuinb upon the plug. No further impediment to the pinfiress of tbe 
instrument is felt (in the normal urethra) until it reaches the anterior 
layer of the trianguhu" ligament An inexperienced hand frequently en- 
counters some tlilBculty, merely because the asisof the endoscope is al- 
lowed to form a coiiBiderable angle with the axis of Uic urcthm and tJiua 
impinges upon one or tho other, usually the inferior wall. Careful at- 
tention to this jioiut aud correetlon of the position of the endoscope will 
obviate this difficulty. 

If it is defiu'ed to inspect the lu-etlira posterior to tlie bulb, it i« neces- 
sary to depress the pendulous portion, so as to obhtcratc the ttugle at the 
bulb and permit tlie insfirtion of the instninient into tbe memhranoua 
portion through the opening iu the triaugulai' ligament. This requires oob- 
siderable coru, uud muy at first be tho cause of much difficulty, sinco tbe 




INSPECTION OP niE UKBTIIRA — EyDOSCOPY. 



7S 



; of the inntrumeut iH often lurested iu the simis of tbe bulb, Aft«r 
the point has been succcssfoHy jiitroducetl into the iiirjiihriiiioim iirotlirs, 
the diatul oxLrvmity laiLst be slill fuilJier depreased in onlei- to xieiiiiit the 
fiodoscops to tMLTenio the membranous and prostatic urethra. Tho pas- 
Mge of the iuBtrtmieitt through this portion of the urethral cauftl is 
URuiilIy aocompuni«d with Hom« pain to the patiaat. Id some cmtes it b»- 
Goniefi neeessarr cveu witii tho loiigor iiiHtrimicnt», to uonpress the iienis 
in the direction of its length and tbua euabl« the inner extniuutj of tho 
tuba to Tench n. portinn of the canal which iiamtnlly lirn nt n distAnco from 
the meatus greater than the length of the tube. Thus, with an et)i3oH0»|>e 
10 ctm. long, it is usually «u.b>- to inspect tbu bulbous and even the mem- 
bnuioua urethra through thiA luancc'Uvro, though the uitturiil length of tho 
autnl urnr coiutiilerably «xoeL'<l Ihfit of Lbc tubt-. 

When the point of tlia instiiimout hnn roitohed that pru-t of the iiroihm 
which it is deaired to in8]>ect. or at Iea*t the deepest portiou accessible 
with the tubes In uue, thu fingvnt uf tho left band, which uavo hitherto eitp- 
ported tilt' pouiH, fire now tnnda to grasp aIbo the futiucl-ehnijed extremity 
of the cudosoope and thus maintain it ui jiositioti a^iijtt th« untiiral c^ou- 
ti-a«tile efforts of the urethra to espel it The plug or ronductor is now 
withdntvm by the right hand and the mirror, attached to the head-baod, 
directed K<> [ut to rcttuuL hght uito Ibe tulM!. 

In nearly nil ca»es the surface revealed ia found coT^rcd by iiiotstiire, 
which must he removed in ortler to afford the best possible view of tha 
mucous membnma For thi» purpose a small tampou, nuulo of cotton, en- 
doMd Id a proper holder, or simply wound avonud n long elonder pt«oo of 
trood (uncut matuli stick) is introduced through the tube and jircHsed 
gently against tlio mpmbnuia Ujion withdniviriDg the taraiion the field ia 
again inspe<^tl^d, and if necensary ngniu eleaneed in the same wdt, 

Thi> entire un^lhin nut^rior to tho point at which tliu end of tlio iuhe 
now restii ran be inHpected by gradually withdrawing the instrument 
towiiid the meatus. If at any time the oi>erator deaires to inspect attain 
ft portion of tho mucomi uembrouu ]>OHtvrior to the point at vrhich tho cod 
of tlio tulto rci^t!^ b« should not forgot to iiitroduco tho coudiictor h^foro 
making auv uiovemcut of the instrument toward the bladder ; fur the sliatp 
matnUie edgai of tho tube, auless thus miuikod by the enclosed plug, may 
laoentA llis raucouti luembmua. or ut auy rate cause the piitient piun. 

If the inKtruirtent iisud be mnde of hard ndjWr, no couduct<ir i« noc***- 
aory, and tlie eiido-tcojie can he moved either forward or bnckward along 
tlie urethra without injury to the uiueous mt-iubmiie. In coiisiiiim-nce of 
the thieknem of mntcriiU rx'qxmed autl the consequent loss of calibre in 
tliis ittstrumont, ths metallic eudoHfOpB is for nearly all cai^es preferable, 
BotwitbBtaiidiug the peenliai- iucouvtiuieuao cau»ed by the unavoidable cm- 
ployuoot of the coaductor. 



DlAOIiOSia WITH TOE ElCDOtll'OPE. 

A recognition o( abnormal 8tat#B of the urethm ia of oouree possible 
only uiter the invcntigntor has become thoroughly fnmiliitr mth the np- 
peanuiceH presented by the noi-nial urethra iu l\w difft-renl ))ortioQ8 of its 
length. It would exceed uur limits ta oiit«r into n dtittiiled aocouiit of Ute 
fcttturoB which characterize llie tionual anil the numeinua abnormiU oon- 
ditiona of the mucotiH tuombr&ue, aa observed through the endoscope^ It 
must aoiBce to jioinl nut h few of Uic most im^K>rtAiit of thovc aa iosbucas 
of the scope of tho inatmment. 




74 



DISEASES OF TUB UniKART OROAlfS. 



Tbe entloscope fiQ<l8 its moht Treqiieut applicittioa in Uie dJa^ous and 
treatmant of cAronw infiammatioti of the mucfma memttraHe, occtuTing as a 
continiution ol goiiorrhwa, tu]<l imiuillv, lliouj^Ii ootalwajrs, accompiuiicd 
witli (tWt. Id audi caws tbe locaUuii or tlit- <U»fHS(-it ]x>rliou» c&u (rfiicndl^v 
l>o remlily defined hy msnoB of tlic eiuloscuiiu, &n<I ti>[>ictil iipplicatkHia 
mode with c*rt»iDty and (micuiuct. Suob diseased em-fiwes may occupy ao 
extensive area, ur utay bi< lot-tili/t-d in uiuUl patcbt-a uf the urethra. 

If tbe exintencv uf KiK.'ii a »iir(jvi;« bo wumptictcd mid its examiuntioa 
vritb tbu ciidosoope undertaken, it luay be advisable to locate it ho Ear aa 
ix»s»ilil» by tlio use of tbe ardiuiiry biubouB m- nenru bougcics. Tb« ]»»• 
aage o( the bulb of this iiistnimeiit over the chronically in flamed surface 
uautdly occoaioiiH a Uturc or It-an puitiful iwiiiULtiuu. It ia, huweter, a niu* 
gnlai' fiuit, Dot«d by alxaost all who bavo r-mpkiyed th« eudoscotM*. thnt 
tli« location of tbo diseased patch by tlie sound lurcly correapoadi) with 
the aetual seat of the pathological cniidilion aa reveiiled to the eye ; the 
diaarepaDcy is caused by the roriatioD iu leugth vhicb the uretbra so 
readily iiiHlcr^^ucH during luauipuhitiuu. 

The cxi»t('tKit' of a looalizod obrouie urotliritia is revealed through llw 
endoscope in the fuUowiiig appearuucea : llie tuiddl« of tbe field ia UBunlly 
occupied by n drop or two of pus, the removal of which ahovra a abort, 
fimnel-abaped dcprosgiou. Tbe rcHection of the ]i<^Lt, which iu th« uor- 
vaal couditioii cuuuex a bright rinu a i*liurL Jialaiice internal to the lube, 
DOW oonaiatH of Kev<>i'al irrej^ulor ana ofteu interrupted curvca, quite diSer' 
ent both in shape and location fi'oui the nonual circle. 

A clow iuBpuclioii of the eurtauc rcvcids tliu csiHtmice of ouuieroua 
alight olovntioiis. such im are oftou observed on tho ^urfnco of the conjuno- 
lava in camth of ^ji'aimlai' lidx. Such a surface bleeds readUy, an escape o( 
bloud beuig perliaps excited by tho aimple contact of tho iuHlnuuent ; 
whdo in other cases tlie lightest touch of the tampon, uecc^sfuin' for tho 
reuiovid of tlie piu winch inuv be prtHent, cmit«<;ii an oozing troiu. the gran- 
uloi' Durfaee. T)ie witlalrawal of tlie tube a short difitnuce so na to bring 
into view n portion of ilie normal urethra, exhibits clearly tbe diifd'Cnea 
Iwtwocn the cbaractBrifitioi already lueutioued and thorn of a healthy luu- 
COU8 jnembmue. 

A thifi.v»in;f of the epilhutium of the urethra la an occaaionnl. poBaibly a 
frequent, coudition, which ia iu some casua at least respuuHiiilo for a 
chronic urcthritia or gleet It is the r^Hult citlier of a guuorrltu*a or of 
tho fretjuent itnd hnbituid iinc uf iiiettniiiieiilM, having beeu noticed iu tlioaa 
who have been in the habit of intioiiucing bougies or cathetera at ^Iltf■r^■ala 
during a lon^ i>erioil. In t»oue ca^es this thickeuiu^ of the epithelium, 
with or \vilhuut an increase in tJie subniucoua conm-ctiru tiusue, oooauoui 
KUch a iinrrowing of tb« caual aa to be pereoptible by the sound or bougie; 
jet in othtr aiM't* tliia epithehid thirlteuiu(j; does not encroach upou tbe 
cahbre of tho urnthrn sufficiently to be detected by the ordinary meonii u( 
exploration. This haa been re]>eiLtedly observed ii]h>u post-niorteni exniu- 
inution, iiud has been remarked by Dittvl ; I Imve myaelf seen two in- 
fitaucea. 
■M The frequency of thia condition cannot be stated, sinee without the 
I||BB of the endoscope it can be determined Duly pust-mortem, and ia not 
' ibsually Hought for during autoptuea They do exist, however, and can 
be eatiily rucof^niznd <1uriiig life when the mUL-oiut membrane of the ure- 
thra is readcred aocesnible to the eye by means of the endoscope. They 
an tlies sean either as biui^ white stripes, or as jHitches of greater or ha» 
area which present the some bluish white color. Tlieou uaually exliibit a 




INSPECTION OF THE UUETUIU — ESUOSCOPY. 



75 



• 



<leri(icd elevntion above the Heueral smrfaoe ; sninetimea by foHowiug tlieni 
tbo obaerror arrixos nt ii jx.iint wLcro tho projectiou into tlio lum«ii of tbo 
nreUira constitutes a deciJeJ atrictui-c. wuile at other timea lUc projectioa 
above the gfotund ui<ettim] narface in insignitic&nt 

This epithelial thickeuiug originates, iu some instances at least, ia 
■n Bcata iiiflmnmitioo or in the cxjnstaut irritatiou produced by the piu- 
aage of instruments. In other cases it cannot be traced to oitbei- of these 
moMH, its ctiuio{,'y boiaK (ta obscuro aa that of cerliuii tbidiL-uiugs of Uiu 
epithelium of tlio ton^ruo oouiwionnlly observcil. Tlio fonner eosfts an> 
generally aooomponieil byaalight uretUmlilittuUai'ge, often observed cbiedjr 
ui the niuming, luid otcaaioiinSy furaiabing threads — " tripperfUdcn " — iu 
tbo urine. 

tirlliifold liiw obst'rreil m.'v<:i-u1 ciMi^n in wluch tliia cmidUiou of tho iir^- 
tlini vas plftiuly pcriTptiiile ; our of tliesn be demciniitiiited to tiie Royal 
Society of Pbip-sicians in Vieuua in May, 1879. 

The tonuUtutiuu u( thuKi cusca is viuioiui ; in Bomtt the eplthvlial tluck- 
ttuinff, and with it the RyniptotuK corupLiiued of, were r«iulily i-nmoved by 
&mp(e topical appUcatioua Huc^b ss iodine in glycerine, while in otliei' ic- 
■tancai the treatment adapted seemed quite ineflectuaL 

T^imom of Ike L'rtthra. — In the recognitiou and troatiaent of urethml 
luniufK tliD itbitoltitv n«ceMiLy of tho endoscope itt niuoL plaiuly luurketl ; in 
fact, the surgeon who undertAkes tlie trentmeiit of genito-uriuiu'y diseaneK 
without employing this ioBtruiJieut in liable at anytime bo nioetacase- 
wliose «tiologj uia trentmeut baffle liim eutiioly, however skilful uud !■• 
suliar be may be with other modcia of esplomtiou aud tn.^utiia-nt Them 
coaes of uretlinil tumor mo pifibably nm; in the mala: Hucb at leoat ia 
the usertion of nearly all stirgti-id aiitlioritien. Tlio nuity of tbo ciuks 
which have bo«n clinically recognized aa siich is doubtless oxphduod ia 
port by tho fai!t tlmt tho cailoncopa, which nffords tins only utvana for d«- 
tectuig uict recogiiiKini^ them, has been but UttJe employed. The urettirnL 
tumors discovered by other means tluui endoscopy )i»vd been seen almost 
•xclniBTely poat-tnortctu ; iu a few coses tho introduction of a catheter hn» 
"beeil, much to the Hurpriue of tliu burgeon, the moans of removing' a urc- 
ifaxel polyp wbiirh had beconio eutniiglud in Lint <:ya of tho iiistnirtient. 
CompamtivBly few urcthml tiunors liave Ix^eii tlinrovered even upon au- 
topsy, n fiet which doea not necesBariiy prove the extreme i-arity of thea& 
gmwtbH, lonco in niiiiiy parts of iho world the iircthni i« not nsiuuiiKid 
poil-mortem except iu those caxeit in wliich a sunpiciou of uretliral diffi- 
culty huH existed before dt^iith ; tliu synL(-iuitti<i fxiuuinittiou of the ure- 
thm during autopsy would doubtless reveal such growths somcwlmt morv 
freipttntly. At any rate, during a tieriesof seveiity autop»i?s in wliieh I 
bud MjM-u and exnniitiad tho umthm, I foiui<l two ctMvM iu which a well- 
marked )>olyi> existed ; in one tho growth woe a slender ]>edicled tumor 
live-eightaa of an inch long, attached in the door of the prostatic huius. 
jiut lo tlie right ot the middle of the rem montanuin ; in tlie other » 
BOmewhal globular out^^rowtli of the mucous nitinbraiic, oh large aa a siuall 
pe*, won foiin<I id>nut tlic middlo of tho foMtn miTiciiliirit*. 

lb woidd se«Tu indeed that however rare other tumors of tho nr«lhi« 
ought to be, polype— fliiapUi hypertrophieH of the niucouti membrMue — 
might ruosunably be expected with some frei:[«eiicy in amen oi prt^viou* 
gouorrhiRa or glcel. The i-uInr^L-mouts of tbu papillic kuowu an [Hiintctl 
oondylomatn ai'f. as in well known, tht) fn^qtient and rnpiil produeta of tin* 
irritation cuused by a gouorrha'td discharge, the seci'etion from n TenercaL 
■ore, or ovuu the uccumuhitiou uf luuc^uui under the prepuce ; that a sinii- 




DBrtaia of tkk ckuabt oboahs. 




i.juMJi'nr- -***' 



tnueoaa 

growth* do 

would lead 

hATC bUen 

nrethnvtaj 

viBpCuu^ or 

of tka cmrtMiM of* 

1«» bwn 

1) of the 

IB c«« cue M- 

oU«A»bdiMnr kid 

_ dnriBgtliedajrst 
Pmmi fc BowoJ Twiowa 

"fc^eyMtiw ags frequent 

« tfc > pwiTifwm «nd iu Uw 

Mac; dnetet as neomiDeiKled 

, theiaatnuneDt in the nretlua 

ft poljrp vaa lound cmtan^sd in 

ppcwed, and bad Dot retnnuNl 

Ifa* nmrt vas made. 

«l Dr. Grflnfekl, I Euul tl» oppor- 

_S i fo*^ tba eytoptoms exliibtted azs 

•B t lm i tii a tostnetur«^ or pimitatM 

tinrt7-lT6 jcart of age, bims^ a 

_^ mdbmd from an obstinate eoDOP> 

I ...... ._ M experieoeed no difficult;, sul^tive 

* ^laifcl «r uriiiary focctiun* Some five yean after 
«y, WttAlind « !i%bt (IribhliDg of the urine after the 
h ^ tk» M>L 1^8 tliibbling. at fiivt of oocaiioiial oo- 



aaKmnl. «" 'luaUv became a nerions annoyance. 



a^flMMwaM %ti> WM** inquentlr ; after eacL ant, often evan after 
^^**Wl ***• *(**"8*^ " tjuADtitv of uritu snfficient to ntumte 
uitt ^M^ iiawJuMtHily uprUnL tlius roiupcUinR him to change 
^ >M^ OiMt iaMvaU to eaeajw the miiiuui. cxlor. (>» Konrml 
^ jlijn WW OTM* buMMrrfaage from lh« iirethia ; tvrice thts vtm 
^N,i,v tturiii),' iiiteroouneL and once dozing n ftimplt! t>rection 
- jw\i\\«it»t it«K Clinfttioat be«aiiM Crequeot aud uligbtly 



1.V 



y^^t^i *\ ttr«t HBMlluwl tlie eiistence of a Btricture aa iht, cause 

'■«* nwpe#»l ttkHiuiiiAtion fidlE<d to reveal any contraction 

;.Ki« Nevortholitffl Bte#I sounds were inti-oduced lUmost 

'lu wriwl. in tlie hopo of eflfcotiiig relief. AfUir the 

..-,iu,lto\1octor presented UiiaseU to GrUnfeltl for eado- 

II 111 wltlMlravriufr the inatninient, Grlliifold diacovencd 

■^ I'l ilu> ui^llim, at about (Le uiddle of the ]mjicUi1ou» portion, 

,•4 ii»U|«. tho laiv*"t about the szo of an ordiiiajy [xm. luid ail 

. M|iMOtt ot ooeindl. These mira at once removf^d by 

l^^^ , «« <>iwrnUoq muaiii^ aome little ixUii but incoiiWi,K-rtt- 

I • 1 lilt wia entire relief from the symptouiB compkinfid 

■ \ . . ilUii Mlowioi; I m«it the patient oil iMivemlucrftgioQa, 

iktitrmvtl UtHl both ([Miitiil aud urinary functious were iioiTuaUy 



now OF TUB VRBTSRA KWOOSOOPT. 



77 



])(rrforme>3. kikI tlmt ho lind enjoyod, since tho ojwmiion, entire freedom 
from Llic previous auuoyiiii; syiuptouia. 

Various syniptoniK, Hubjeotive and ohjcctiTe, usually produceil liy oUitr 
COD (li Lions, lisve been observed in special cAsea to be dependent ii]>od tbe 

Brenpnce of polype in tbo urDthra. Among theae arc frciiut'ut and ilrib- 
ling uriuation. hfemfttiirin, a gioetj diBcliarge, Iho senwition of a foi-oign 
body in tho urethi-a, cystitis ; iu<le*(], mony of tlie synipioma of stricture, 
iucliuliiig impedimenl-H to the introducrtioii of tlie sound, bsve been traced 
to tilt! ftauxe cauae. In womeQ, in wbom the (linguosis ia esflily made, 
uretliml polype are known to vaaw vnriouii Byinptomn of womb iUsoabo, 

{imritutj, ]»uuf\il uriiiiitioii, eU:. In ono cane r«port«rl, cystotomy w»s jwr- 
iiniiijd in lui «ltl(u-ly man to relieve an obatiii»t« cyaiilia. Tbv patient 
wore ft cjinula nntil hia deiitti, Beveateen ninntliH later ; at the autopsy, it 
WAS found that the cnuse of the ti-oiible vran a eniAll poly]) situated at the 
TCsical orifice, whereby (he viretluii was eonijjletelv pl*)!^!!. 

Dr. H. G". Klotz, of New York, reports ' an interesting caxe, dhowinji 
tLd dependence of gleet upon urethral pulyjja The gleet had continued 
since an attack of gonorrlicBn, throe yeara previously. Exiuninatiou do- 
teuted a utriuluro 13 ctiu. from tbo ineatiiH, rLdinittiiitr No, 14 Frouctt ; the 
puaOf^ of Hteel eountht <.'niiHed slight heinorrhji^^e. In a ftiw weelta the con- 
striction was dilated to No. 27 Fi'ench, but Bmall olivivpointed bouses 
were always arrested near the seat of the stricture ; tli© diacbargG con- 
tinued alnif.wt as profuse na before, ^lumnation with the endoBcopft re- 
vealed s«veral polyps iu tJift meDibnuioiis iiretlira : about a dozen of them, 
varyinjj in Mze from & canary eeed to a i>ea, wei-e removed in several ait- 
tings. " Cnder the appUcatiou of cnusl-ics and astringeutB, the uucouit 
tuembrano i» returniug Blowly to ilH uonunl »)Ddition, the e4.'nt of the 
former ittricttirii bi'iuf^ recogiiixcd by tlio ncjir-liko, pi'rft;cLly white appear- 
ance of the murnua membrane of the upper wall of the arethra, immedi- 
ately in front of the sent of the polypi." 

Tbo tliagnosiH of uriithml j>oly|H]« ciiii bo made wnth the pndoKcope 
only, and tlie ti-estnietit likewise consists of removal or of cauteriitfttino 
tbi-ongb the tube. In eaaea in which pernisteut aymptoma referable to the 
Rtnito-uriDftry tract cannot be explained by anatomical conditions revealed 
by thi_' UBiiiil modtts of explunitiou, the jjosHibility of urethral polyp slioiild 
be borne in mind and lui ciuUan'oin: ^xainiitntlnn nuidc. Siiuli »xiuiiinattou 
reqiiirea the most careful and thorough iiispccti'>ii of the entire urethral 
Hurfuce, first in front of the bulb and au baeoueiitly, if thin exiuainutioo 
prtn-c negative, in tht* pfiKtiprior (ir>itlii'ii. In this exnniinnlion it is essen- 
tial to iiiaiM^ct not only the ueutml field as aetn wbou the eudoacope ia 
held parallel witli the axi-t of tiic m^thrn, but also tho wuilti of the oaoaL 
To <lo this, tho en<!oscope shoulil he djrerted to on© Bi(ie and the oth«r, 
nitow and holow, by iutikiut>; tlie tube funu a sh(^ht ant^lowith the urethra. 
Snnti^titncii a ili.iiiiict itimor CJin bo recognised in the field of the iu- 
Btniment ; in many cases attention i« flrftt iittrnctctl hy the midden displace- 
nient of the (mlinai>- Held by what aeeins at first tn Ive merely a fold of 
iniifoUK membrane, wliirh disjdoces partially or completely tho ccntnd 
cniie or funiirl mwle by Mio iiumml uruthiiL The new prowth pops buiI- 
denly into the tield, aa it were. A aoniivwhat niniilar appOArance is some- 
tiiniis seen if the endoscopic tube is eiiddt^nly turnvd from the axis of the 
arethra toward it« walL In order to be certain titat the object seen is 
really a new gruwih, it ia ncccssiuy to seoui-e a field in which the usual 

■ Hediaal lUoord, July Hi, ItHl. 



78 



DIRGASES OP TnB tUtlNARV OKGAKS. 



cone or funodl u partioUy olwcured hj the projMLisg nuuR. It is also to 
bo i'cmi-ni1)rr<'i1 that the nomtnl nppeiiraDcc in the prostatic urethra Is 
Bomt^nhnt RiiiiiUir to that piodnced by n nniall aeanle pol>'p Id the pcinln- 
Jou?j portion, for the veni iiiontumim projects upmiH from the floor of the 
uri^tliriL Hii lui to piirtiiiltv oltKcurfi Uin livid. 11 iit imiil that uii t-iithiuilfkKlio 
endoscoiiiist once iimlpriook tn lemovp n ixn-tion of tbe veru tuontaDum, in 
the foml l«.-lit;f tliat lie bod cliacovei-ej a urt'thmi polyp. 

Peiliclcd ]>nl)-|)ii do not UEunlly iutlimto their ptcocnce by tbns 6nd<lflnLy 
Appearing in the ti^lil ditiiiig the withdrawal of the endoscope. Th^ are 
genertdly TiKiblo mn hriglit rt-d protub<^nmci:)(, ot;4-uj)yiiig n Ul^er orfunaller 
part of the tielil, the reiuatndcr of whioh in rximnimed of a OTMOentic por- 
tion of mucoiiH membrune, tiHually of linbttir t-olor than thp polyp ttaelf. 
Tills crescent raiies in nixD acctirdiiifr to tb*! dimciinionM of the tiitnor ; if 
tlic latter he Hmall it inftv bt- niirrouiuli'd oiitu-ely by n ring of nnioous 
meinbmiio visible in thi^ fiL-bb If tbo tnitior bo sumll and the pedicle com- 
poratiTelj loDj;, the blight red object can be piiehed backward by the 
lllovi>ni(>nt of tjie endoscope ; if, on the other hnnd, it l>e laiKC Iho jxilyp 
oocupion morp of the field as the iiwtnimciit in winitlniwn luid miiy fiTinlly 
completely fill the end of the «iidoeC'Ope, cauRliig, of course, the disap- 
pearance of thfi cone ordinarily Heen. (irOnfeld layx especial Btresa upos 
tli« shadow cast by the lumor nhen this occupies but ii portion of Uie 
fi^ld ; the ehiuluw inoreiueit luid diuiinisli(?(i lu-cordinj^ 1o the position of 
the instniuient und the nnkoniit of the t^lyp included in the Held. 

Pol;«'ps of Uie wethi-a vary cousidcntbly iu siz« and in the number 
found in tbe same individuttl. The largest yet rejtorled m obseiied dur- 
ing life wns one detect**! and roniovod by Griintield ; this whb QS mm. 
loBfj and 13 mm. broiKL Iu aiioUitr wmo di-inoiifttruted to the Vienna 
Medical Soeiety, fiv« po!,\-pfl, one ns larRo an a iH?a, were ohscn'ed. 

Simple graiii'lations occurring as the resitlt of ^onorrhtxia also ocon- 
eionally couotilulf timiorH rfcot^nizublu with the fudowopic- These lU'e 
usually Biirfoiiiidc-d by a ^fnuiultu' ni-^on, na itlrcndy describitd ; yfit the latter 
may c^ist nithout any distinct gi'auulationa of such size as to project into 
th* liiimn of the urelhrn. Such fiingoua (jnuiiUatioDK are readily iletected 
with tlio Midiinciipp as bright red ninsNcs, iimiolly covered with tt layer of 
pus and bleediog reihlily iijwa pressure even with the touipoii of cottoo. 
They are fre<tueutly jireeent in CRaes of gleet, and render the affection ex- 
tremely obetinnte, ns in the following pereoiinl case : A uinn Iwenty-stx 
years of age consulted nic regarding u glet-t, vliich Imd CAiisted for the 
previous nine montliB. Ho stated that Ave yeai-8 previonsly he had had a 
gcniorrli(£a, and two yeara aubBeqiiently had been infot'nied by a physician 
vrfaoiu h» consulted concflming ^-Hriotia urinary iiTeguliirities, that there 
was a Ktrictiire in the niitcrinr jioriion of th« iirollirn. The BLrictiiii' luid 
been dibted up to No. 12 Eni^tihb, and tlie patient instructed to pass a 
Bound every week — an injimetjon which he Jiiid of course neplectud to 
carry ont more than a short time. About a year previous to his viwt to 
me, and therefore two yenre after the klilatation of hio Bti-idtire, he had 
aociuired a bocoikI gouorrba-a ; tlic dischargQ had never oenaed entirely. 

On examination I found a stricture admitting Na 17 Charrifre, about 
one and one fourth inch posterior to the mefttus : there was u flight l»iC 
conataiit semipuruleut discharge. I dilated the wtrirturo grtt<luall,v oi)ltl it 
admitted reawlily No. 2S, expecting that tlie discharge woidil prol.iably 
cease. In tliis I uae disappoutt«d ; for two weeks after the dilatation of 
the slricturtt up to the point, niiiuird thei'v wns blill a discharge. An ex- 
liiuiuatioo with the eudoscopQ lUiowed that for three-fourths of au iucb 




INSPKCnOK OF THE CRETItBA — ENDOSCOPY. 



7tf 



ek of the alricture, the mucous membmne was uuuRually red bikI vaa- 
culiur. Several tiiiitii4« gmnuliLr points wcie obHcrvecl, nuil on the ri^lit 
will was a iiiatHH of flabby ^i-auulatious covering uii nriii iibuub liu oigiitb 
of Ml inch in tlianieter. Tho removal of tiii» muss witli tlio Rniire nntl tha 
a|>i>UcutioD of bluestone to tlie ItoHe aud Biu'iouutluig surface waa soon fol- 
lon'ed by a complete ceiaatiuu of tbu (liHclinrge. 

The conditions idrMdy mtntioned constitute ilie greater number of 
oosfca iu wliich the euiloncope U eaaeutial fur purpooM of tlioguoitui. There 
itre^ however, variniiH otJier nbnomial oonditionti of rare occarreDce, vhieh 
can be reoofn^ized and successfully treated oiilv with the aid of tbia in- 
HtrumeDL The vciiiu coetaiaed in the urethnu vmlls nre uometiiiioB <ui- 
larged uud varicoi^ n condition wbii^h may give mo to vftrioiix uiieftsy 
MMiaaliuiiM rcfiirrvd to Itio gUuiK, tlio ufGlIini, or tbo bladder- iier^k ; tliese 
Tttricesare readily recognizable with the endoscope, 

Erwiionaand Uleerg of Ihc Urelhra. — These probably occur as the result 
of j^ouorrbow, cnuwilfi an olwtiinitc and pcrnisU-nt discliargi* wliicb i\«Av9 
all oth^T modes of Ireatmeiit than topical npphcalioiia. Huch eoRes have 
never fallen under my own nolire, but Imve been described by imioua 
writors on cudoscopv. Thus (irlmfeld exhibited in the \'iciuia lioyal 
Sodetv of PhysieianH in 1877 " n luan who had tmltcrod foi* s»vend years 
with chronic )ir«thriti>i, on the luider HUrface of whom: urethra tvto ulcets, 
visble through the endoscope, were seen. One of tliene ivaa located be- 
tween ixe and sis ceatimetree. theotlier from one to tvro centimetres from 
the uicntiu. The former visa 1 ctm. lot)};, of DOirly trinii^^litr form. Tbo 
Anterior of the tvro M'a>t of hoi-Keshoe Hhape<, the antis being 10 and 12 dud. 
Iohr reiip<t<;tively. Those uloifi-a wvm quit*) Huperficial and were euaitjr 
htued by pencilluig with a solution of lunar caustic aud with EugAr of 
lend" 

TiicMtntc obtU'.rver reports hnviug repetitedlr seeti goiiorrhrea, or rather 
urethriliH, which was certainly not {hie to inl«rcouTHe, in indindunln who 
were subjeet to herpetic eruptiotia on the ^lotis and prepuce. £x)iin illa- 
tion with the endoscope has slmwn herpetic btistent within the urtttlira. 
He nsserts that tlie cure of these blialfirs by local applications has been 
iollowe<t at once by the cetMatiou of tlie dittcluirge. 

CertaiD aboonnalltiee of the mucous membrane poeeessiiig clinical im- 
portance ur« mout reatlily or exclumvely detected by the eudusoope ; such 
ar* diverticula, Ic>cil1 diUtntionii and vnl\iilnr foldx of the urethriL Huch 
aboornuditien are ru'e and have but little iinportaitr,e except after the oo- 
enzTanee of urethritis ; umter those circumstannes ajiy of the conditions 
mentioned may bo rei^onuble for the ioexplicAble obstinacy of a chrouio 
disobarge. A caMe of sac-Iilie dilatation of the urethra i» related by 
Ofunfeld:' "The Htibju<;t wiiit a medicnl ntudcnt who in the auniuier of 
1871 experienced for about four weeka after cvuty micturition a eensstioQ 
as if a iKjrtinn of the urine had remained in the urethra ; yet prosBure 
ticvi>r siictiiH-dod in vvacuntiD^ such additional quantity. The urine was 
clear. Id tlie summer of 1878 the patient noticed a dribbUu^ of the 
urine ■ftar micturition. Tlie ilumtion of tliiti dribbling nn well iw tha 
quoutity gradiially increased, so that in 1877 it |>ereiBted for two hoursafter 
e«fry act and the linen was correspondiusly saturated. In the winter of 
1877 there ajipcnrcd aitcr every utitiittion an ovid tumor in tlie vicinity 
of the bulb, by presKure upon which urine was evacuated. During the 
period immediately preceding this condition it had been noticed that the 



■LoadL, p. 187. 



80 



DI8SA8B8 or THS UBUTABT OBOASS. 



■MMD expeDed dorioff fr«<)Deni poDutMiw ms abDoat conpfet^ eno- 
iwitod. pf I— ur» upon the tirt^thi* wmeltog «drop or twg Ttw ijiilwiinliii 
ilitnKl action of boTigiM (on t« So. 12 Knglisli> w«s aasoooeaelal in chssg^ 
tug tlie omditioii. «xoept tint Uie duration of the dribblxng at each act vas 
HMsawlut ^torUnad (1^79). The me of the urethra waa aeldom con>. 
tdataljr encnated. Eotnmce into a ooM both whea the sac ma foQ 
caiUkM a eoonilato eracnatioo of the aame ; but ffjratematie cold bathiiijr 
WMWWW"*— ™ "» rabariiigUic eoinlitJon. Tbe nao of the FWmdic cunwnt 
ffonrtean aittion) oecanoMd immediate coDtntctioD of tli« aac, but ao jter- 
manmit bracfit (Decafflber. 1878). An the patient siisp«ct«d the exiflt«nea 
r(f A valru tit front of tlie aoc, ho prc«rDt«<:l himwlf to me for endoacopic ex- 
Mriiiii«fif>n (January 15, 1879). 1 fouud the tliumcti-r of the oretlin in 
fr<»«il "f liio bulb <>' MtmordiniUT axe, tho troniwrrw wrntial figure haring 
UlfM ttiuaa Uio iwuuJ Il'iik11>- The luucoea was oth^n^ise nunuul uiid the 
itrifta Hitlla elaar Ku'l'wrmpe No. 2-1 was used. I pmposeti tlioruugh 

iM'ririn'tij; "f tho fM'- 'ill mtctur^of iodioe. in order to accoicplitJi c«q- 
milltin hi till" vtiij > " rusult was iaTomblc, tiuuimucli as after Iho 
(oiirtli \H-iui\Uuu l)>« »■'■"" WM (^nmjiletel.y cvamotad tbx«« tiinea. Tlio 
iifolltru i'i(ip»lii"d f«Mn|il(ii*l^ contriMTted for two da^B aft«r eadi uw of the 
MftnlL TtiM iliinitiiifi «r I liin i:tmi])leUt cootraction of thf ear after a tunj'te 
nHHi-r .>,..:|iinllr liirri'iMod, no tlist, for txamplo, ill the time betwetu Fi;l>- 
rtiHF 1 ■ lid Mwrrh a-l, i>odribbliiigooourred,aadoiithcljittcrdateonly 
nlf'-ifl-' iMuMliwi IwliiDd. The penctlUugs vere p^^rfoniied now leas 
tfhiiHfhUn. t'"*r tliiiM 111 MATch, three timea in Aprd, and ouce each is 
MMf afxi 'liMw Htiww that limg (fevo yean) tbe paticat baa remained 

I i..w<f>iM ItJM boen oooanonally employed in «asen of tight sbrict- 

Hff i-M 'if iUm\uiunng tba eutrawc to the stricture and of nsust- 

<- III A bou^ ; it hoj! alxo been aei%rted to jmmscss a 
]'<Moil nitcmn] urethroloRiv. It inisitid Ihnt by iospectp 
1 1 • lui Iwat be determined at vrhat portion of tlie urethra 
il'l >M> iiiiule. The cnsf-e in which such applicatiou of tlie 
ffH,) .'(••■Ucal valoe must be infrequent. 

I |.ir I'uiDiaatioQ of the bladder Itns Iwcn thus far a matter 

f^ , ifln int«re«tt. Foreign bodies, calculi, the swolltoi mucous 

, - ' !'>[iii of tumon. and even the scars of opemtiona have all 

I ' ji with Uiu aid of tbi* instrument ; yet no information 

ti"|iiki'^d by other and Whh objectioiiiiblv mvims has t£ 

i'< I l>v till* cndoRTope so far as the bladder in concenifd. 

'ftt^ -hni' >iiii>H wiiicb beaot the ondoacopic exauiiualiun of Die blndder 

flMmb ti"i "Illy llioao euooontiprGd in the intruduclion of the instru- 

, MMI, fwl' u'lM' ■)"> ftt'^l Hint the field of vmun is m-^u iu tho ht^iilthy blndder 

MJMIWfWfl by lbi> iiriii't; in nbiioniuil cotiditionKiurcoitipiiiiied liyiiii osfuba- 

IV/A "f 'I"' ■i'lili'-hiirii. and ittalmpB euppumtinn in tiie bladder, tliisob- 

U .-"H'li iia til |ii'iUTlioiiIly prevent endoacopii! examination. 

I wiia lb« l\nil to ■ooompliHh, by meAOH of the endoscope, a 
,i..i] Mbl'ili inlttht In axoeptiauid ctvmn hu.ve extreme pructica] 
Ibu liilfiltii'ltiiN of n catheter into the urctvr. ThtM in of coimM 
i^f. '.triy In fiitnalva It had been undertaken bv .Simon, who readied 

Lf/i ./mi llin VKNind orilititt of the ureter, not W the endoscope, but 

jff ■ ■ . |iilr<"btnMil tiirMilt,'bllicdLliit«!d unttlu*!!. Simon prrformod thia 

f4ii ' 1,111 id III* iin<lr>r M'veiiteuu timea in tlie liriDg snbjert, and in all 

.1 u»« iii>r»bbidt>i iutrotluce thn inintrumeiit as far asthepclviaof 
,,, til iilliriiiiiUnif tu perform the mtrng muuccuvre with the endo- 



•iW»" 



^..^ 



J 



INSPBCnON OF THE URKTHRA — BHDOSCOPT. 



SI 



mope, ]ie alwaji-s faileJ, notvritb»tanding the fact Lbnt tlte iuatntmeiit eu- 
pLoyed was introduced tluwuRb tUe Lliliiteil iireUirn and had a diameter of 
about two ceDtitnotroH. Utbcr obHervcre, uotnbl}- Winckol aod Rutenbcrg, 
ubo failed to discover the orillee of the urt'tiir. OrOiifeKl wiis^ iiowevcr. 
enftbloil to Teaeh nnd iotroduce an inHtrumeiit into tlic! ureter of the f^maln 
-u-illiout firevious ililatatioii of the urethra — an operatiou which he r&- 
|>ea.te(Uy denionstnitcJ upon the cailavpr. The vtJue of the endoncope for 
this purpose has beeii, however, materiallv \'itiiit«d b_T Pawlik's d^mousttu- 
tioD that the eamc manipulation can b« readily accoiuplisUeil witbvut eodo- 
seopic or other iUHtrumental iL»^8t!LuC9. 

Tffrapirulu-it icUk Ihn Ervl'utcopr. — Tlio raluo o( thif instrument ia to be 
foiuid nhno»t aa much in the trentmeiit as in the diagnotda of urethral dis- 
MHL That the lond application of remedies should be more tuc{.'6s»ful 
wliea (lirrctod hy tlic cyv tli:ui vtlum tuodo hiipbiUAnl Viv injcctiutiM iulo 
the urethnt It self-evident, and has been amply derooQ»traietL in pr&ctioe. 

Loiml the rap en ties with the e]idoscO[>e require a few especial inatru- 
meots uduptvd to the auutomicol rolatiuoB uf the partt* iuvolvcd. ThcM 



on 



Tampon ; 
Pencil ; 

Caustio-holder ; 
Powder-blower ; 



Snare'; 

Scitntors; 

I'tHvepa. 



SoRio of theHci IiaTf a very limited uae and are rarely required erea in 
rstirrinivi; trinployriiiait of thu i'iiiIo»rupc. Tho tuMi]H>n, pencil, niid cuiitti^ 
holder are iiidJtipipiihable, and Ihe poivdcr-blower (reiiupiitly convenient. 

Tho priiieiplea involved iti th« uai* o{ these intttruuientB requii-e do dia- 
caasiou, aintiJ tho conditions which- they aio cuiploytd to rclii-vo arc iden- 
tical iutlio iimthm and in other mui-on^ niotihttuies, t^pocially the eon- 
jimotivA. The a^eiivral fiict in ta U- rciuembefed that applioationa to tlio 
tirethnii eBpeciaiiy the poMlerior portion, should he made with greater cau- 
tion ftnd eODServatism thun ftre required in tho tri>atment of conjunctiva] 
affwrtions ; miieo the rc.ictiou buth lucnl iiikI gcucrnl it Jipt t.o bo f;ri.-«t«r, 
and in CODsequenee of tlit* ftiiiitomiijil rt-lalions, Ie*s readily CDntmllHl, 

The tampOJi, coiiaiatin^ of a watl of culton, itui be litUd cilluir iu a 
cluiup pr6vidod for tho purpf>se. or wound aroniid the end of a tine aound, 
iW is ctLstomary in ititr:iiit(>nne upplicatioiia. The diandvatitage of either 
of tiieut utcLlioda ariurs from tlic uoccssity of frtM]uent chivngo of tlio cot- 
ton ; for the tain)ion ia io conataut tue in clearing the field of moisture and 
powibly blood. Hence it will bo fmind advantAftcoUH to uae tamipona rondo 
by twialinf; (-Dtton arv'iind tho end of pieces of wood, a purpose for whirli 
tbe fine cylinders used iu prejuriii^ nistcbes are especially couvenient. 
These may be out iDtnpioneiiMx oroight inubeit long, and n number arnic<l 
with the cotton are ko])t io readineas. In tMa way the loas of time an^i 
frequent Iuem of the liuld, nniiruidable if the cotton must he changed in the 
tirduiary bolder, are avoided. 

llie pawU ia identical with that uned in treating the ttiroat, except that 
the holder ia somewhat lonper and atrai(-ht. Tbe ordinary larynfcaal pen- 
cil cnu be adapted for ondoscopii; use if the shaft bo tbiu and dexibla. A 
tampon can of course be made to eupply the pluix* of a penciL 

A aiuHvshcldi-r for the uppUculiuu of bloeatone and volid uitroto of 
tiitvor is a ffteai conrenieuce. 

For purpoaea of medientiun tbe Tsrious agents commonly employed in 
the treatment of coajunctivid afiuctioua mav ho used. jVmong tliew are : 
6 




82 



DISEASES OF TTTB URIKART ORGANS, 



1. SnluiioiiB of silvor nit;rntc, the strengtli Tsrying from one to toriy 
graiuslo tlie ounce of vntter. Thi'sc nre ospcciullj vulunbli- in frnmuW 
nnd iile^ntted con<Iitunift of Uia UT«tlin, and nre beat ii.ppli(MJ h; in««n8 of 
the pencil. 

'A. loiJine, <Htlipr us tlie linoture nr on a Bohition in Rljrcerine with the 
iodide of jKitiiwuiiRi. 'i'hc following fonniiln is generally useful : loclinr, 1 ; 
iodide vf polatwiuu, S ; fl^ci'riiie, 50. Thia is u u«>ful B[i]>licntioii in 
aacs of chronic ureUmtis. 

•3. AetiiDgent^ «si>eciiklh' Hliini. sulphate of zinc, antl innnin. Tlie tvro 
foniicr con be iijiplit^d cillicr iih nulutidn vitb u Ijninti or am be blomi in ' 
lut jjowdfr; tnmnii w bort npplicil n* n solution in glvMirinf, 

Iodoform ia an eapeciallv ii»t-(ul njijilioation tu L-QMrs of cbroruo ar«tlintift 

For the mediration of the depp urethra these ntid other remedies can 
be conveniently and ndrnntn^oiislT npplied through the eudoecopc bv 
meuiD vi ijolublf gvktiuu boui^ivts, Huch u on audi; bv MitcLcU iu Thila* 
delphia, 

Ctttiterization of tlio urethra can be renJil;r mnde through the endo- 
Bcope, more ndvantageously, indeed, tlian by any other inHlninient em- 
ployed. A stick of the milphatc of coppor-or of lunar oniustio. HreH in tho 
causti I?- holder, ciui Ije toucbed diroctly u|>on the spot reijuii-iug BtimiUa^ 
tion. 

For the removal of exuberant p inn illations of polyps, a wire sDnre «in 
bo cinployc-d. TLiti unHwcre the purgioae etitisfuvtorily iu the uuterior urc- 
thm. but i» not so RiiwpRsfHl in lint Irpiitinrut of iinlyps in the poHterior 
-portion of the eauid. For thi« latter purpose an lustrument has oeen de- 
viBcd by Dr. Klol^. which is said to hnve been quite witiHfnctory in liis 
hnndx. It coiiuiKls of two ponecutric nietAlIic tuljoB, tjio inm»r one rovolv- 
Ing reatlily within the outer. At the eanie jioiiit, near the visreml ends of 
the tubes, there is in earh an elliptical nindnw. The jnstniment is intn>- 
dneoJ so that the polvp project* into its lumen through the two openings ; 
rcvuliition t)f the interior tube (the edges of who«i window are nbarpened) 
then euls cleanly thi-ou'di the briKe of the tumor. A full deiKriptioti of the 
isfitriimeut and its applioation is contained ui the Medical Record, July SIX 
1881. 

After thia l>rief aketeh of the eapaeity of the endosropp, I would agiiin 
oxpreea my coavietiou thut the instrument poasessee far ffreater value for 
pnwti<'iil purposes than is genemlly believed. For tlic Bperialist in tho 
treatment of genito-urinnri' diseases, it is indipipcniMibl* ; in peBeml prno- 
tice tho ciKfi-n retpiiring iUt employment are eoiupm-fttifely ftw. Ilie tteld 
ia which the endoHoone renders extremely valuable service and fumisbeii 
information inaccesBiule by othemiethods is quite limited, but includes 
DcverUielcFHt n cIoeh of cuhcd which ore by menus of it mndily ourod and 
without it rcniftin nliRtinnto and cvon incurnblo. 

It is not asserted that every ease of urethral difBcuUy which haa »- 
wnted other means of di-i^osis and treatment vields readily to the endo- 
scope ; nor is it true that all coses in which tlie diagnosis enn bo by the 
cmlofwopi- n*iuli1y eitlnbliidicd areas n'lidily curi'd, I have seen casea of 
glt^et which had l>eeti treated with tuject-ioim nnd Houndt^ in which, upon 
emioseopic eiamination. localiKi-d granular urethritis was detected ; and 
which, notwithstanding the use of topioil applications applied throuRb the 
iniitnimeul, have not resulted in a stithifuctory cure. In such onscs the 
discharge can often be arrested by a fi:w njijilication*, however obHlinate it 
may have been toward injerlions and aoundn ; but in the eourae of a few 
months, either with or without provocation iu the shape of exeesaes, It »- 



INSPECnOS OK Tira IIRETHKA BNDOSOOPT. 



83 



upprant. \gaiD it is rewHIy iMTPstctJ, but is npt (o return. In th^se cases 
o( gleet (from gramiliu- urelliritiH) wlu<:h KtatA to)>ical iipplioitiuuM tlinnigh 
Uie ciidoacopi', I Imvo always fouad a canHtrif^Hoii of the. urethra, ofton of 
Isr^e c.ilibitj aiiJ detected only by tLe uretliram«ter or large bulbous 
douud : imlcei], my cxiuniriatiou of tlie uri'tlira iii a cosy of pltet inclurlctt 
llie uBu of both iustrumenta, uretJimniPtcr ftml ohiIoscoihi. unices n pro- 
Hwuuced Bti-icturi; iw fini«>l. I( h aliglit conntrictioii and f;nunJiiT uretfaritin 
are both discovureil. I treat the luttcr conditiou for a time wilh topical ap- 
plications and rcMOrt to dilating Tiretbrotoiny only la those casea ui wbich 
»udi tivatJtiHnt prnveH iaeltectiuiL 

The fto-'nc EnJoAi-of.—Vt'iUnn tb« Uwt few years iiiHtniiriEints have 
been devised wbontby tlie ruiivous nieiiiliriuie of tlie urclltnt ntid bliwltlcr 
OkO be inspected when iUuuiiunted by an iiicandescBnt plntinnin wire. The 
Ulou originat«d with Dr. Sitxe, of Dresden, and waa aucc^eMifulIy roftlixcd 
by Leiter, a protnineut iostrument-mnkor of Vtvtinn. Tlie same principle 
bu been applioti, tbrou<;li modificationjs of inHtniiuciiits, to tbi^ illuiniiiaUon 
and inspootioD u( variouM otliur nivilinN of tliv liody — tb« Liryiix, tlit! var, 
ibe TAgiDA, iit^ruH. rectiiia, (Sfiopba^uH, and Htomacli. 

la eooli of ibesa iu-itrutDent». including tliose for the inHpeotion of the 
urethra and blmldrtr, tlip wim ivlinsM incandesccnco (produced by an elec- 
trii* current) (iiriiinlmH tli(! tllmninittion is carried ititu tbe cuvity lo ba in- 
apnrtftd, thereby f urn iaSiing aji inteaaity of illimiinntion iiupnwrticaUo by 
any other means. Ji^ch iiistniment i>4, moreover, provided »'ith a eetws 
of lenaed — a uiicrosi^ope of low poiver, in (mil — whereby ohjeL-ta brought 
witiiiQ the nuige of viKi<)ii upjicjir mnguiSei). Tins ntnplifying arranf^e- 
meut, readered necessary by the conatraoltou of the inHt^uiiicnU omkn 
eerlain disadvautut^s lu well lus tba one evident advaatii^ of tODdering 
visible objectM whiidt would wsi'Jipo the naked eye. 

The instruiueiit ia a marvel of iiicdumical conception and ciocatkm, 
but ao coinnliaUd as to practically vitiate the value derii-ed from the iu- 
tenaity of the Uliimination >wciiried by it. Furtbermore, it is eo expensive 

Sostiug about $130 in Vienna) that it ix beyond tbo reach of all encept the 
rorod few. Wlu-Uuir or not it in cjtpidilc of ntTordin^ iiiformntion in Uie 
diagsosis of urethi'ul and yesicol diseases wlucb cannot Ixj Ac-cured by 
other means roruainH tu be seen. As yet only very few surKeons have had 
tbo o|mortiiiiity f>ir ticsting itt* jmiwits, mid tWiM) few do not profcsa to 
liaTR euiauHl«d itri reHoun^en 

My own practical aoouaintAnco with the instrument h limited to an 
olMcrvation of ita mw in tiio hand)i of Pi-ofeiwor Dittcl and Dr. OrUnfeld, of 
Vii'Diia, who, by the way, luive been most prt>niincutly identified with the 
pmc'tical H[>{ilicafionH of tlie inatruiiieot (no far iw its iikt in the urethra 
asd bladder ia concerned), and have devot«<l luiicli attention (o iUt (employ- 
ment Oraufuld, cunftMsedly the most skiEful and experienced of endo- 
acopists, vnu) CNpatciiklly zealous in and hnd most ample oppoit unities for cm- 

goyia^ the new inatrumeat. In hiu liauda, an well iu» in thusu of Profcauor 
itUd, it wsa barren nf practical re»iultn ; for notwithataudiiig itn pf-rf<-ction 
aa an ioatnunent. its employnient was attended witb most aeriouft, and in 
miny citae9 uisapenible difficaltica For purposes of dio^iosis and treul^ 
ment il WM indeed far inferior to the nimplo MidoHCope illuminated by re- 
flected light. Wo can indeed imagine oertniu conditioini in which it laigbt 
tumisli raluable infonnntiua onatUinahle by other meann ; but, so far iui I 
lUa aware, it has not as yet domonstntod such value in practice. ¥et it is 
poaaibin that furthtir experience and a more gunvml use of the inHtnimcnt 
may ontilld it to a place in the urioament of tbe (^nito-urinuiy Bpecialivt 




CHAPTER vm. 

UWrUBMINATION OP THE rRETniWL CALIBRE BV THE 
. CRETHROMETEIt 

Tn NOiirulfl nnlinaril^ u«ed for tli« exploration of tb« urethra Ar« cajMV* 
V$ 01 dllMilmtt nn\y stncUirw of suiiill calibre, tbom wlik-h smuuslv eti- 
vruft'ili uyti lh» lumen of the oanaL By idmos of the aoom-xx'intocl bougim 
uml wjiiiiils, Btrii'Uirea of larger cftlibre whicli ««cape delectlou by lbs 
ttiiniottl niul cyjintinnil Hounds can be rocognisad. Yot pvpd tli(>s« foil to 
ilu(«ct certain proiiwiii<-<i>l niriclurrs. For the UK-ntiiH in, iih it rule. Um 
iMfMsimui tbnii thv jwnduluuit urt^tlini, junt nn every oiIkt tiilx' wliicb na- 
turs dMOfTfiti for thmwing a stream of liquid some little disiance iitniir- 
Mitmotl at itH oritiee. Now since tlie iuHiriimeiit whivb explores th«arethni 
mutt Iw Miinll i>iinuf;li to piuttt tho mestUR it is evident tlin it in too small 
bi diitcnt n atrirlura of itirt pcnrlulous portion so long on tlio cnlihro of tlii* 
Ktriotiim cxcopibt tluit of the nioalux. If. for ostunple, tbe meatus, b» ofloii 
ImppoiiM, ivltiiitj) onlT No. 22 or '2Z Vnncii. -vcbile tlie (;etionU rulibre of 
tliK (■•■niliiioun iirotlim is :12. 34. or 36, a mhiikI, even nn olivepoiuted 
h(i)i|,'io, nennnarily no larjiror than tbe tneatun, itii^lit fail to delrrt iietrict- 
urfj ulDiiltiii;? 24 or 25. An «xnuiiii»tion with sucb iiuriTuments mij;bt 
llutrofora trfve n ucffnltvo nwult ii» to »tri<-Hir«i, wbile ns n matter of facl u 
dfH-iiloil rritmtrirtiou of the UTOtlim nii;j;)>l •'^itt nt one ur more- points. Tbe 
muittiu tlterefoH^ conatituteB, in most nuea of uoniiul ciinfnrtnation, * 
biirri«r t<i tlir n<-<-iirkt(> exploration of the urrlbml oklihre, This obflUtde 
mn of ccitnw brovt<n>>m6 by MilAr^^g tb« lueatusv but is more readily 
•nded by ^Mciid inxtrTimrntA 

In ortler to i^^ijilore tbe i-^ibre of the uretlira iiidependeutly of tbe m»- 
tiia, I>r. F. N. (Hiit. of New York, devised ao inittrument which he ealUi tbe 
" iirotbra-nieler," but n-hicli i« penornlly dosi^;nat«d iirT>tlironieter. This caa 
lio iiiMMi«>d llin)U);b u nnrrvtw inmtiu niid vrbeii within tbr uretbni dilatf^ 
at tbo will of the operator, the ftniount of dilatation lieini; re^stered by nn 
ibdex at the bniidle. " ^\'ben intrtxluced into tbe unthm nud expanded 
up lo a (Miiiit wliit'li is rwoanized by tbe patient as fillins it i-ompletely — 
Hi'i y«l (Himly i»<iviug bcu^-k and firth — tiio index at the linnillc tboo abowa 
thn itonnid (-in'mii(rn>]]('i> of lb*' m-etlim uitder exnuiiuatiou. In wttbdraw- 
Ing tbo ill Hi mil Kill I. i>i)ntnu>lioiiH at nny piint may bn oxortly men.iui'ed, 
and any urtiiit of i<orr«'S(>ouilenop between die ndibre of the eaiial and tbe 
riUtnwl oritice be readily apprcciiit*\l. Auiuiig the adrantAKm cbiimcil for 
tliia iiiHtniinent are ; 1. it« enivioity to incoanr* tfaa nse of the urethra nud 
to AJiiTTlnin tbo Uiealityand aiseof any stxieturea preaent, witbout reference 
to Uio aixK of Ihs innatUB. 2. It enables the mir^^eon to eomplete tbe ex- 
runinnli'iu nf nevnml iitriotare« by a ■in<rl« intrndnction of tbe instrumenl.'' 

All tin|>roTi'nKiit in Ibis in stru incut bfts been dorisrd by Dr. Robert F. 
Wtir. al Niiw York. Tba iniproveinent consists in the gubstitutioa uf an 



DETERHirfATION OF THE UBETHUaL CALIBRE. 



85 



I 




orD-«ltap«i] bulb instead of llie uvnl eitriMuily, thereby inorooBiig tlie 
dolifiiu:}' of the iiiBtrument iii deteotiD;; alight otMitroctioiiA of ealtbc«. 

Dr. Otis nnd otliei'8 bitve 1QIU.I0 nuiupi'ous lueusui-eiucnts of orothnu 
HUppuiMfd to be uoruml, AUil biivii cli-tluc«stl IburbCroin ra- 
noii)) coni'bisiotis us iti the tii,iriiiid ciilibni iif Iboui'uthm. 
Dr. OUe) tludd liuit the bulbous purtiou of Ibe urctfanii 
about aji iucb in lengtli, is usually more cupacioua than 
lb« reiaiuQiIcr of tho jienduiouH iirctbra ; tbat vrhen the 
urothi'umctcr is iiitroduct^d iuto the bulbous urethra, 
tbon diktod nnd gently witbrlmvm tonrai-d tho tiuifttus, 
it beootood uvveitaary to dtiiuiiL^h thu cidihre of Uiu 
bulb 3 or 4 inin. in the tiriit inch travenuHl ; the calibre 
of tbe canal then remaiug jtractically uucbaut^cd luiLil the 
inKlruuiuiit rcucbus Ibu iuituudialu vicdtiityuf tbu lucittUB, 
vhich in uMually dccidoiily MEiinUur. Ho 8Ut<t8 tiint in 100 
cjweH uf Bupjujued iiuruial uratluit, carefully lueotturcd 
witli liiH iin>tbrametcr, thct colibro of llio aiitc-bidlxiUH 
portion urern^d 3:j.it5 lum., the bulbonu portion itself 
boiug cm lliu nvL-ragi: ti't iiitii. In 13 iif UiniKi 101) atutoa 
\ta ilRtM^I«d no variation at all in liie calibre of tbe tire- 
tliri fmiu the bulb to tlto niealiut. 

l>r. Weir, aflur uunicrouH vxnniiitutiuuH, cornea to 
Rotnowliiit ditlToreut uocicliuioiix a>i fullowH : 

Tbe itrclbi-al utniil iit, in the woida of Jarjavuy, "nur- 
mw at the mentus, <lilnted in the ghaie, and very shghtly 
nsrrowod ut thi> lenuiiiatiun of tl]>(s fosaa naviculariu; 
thui it fortiui tt ryliiidc-r iiiutrly iitiifunu to Uiti [M'Cpubiiiii 
ao^le, tvberi> a canrctatinii is found. It eulorges then to 
the bulb." 

Tho KPoiit^y portion of tho urrtlini i* the i»uallti»t 
(eioept tli« Diefttus) ajid lea«t dilatihle jiortion of the 
canaL 

Normal rouHlrictiona (or obstruutioufi) arc to bo met 
with in tliig poriiun of tlio pjinol lut ttiunll corhiiijly u» 
No. 29, and the lueuia at preaent cui|>loyeil ai-u iiisuf* 
Scient (or the distinction of aucb from "strictuica of 
hkrge calibre." 

Tlio heiiltby urethra in Uiiit portion otn gonemlly bo 
reuUly nnd safely dilated iip Ui an nvRi-a^ sixe of 32 mm. 

Tbe tiormal size of th«i meatus u from No. 21 to '2H. 

These ooncluaioas of Dr. Weir arc corroborated by 
Buuuteoil and Taylor. 

OLiH, rtdvioff npan h'm nieimurytniCDta, in inclined to 
pep^rd any oonntriiiUon nf the nrfithnt in tlie atile-bul- 
boiu ])orliou tuousurin;:; dt-oidcdly leas than tho bulbous jwrtiou an sa nbaor- 
niiility wliirli vji!l» for divinion in caso the patient toiiipliunx of obscure 
Hytuptomt« tijiiiiCL'tfd with the bliiddvr, uretlirn. or (genital fiinctioiia. Ho 
bits at different tinx^M, rs|iot!ially in hix riHimit volume upon " Genito-Cri- 
aary Diseases and Sypliibs,'* re[>orteil miinoi'oas cases in which Uio division 
of suitb <ionatriatiotis boa been fuUowed by the reliof of Hyiuptuins wbieh 
bod pemiittml in Hpil* of otiie-r nnd oniinniT- tn<uwur«» tif t-njalminiL He 
muiitiuns, fnrtlitM'iiiorc, ilmt there U a utii^t/iut relation betwetin Uie cir- 
eamferenoe of the penis and tbut of the urethra. He saya:' "When the 




IhronKto. 



H enxDierenoi 



>Loc cit, p, 441. 



DISSASES OF THK DBINAR? 0U0A1F& 



ecntrMtioBH arc below the calibre of tlie doaod bulb, or wlien ibej 
and closi' U)g<<tli4?r, tUe Dormal nalibiv of t)i« Mual umj b« 
trom ihe arrMV^tervnco of the flrtccid peui&. When Uw circuiii- 




wUod by thu auUior's (!ar«fu] mGaHiiiviui>iit in oror one thoiiauHl 
wiM i rnH y* camm, vritboiit mcctuig nitb a aiugle exvepUoa in iii£uic)j, 
dddlMKKl, ndulL Life, or old ast." 

O/iubinin;; llirao two propo«tions — first, that thb calibre of tb« nrvthra 
Iv ynetienWj tiiiifonn from tlie btilb to the uentuii, nnd, scooud, tbat Uiia 
Mbtea buinm dtjfinito mtio (a:i set forth in the j>rei-«^Iiii[.'' titble) to Iho 
itowMBhriiUoc of the flnccUl pcnix, posterior to tbe glaus — Otis furmulat«a 
II <riH|fa ptau of procedure : Ihu cnJibrv of tbo urethra from bulb to 
iriwuld be madn to li«nr tiiia given rolation to iLe i-ircumfcmiee of 

I fm» ; a couiitriitioa iu auy part of the peiidiilotiH nn-tlira wliicb con- 
I a (It-TiiUiou from this ratio should be ilivided for the relit^f of ub- 
iq-i»I>t4>io)i. Th« fftct tliut n large Bouud. «v«ti 28 Charn&re (15 
KtffiiA), it ixhiiilL^Kl, doi-H not, ari'iirding to Otiti, {ircrhidt^ tlw; exiat«DOe t)t 
• alrieturu whit^h luny be r«»|H>n!iihIe for aiinoj^ing R<nji|>tuiii& Au inBtuacQ 
tit Vt. (KiM IlK^itry aud practice in furoiidted in the foUon-iiig «a«: : * 

"T W .aaod tbirty-firp, bad f^uvrrhwa fifteen yrantago ; liaie had 

flvrvvral liiuvH hIir-o— tho hwt tiiue, four >'vnr« a^^o, <;omii]t; on forty -«ij{hk 
l^mra froiri di^Ui of DXfioHure. Aft«r tlie <1iHclmr(in Imd existed ten or 
(Mwlva daj'it, liH t>liit(>H tliat ho 'atopped it with n powerful ([unvk iDJt-ctioi:.' 
Ttttiii ia four <\aya sulMequt^iit to tlua lie h«(*aii to sutler witli a neuralgic 
pVit (It (If lift U»«li<T]r>, tboMrrotiiiii bt-camo tvndcrand rpd, testicles mov«d 
U^ arid <l»wi) ii]l«nist«ly much of the time, and the |i4'iiii« «hs greatly oon- 
Ua"t«>l ; thrrn wim hhcwinf! piun la the ffroins, described as drnvting and 
tttMUthiliif' wlti'li Mt^uded donii into hiit Kueeaand the bottoms of bis fiiiL 
YM* iM/ii1iiiti'*d tf itb rur.riug »vvL>ritr idinOKt without i'i<t«ntioii tip to I'Vh- 
ftM/^ 'it'^-i. wtMii ho i^iiiim t«> Nfw York for trc-iittuFiit. He fell into tbe 
h* '■ ciidoM-opJal, who dit»covereil niiiEieruun {^rHuular spotfl deep in 

ii,. Apj'limlimia made at regular intervals for about tW« mootlie 

^,- I ' ST. All upjtiicatioii of carbolic acid to tbo scrotum gave soma 

MtK I "• "•« iiiTTuuM fwliiiga. but this caused wtdi-atiuu and the i«lief was 
(mH UttiiftTnty . About Mny IhI hi- ttought tko adrice of a Kiir^^fon ddlled 
Ht tfmii" tirliiary ilim^iMO^ ::>U^'ht alricturo was discovered near tb« tneatiis 
iw7»v(ital i»dur.^tf<d iioiiita farther donrn. A 28 FreiK'b wlid st«el twund 
w*t tHit'i'lurfl, Mild afl^T some rp]X'tiliiin during ona- moath was given to 
0*iifrali<'id, Ut l)«in>ffiilarly uaodumwiu three <hk>-i( until Ina troiibla oauiad 

" W«f»t liM^k to hiii hom«, aomo eight iiinulred niilfxdiiiilHnt, and ]»iirsu«d 
IAm tfiwi l«^l "ot for him, but rrceived no benefit. Tlie luotion of his tei»- 
IMm o>»* nImoMi mriHlaiit, and the nerrous feeling thht induced drove liim 
•lM"a( franlif. <>(iii]Mrcd vtith it the paiue in bi» groiti)«. kiiffi;, and feet 
•wf* a i;<i«itirr r<'lii-f. He lienme vorj- low-npirito.1 luid deBiH^udent. KatIt 
Id IM/^ltur bla ptij-aicinn adviwd biiii to return to ?iev York and put hia)> 
mU utfiur my chvu Hj exniniuatiou discovered a penis of normal sue. tliree 
iU^tm ill i'irr-ijrii^mu.'« ; acmlum greatl}- rchixed aud cororrd with eeLo- 
itfff*— jr wmImi pri'xlu'.-^d \ry tbe carbolic acii) ; tcwtinW hanging very lov. 
Mr aUwiu'Wif WU4 at once dravm by tbe patient to the rfaTthiuical contraction 
ttl^B iMuutiAtu uiujwlea. tbrougl; nhich a see-naw motion of the testicleK 



I 



I 



DETKKMl NATION OF TIIK URETtlKAI. OALIBKE. 87 

was kept up, and which cooBHtuted liia chief annovnDC«. Palbous Muntl 
HQ Fruocb passed thu UMiiitoH, but vim iim-itUid n\ haU an iucli, u point ta 
wliicii liiU ffrontt^mt soDiiilivriiot^fl during piLssoge of InsLrumeiitH hiut iUwh^a 
beou referred. Bulb ^H Freuch {>a«&uH through aud detocbi another strict- 
ure At two inclics and still another ut twu and a half. On Fridujr. Octuber 
ITth. at my invltHtiou. the pnticiit wm cxiuiiJiiod by Dr. Coldlirun, of Tole- 
do, and DiK. Wco^drulTiind Howe, of Now York, vtipt-uiidh' iti reference to Um 
fl{iK8ino«1ic action of llie creina.itei'H. This wiia very iiiarliRil aiid coDStanI, 
and ooiitiuuutl until the pntieut was placed uoder the iuilueiice of ether 
by l>r. Howe. I then dciuuuistratcd tUu uizo and lucuUty of the HtricturM 
before aienliuu^d, and dividttd th«iii tii xuecc^ou with luy Iili*^ diliitin)? 
uretlirotoiDv, nftnr wliii^h I ptuiHcd with ututt! a 30 Frtni-Ii !fU:<A Hnuud 
tlirongh all and into tlic bladder. Ah the patient emerged {mm tjie in- 
flaence of the etlier. it wa§ oboerved that there wna do lonfret any of the 
anumodic tw^lion of the? cremiuter. When h« became ctuiKrioim he ntntvd 
luat lie nlrviidy hit I*>«m of bin uenrous feeling tliui for many diodUix. He 
waft cerLiun thnt iUt< ri^lit chord had b«eu Btrualc 

"UctolierSth, IniproTemeiit continues. No return of spasmodiaMtuMi. 

" October 20lh. Exiuuiuutiun tvith 3U Frt'tich ikIjows a slight clinging tit 
oiiefourth of nu inch from Lltt; c-xtcrtird oriBi'u. t'ut tliLs ut oiiott ana Ireeljr 
with stniiglit biat.oury and piia» -il French. The pntieiit, on the foUowJog 
day, eiin-eflB^I hia belief that a complete cure had been eSected ; that aioce 
tile Rnal divUu^it of the montus ho hml nut th« ii)i);ht«ttt return of tlw: ab- 
DOnnal seninatiDiis and piuu uLtli vhirh ho Lad in houm^ de^n'ee i-onittaiitly 
suffereil fur tlm jirtvioiia four ytsirs. litily iuli-oduiitiou of tli* bulh wutt 
kept »p in this case uatil all bleeding ceased, when the patient wim dis- 
luiiued with the jjrouiise on liiii [uirt to iDfumi ue by pu«t if he hod any 
return at Lliitt troiihk'. No Mut-h iiifortnniictn wiut ritci-ived." 

Dr. OtiH* vientioii th« normal calibre of tJie urethra, the morbid in- 
fluenue of alight t'LHiBtrictioMa of that fhanncl. aa well uu on the rutlical 
cure of Mtricture, li»ve btMiii before the profewnon for (t number uf ^'outm, 
bat hare uot b«ittu very extensively Ai.loptetl. The expkiiatiuii appears 
to lie largely in thA fmit that comparatively fow 8UFt:;couM have token 
tbe trouble to in^-eati;,'at6 the rosulte obtained iu prnctice bv the applica- 
tion of thuae idenit. The o])pi:)sitiuii and ho«tile {.-rilitism so pkutifuily be- 
atowcd aoi'ni to h*f biiKvd upim li prinri tlieorelic^d deductirnix rnllirr timn 
Open faiUirea in practice. In his recent work ujion g^iiito-unuary di** 
enaei), Dr. Otis mentiutia nunierouH aurpeona who linnt giTen the Biibjeet 
a fair laveKti^ittan, und who crrl.ifr to the favorable i«eulM obtained in 
pnicti<% by the Hp|i!icatioii8 nf tliv principtcH i-uunciated. 

It >3 diffif.ult for one who Una nuvfitlly invcKti^iUid the anatomy of Uio 
uretlmi in unmeroiia post-mortem exaiuinationH to accept the etutemeiit 
that the normal ciUibre of tlie urettiru in practit-aUy unifonn from the bulb 
to the mvatux ; and nieaKiin^mciitH mndi- ihiring Hfe with the urethrotneter 
ooD&rui the general experience of onatomiats that ttie urethra nornnllj 
and generally preaeota certain ali^bt eonaliit^tiuns in the pendul'^ns p'lr- 
tioD tuw\a fn>m that nlmoHt invarinbty fnund at the montua. Indeed Dr. 
Otin'owit mtviiturementit exhibit the fmrnt fiiot ; fur in bin tiibk- of "meoM- 
urenienttt of lOU aamt nf Ruppoaed uoi-mal iirothm- with tlie uretliro- 
riieter, tlie laensnred difference between tlie bulbnuH nrotbi'a and the part 
outarior to it woh." in ti vast*)!. 4 uql; in 2 ooae^, 6 mm.; iu 2 rjiHett, 6 
IDDQ- ; in 3 cnoeo, 7 mm. ; in 1 eoac, 11 mm. 

Since to these coaee, as well ns in those mcaaiired by Dr. Weir and 
otliem, there were uo tiymptorua whatever indicating au abnoruial condi- 




i 



8g 



mSRASBft OF TAB TIUKART OROAlf& 



tk>n of the (■enito-urinAry fimctiooB, it must bo uferrod that tlieae tilLglit 
ooobiM^iwiM nrt! normal and, of theoiBcIvcii at leoet, incapable of origioat- 
ing liny (liHturbitnrc of function. 

Uveii if there were pottsibilitiea for contciition u« to Ui6 rrlotivv ciililire 
of the urotbru at diS'trcut porlioDs, there can be no dixpute as to the fact 
that ill tbc vml uinjunly o( cases tlit meatus is decidedly mnallcr than tlic 
nTorng4^ of the caimL It wrouU lu^zn tliut il coiitmctioa nt the meatas 
ought to esprt at leaKt ns mach distiiibing infltieiiue ns a tiiiiitl&r coutmc- 
lion posterior to it. Ur, Otia fumiahea' ft table shrtwinjt tin- rahi*™ of the 
urethrol oriluNi iii llM) ninp^ in which no inllntDtiiBtory condition haci ex- 
iiit«d. The cin'inufciein'T of these varied from 13 t«'37.5 mm., the awr- 
ngi> nf llii^ lUO betti^ 24.72 mux. '' In nu Ruse v-aa the iirothra, in tho 100 
cases, below a calibre of 20 utu. — tuiiging from this to 39 — the arerage 
beioff 32.95." 

It vrmild KtH'in, tht-rrforrr, demon stmt4'd by I>r. Otis' n\rii meaaarQ- 
meuts, aawell ns ihoae of others, that eontrftctionn in the ndibi« of the ure- 
thra as well ii« it« oritie© nre perfectly normal ; tlint they tiro found in 
cases wlwro no iiitl:iiiimiit«n'}' or other abnoroia] conditioa of the iirethra 
luu «xi(tt«d to or(<j:iTiiit« them ; thiit thoy ore in other wunU cont^nitul and 
fi-ei|iU!iit ; and (hat tlu-y oc<.:a«ioD no distiirbiince of fuiictiou ko loti^ ax the 
urethra reiiiiuim free fi'om disense, notwithstanding the great disproportioii 
of tho calibre itl tiif%i> poiiitK of coimtrictiuii tu the getieml size of the oie- 
thm iind to th(^ circtimfcri'iic** of tlic ihmiik. 

When, however, the tiivthm has been the seat of inflammntioa, it is 
qmte poasible that these eonRenitiJ and nornial constrictions of its calibre, 
cnren when wi slight iw t-f> cunnpe drt/tction by tho or<linwT inst.riiiiicntit of 
•xpluration, iway afjf^nivate and pnitoiii: tJie atfwtion and Jitdnco coiiiplica- 
tiofiH which I'tiM he rehe^vd ooly by tlie removal of the eonstriotioii. In 
m[>port of this assiimptioa there nre certain analogous facta aud dii'cct 
<tt*tn<>u Ntmt io [iH. 

It IN n fntuiliar anrl unqueHtioueil oheervatinn thnt u decidnd eonfitnc- 
tion of the uretlirn nr of tlie tueatua originated (X)niplt»ili<inR in the cxiurae 
«f urethral LulUmmnliou which can he relieved only by thi> removal of the 
ronBtricti-:* ; iiin.ny i» oaeo of gloet, of drihbhng^ after nriiiation, of nound- 
giu of ihe ufcttini luid bhwldtr-iiwi. liss been relievwl by tlie dlhitntion of 
ft nnrrnw ntn.'turfl or the divi.iton of a nnrrow nieatus. It would seem, 
therefire, plausible to suppofie tlint a eon«ti-ictio» of th(( urethra, even 
thoui^h it admitted n In.i'f'er sound thiui oould pit»8 the nvtrii^e nie-ntiiK 
Htt^ht exert 'ffprtu Kimilnr in Wind if not in dt-greu. Dr. Otis Iihh certainly 
duiuounti'ated Ihiit !<u('h coiiKtriitiouR, congenital or acipdred, iunycxi«tiuid 
eBcape det>ectian by any other inBtnunont tban one cuiistructed upon tliv 
j>rin<}i(pJe of hie uretlirometer. 

Yctthe cjHCBtinu most be dotiided, of rourse, not by d joriori rcnson- 
iog, but by actual U-ut in practice. Aa already stated, thia lest hiis not bean 
mode so exteuflively aa i» required to determino finally nnd delhiitidy how 
far these " strictures of larpe calibre " nre to be held reajionaible for ccni- 
tnl and iiriniuy iliHordrrM. Dr. Otin hiiuitelf liaa fiirniahed a Ion;; list of 
iiues in which the division of au<^ oouatrictiona, both in the couivc <^f lln' 
urethm mid at the meatus, haa been followed by relief from sjniptoms 
which h.td defied all other ntethodit "( treatment ; nnd xi'viTiil other sur- 
geous, notably l>r. S. W. Gro»», of Philadeliihia, have upon the bosia of 
pnuitical cxporioiiec indomed more or leaa completely Dr. Otis' iuu>eTtio&& 



I 



XtKTKRUlKATlON OP THE UBSTHBAL CAUBSB. 



89 



Hjr owu Byst^mntio invOlMgatioll of thimiubjoot hegun onW a1>out four 
yeam ngo : and ntthniifjh oppoitunitiM fnr ob«erTtvti<»] (turini:; tiiAt tinif 
hn-vv Ixi-ii raiher extensive njid have com-imreil me that atrictuntM Lit Inrjro 
onlibm are ofteu responsible for morbid noiuiitioiiB, they have not piiablcil 
ine to ileU'i'ininc- ti> whiit rxU'iit tlic>H« constriction a are imlirectlj,' prmltic- 
tJro of functiuiiiil tibnoriiialitic^of tliu urinary and guDitul orguua, oa luain- 
tainflil !>>' (JtiH. I liavR learned in rt^gnnl the iirethroBietor as ad eeeontint 
meaitit of dia^oFiiii in inniiv diaorJent of tlic- g«iiiL(><urit]arT a[i|irLnitus ; 
indeed. I m.iK« it a port of fvnry examination of thase organs imle-'*s speriai 
cartiumstiinces foi'bin. Yvt I do not regard ev^rj- alight conBtricUoi) which 
lauy Ix) d!aeoTer«d an rd indicntioii fur oprnition until other DiOHiiti of 
diAgDoHiH havfl been employed and other jmuiible abnormalitiea hnro heeii 
removi>d by 1^h» rndiml meftaiir^s. Even casea of gleet aro Min)«Liiiics 
curable by ttipical nppliuntiou» without divLsiua ol untliral constrictioaa 
which may iw present ; and I Imvo ri»poale»lly seen a glet't uuutinuu aftar 
ihe reinov^ of such con^trirUuii)) and tb« paaaoga of large wjundit, until 
such topical upplicalionn weru mude. 

A careful cxami nation of tlio iirothrft in twenty-two men who hful 
never had gauorrbti^ nor otlier wetlirnl difBaulty hint furnUb^id iho 
following resiilU : 

1. The bulbous portion in the most capacious and gradually decreaacH 
in mlibre from hehiud forward fur ubout an inch or au inch and a half ; 
from thiti point to the meatua the calibre in aometinies practically uiuform, 
but often exhibits slight cotwtrictionB which are not oonatont as to looatiou 
or nisc. 

2, The nnrmweitt point of tho channel (pxnept th« mojitiit)) was found 
in more tliao luJf the caieos at about the middle of the peaduluiia urellira. 

ii The diSisroiice in wipacity bfhvt-cn the widen) porl ton (the bulb) and 
the narrovoet point (tho tnid<nc of thu ]M)nduloiiH urethra) nny omoimt to 
fire, t«n, or eren twelve milliitieti-eH. 

4. There is no «>Dataiit relation betwettn tlie ReQerol urethral calibre 
and the size of the incattw ; the lntt<ir in Komotimes almost ns cfipnciou§ an 
the urcthm (iu one iuqtam-e admitting easily a Nu. 96 bulb) but usually 
isiinh uniailpr (by ten, fifteen, or even twenty nuillimetrrs). 

In another aeries comprising' aixteen cases I measured the urethra of 
individuala who had hnd ^^unorrbcrta ono or nioru tiiiiL*H, but y/cro entirely 
tna from gleet and other ahnnrmalitinH of the urinary organa. I wiw not 
enabled to aatiitty myself that the uvethi^ in these cau-s exhibited ajiy 
marked and confttant dsviation from the features presented by the caHeti in 
the first serieti w!io ha<l never had gonorrhoea 

Slight coiitractioun of the urethral channel seem, therefore, to bo eith«r 
OOitgenitAl and iintund or are fretjuently nrodueed by other influeneeii than 
flonorrlusa ; they way doubtless result from mnsturbittion and probably 
from litbiana kIbo. 1q every ciiho of urinary or Hcsutil dvnui^'Mnrnt, tliutr 
•lintoiioe should be notud ; whetht-r or not 8i]<>h ronsLrielionn ahould ba 
divided itt a (|iii-Mtiua which inuat be d('<-ided by their prohable relation to 
the morbiil mndition aa well as br the remits of other remedial meoBitrea. 

Idke other methods of examination and treatment, this one haa ac- 
quired much disrepute from il^ nniplnyiuciit in cn-ieit to whioh it is not ap- 
plicable. It ia tiufortuimt<> that tho Kpecinlist in senito-urinnry. aa in other 
oiseaaes, actjuircA a routine method iii dia^osis as well as treatment ; h« 
ia )>rDno to the wloption of aome onu uitilhod to tho cschiHion of all obheni, 
and in hin i»>aIoiis application of one ignores othen of equal value. The 
endoaoopc, fur exiuuple, has a most Tsluablo lield in toe djagnoaia and 



90 



CI5EASKS or THE URtKARY OROAK8, 



treatment of nrotlinil disensciii, n Itolcl which cnn Ih> or«tipieil hj ao other 
nmuis or iDStnuii«utii ; vet encioAcopists have etiileavorvJ to crowd into 
tliitt limiti'fl titUil clAftBCii of casoa iu which the endoscopo ia either umIms, 
or at l6a>4t fur inferior to other iii>«tnim<;at0 for dia^uogis and treatincnt. 
The reHull Iiuii b«eu Ihut tbo pruftiH»iuii praelio-ally i<;nui'eH the eDdoorope ; 
for, liaviDg provMi Uio fiUliicv of Hit- cliiiiiiit iimkU; f<)r it iu niani,- caaes, we 
Hje dispoM-'d to i-egard it fu e^guallv useless in all — to reuoou tlutt eiaao it 
eiuinot do flverytbiiig ai>>ierte<l for it, it cuu du tiothiui;. A iiiniihu* hjimod- 
Di*t)Uoii preTflihi Inr^ely, as I tliiuk, with rcgnrd to the " strictureA of lafCO 
ciuibrp " nlioHc putLuluj^iiul iiujKirtAuco Dr. Oti» hus hccu »o inBtramental 
in hnrifni)? L>oforo the pt-ofotutiou. The oliniraJ iiiiportjuicfv of theee strict- 
iiTfM liiiK liw-ti much esa^Jtgei-ated ; that is, they have be*u held reti]}oiiHiblo 
not only for Kome but for all of those cattcs of obscure and obstuiate affeo* 
(ions of the urethra imd bliuldrr which rvKiitt priiuitivo ti'tvtment by sounds 
and inject ionx. The ri'SuU htm b^u that eDthuaiitdliv suppurteis of Otia' 
plan of trcntineot bavR Roufifht refuge in a reid or iinu^tary dtrii^tiiro of 
large calibre iijjoii slight provocaiiuD, luid without a coniplete invfett^^tiOD 
aM to oth<-'r morbid fuctors ; luid thu failure to n-lievc obHtiuat« symptoiDs 
by the division of mioli stricturo in oascB wliere other pntliolo^cu coodi- 
litiiiH were jiit-'Bt-iit, has brought uudctwrved discredit u|M>a tlie entire aulv 
j«fit Tlierfi CfUi be no doubt tbiit a divisioii of a utricturo of lar^e calilire, 
recoguizahlo only by Otis' or a Riinilnr urnt}irom«t«r. Las e&octcd the relief 
of*yuiptouiit which t^ouiidnf, injectioiis, and the endoscope wer*.* po>^«.-rlfe» to 
I'tUDOVe ; tut it ia equally (certain that such dividion hiui been i»erformed in 
many cases Tvitbout beuefit, simply hocjiiiso the morbid symptoms were 
dependent itpoii isouie other putholo^'iejil coudiUoii. The ilucrL-dit re- 
dounds, of c.oiiifie. unt tn the method but to the surt;eon who iii8tst« upoD 
curing all cases of whatever nature by that one method : just as the dis- 
credit iiito whirh the ciidoftcopv hmt fulltu ia to bo tuM:ribcd. not to the in- 
etruincnt itself, but to tlio fully of thoao who can Sft« iio other 4»iuM for 
urethral aymptouta tlion a real or imaginary granular patch in the mucous 
membrane. 

My own experience lias denionstmt«d tbo morbid influence of stricturra 
d( Inrgo calibre and the nccvsaity for tlieir complete dirisioD (by Otiu' 
dilating: urcithrotome) in the follonnog conditions : 

1. (iUvt. Tliat a gleety discharge which has mode the usual round 
amon^ phyHiciiinB, and has for ycnrB ri.'Kietti;)I medication by iiijcctiuns 
and the piuwiLgo of lar^e eoundK {i'2 to ll> EugliKh), ia often maintained by 
& alight conittnctioQ of tli« urethral calibre and completely and immedi- 
ately reUeved by the dirision of such coHHtricLioii. I have repeatedly dcmon- 
stnted ; in one of my cases which were pi-ouiptly ciintl by tlii* itiellitK]. a 
No. 17 Kni^UaU souud passed readily into tlt« bladder ; in another and 
uniqun «(i«o (naiTalod on a prenons pnce) the urethra a^Imitted a No. 22 
BOuud. Yet with thii greatest deference for the authority of Dr, Oti», to 
whom the credit of di^iuomttifiting this important rehitiou ia chieflj due, I 
mtiitt dinaent from hia (insertion that ftle«t i« aliiv}/" a proof of stricture, or 
fu» he states it, that ■' {fhtet is the signid which nature liuugs out to notify 
the patient and bin 8urt,'*oii Hint the urethra is strictured ut Bouie point. 
For I liave tri-nted u f«w catieo in wliich I was iiiinblo to d«t«ot even a slij^ht 
strictiire, ami in sevei-al otliera I have seen a glvet continue alter diWeiou 
of kli^rht strict ureB and pUHSuge of fuU-stzed soiiudtc One of tliese was the 
foUovrinf; : 

A railway conductor, aged lorty-onc, bi^d had three attarkit of goDor- 
rh«ea, the last ten mouthB before he couBulted me. He had been amioted 



DKTKRMINATION OF THE DRETHBAl CALIBRE. 



91 



innce t3i« last attork with « persistent gloct, whicli bad ttaiateil troatment 
bv aouude ftitd injections in tli6 hftiidA nf hin phymaiin. After sevmil 
months ot tliis* treatment, tturitig wbit^li no iibat«meiit of tb(! <li»cbiir;5i- hnd 
owuriwi, the pliyaifiian explore<l the urethra witb t>tw' urethnmiflitr It 
wax foiiiitl tbiit the geDeral ciilihre waa 34, while n coiiHtrictioii to 2^ wiut 
deflected about oni; uud a hnlf iucli back of the* inoiilun. the Uittor meaa- 
urin*; 38. TLia couutvitrtion was by lURaniiof Otis' uixillinititmit cularg«d 
to 3'i, tho meatus I>f iu;^ also iucised to the same osieut. The calibre of 
the ur«thm. was niaintaincd b; tho dnilj piwimgo of a 'i'i unund. 

The t'leet cAntinued almost iks prnhisol^ ns befor<>. Two months aft«r 
tlte ofMtniliun, thu p:itivut ei^nsulted tut. At tliitt time n 31 Prrnch sound 
posted without difllculty Into tlie blatUier, cautting eoinf jMiin «t a jKiiiit 
two iiiclicH behind the meatiia. Upon esamiuatiou witli Uiu eadoai-opi!. I 
found the niui'ouH nicaibraao juHt posterior to the former stiicture ({uite 
rod, etii^htlv (^muiihir, mid proHeiitiiig near the iiii>diiui liii(> uii tlii^ th>ur uf 
(Im cannl » mans of ditbb^' {fniiiuliil ioiix mni-e thun an (-ighth of an inidi hi 
diatn<^t«r. Tlieae were reinnved by meaun nf (he snarp. thR Iiiise toiicJied 
with a (oi-ly itffT cent, solution ot the nitrate of fiilver. and the aiurounding 
t*h1 Kiirfiuiti penHlled wilh btiicirtonn. In Iphb than two weeks the di»- 
clmi'^'i.^ o-nitei1 entirely, aud up to the pretteul tune taljout ]iv« mouths) han 
not riitiii-ned. 

'i. Irritabitilij of the bladder, manifCHted by frequent urination, •with or 
without p,tiii. In nil of my ca»eH of this c»t«f^»ry thtru luw bL'Bii mure or 
loan hyjKntHit kexiit of the urvtlira, atid the kouihI Iuim ntvcolud v«:ry iMiDHi- 
tive Hpol« in thia channel. 

3. Varioufl »'j-tia[ disordvri', caperinlly thoue npparGiitly due to hyperaw- 
tliMiin of ihv {iro-itAt(% and niatiif(iNt«d by ubiionnolly frvgucnt puUutiouii 
and piviiifttiiro (^•jfwriilntion. 

i Ohronif: infiain motion of the prostal^ and bladdi^r aa a sequel of 
gonorrhu-ii. Thu division of comd-i-iclioosof the mcntuHAud urotiuii hiut 
omasionally trMnnforiund an nlwtjimtft into a tractablo ctwe. 

Duubtle^ die pasaaRe of a wmnd largo enough to ooinpUtely distend 
the urcthni — posisibloonlyaftvr tho divisiou ot ouch constrtctioUB — coutrib- 
uleH larj^ly to thi< bciiolit i.-oiiforrod in luauy of them atseti. 

la itev<;ml otiw-r uixlatinett I huvo divided idigLt conxtritrtioTiM And (Jiiut 
renderetl the pendulous urethra of uniform palihrfj throughout, without 
the ali^dit^st peroeptiblo improvement or relief ot symptoms whioh. after 
thi; failurvof othi-r nttnodinl iniuiitnroH, I hail beliorcd t<i be produopd or at 
lewt miiiiitjiinetl by urethral contttrirtionit MoHt of Uiesv cjweii ha?e ex- 
hibited irritability and neuitdgia of the bkddoi-. The fnilnii- to wdieve 
thctv pcitioDtii does not diHpruTo the morbid influence of ahi^Ut urethral 
Rtrinture* in many othi-r K:im», but merely demon»mti»H my error in «t- 
trilmliug the Hyiui>t<>iii.t in tln'Mi ii)Htnnnt->» to xnirh coatifcrii^onM. How- 
ever, the oporatiou haa rarely produced any serioua reaction, and usiudly 
permitii the pntie<nt to resume )us voeatioii in twenty-four hours: I h&ve 
ime«t«dly ptirfarmtil it without nnFcnthexin. Hphco in nbncur»t or doubt- 
ful cases the division of Hlriotures of Ur<{« caUbro in jiistitlKble as a teiit»> 
tiv« and diat^noatio oi>eraiton. 

My improMiou in regard to tbia matter ia, then, that tlie presenoe of a 
»t]-inture of Inrge calibre may he the meima of prolooftin^ aud agf^mntiug 
various diaordor^ oriyitiating in a urotliritis ; that in ovoiy caHO in which 
urethral inHanunatioi) has occnrrod (perhaps in othent also) which exhibits 
a rofraotory hitliavior townrri ordinaiy uempeutio moann. the urethra 
should be esatuiued an to Uio puMsibhi ttustcnoe of sach ooOHtrictiou!), and 



03 



DISEASES OF TUB VBINA.B7 0B0AH3. 



tliat lbCB«, if detected, ehonld be removed. On the other hmtd, it is doabt- 
Ivus a mistake to Kuppose LLhI UieBe " 8tnt;tiire)( at l&rge calibre" consti' 
tiito tlio knr to nil tlic<)bHtii)ut« nnd obawun- ittT<^(!tioiisof tlio gcnito-arinftiy 
ort^ADS. The explorotion of the iire^ttini with an instrument consLruotml on 
the antne pnncq)ilo iih OMs' uretlirometer sboiild b« reoofpiixed as one of 
the means of tlingnoeio, but only one, nnd not « complete and thorougl) 
examination in iloclf. Mo■^■llV(■l■, tLu <]i»rovenr' of sucb n couatrictitm in 
not of itAolf A Hutiifliont vnrrant for uKtiirotoray. until iho jtvmptonig and 
the elTt-i^ts of treatment indicate etroaglj that the conatrictiou is the cause 
of tlie di^culty. 

CATHETEIUZlTMISr OV THK CbTTEB. 

^is is a measure wliiuh rntght in exceptioii<J casea posseES extreme 
value id diu^nuaiH, {wissilily la treatment also. The atlY(int»<;fH are obvi- 
ous : it would bo n repuiar preliroinary to any operation wliich mi^lit in. 
tc'Tffire with the f iinctifiiiB of akidtic^', sticVi nsDc<plii'ei.'t«iiiyor neplirotomy. 
Tho iiitruiUK'tioii vt a cftliicttT into tlie opposLl** iiret*r would enable tlie 
siirgeoti to Hiil.irtfv iiiiiiKiilf whctliiir or not tlit! tw^t'oad Iciilae^ vtiM iirt-wcnt 
und iu a heidthv coudilion ; for it baa repeatedly happened tbut fitter tlie 
removal uf one Kidnvv thf jtatli'iit hiu> died of un(.>uiiii, bE>niuKe. as lias been 
revonlcfl pi>st-tniir(fm, tlie L-xi-iaed orpin wim the only kidnvy prrwnt in m 
L-uiiditioti to tliwhargo its fiuictiona. Tiie introduction of tin- aitliil«T intu 
the ureter mi^bt iibo solve nqUGBtion iu diafrnosia which roniiot alwajubo 
docided by tho pi-cspnt tnctbuds of eiaTninatioB ; namely, whether a g^iT^n 
fluL'tuntini;; tumur of tlio ubdom^m in u, bydroiiopbiYisiH or au oturiau vyrt. 
Pomkihly a hydroncpkrofiis could bs evacuated in t-hift wny. Such a meas- 
ure would give certainty to a diagnosis as to the pi'eBence of a calculus in 
the ureter ; it miffht even be uneful in pushing^ back the calculuji into the 
jwUnsof the kidnry, or at least of detenoiuing wlwthcr or not noplirctv 
louiy would \tv necessary. 

Sneh ftdviiiiLapeu would undoubtedly accrue from tlie introduction of 
the catheter into the ureter if this nieostiro were (^ciiemlly practised Up 
to the present time, howeTcr, but'fow have been iible to overi-onio tlif ex- 
treme difficulties which oppose the 4<xecution of thiii jilan. Indcc'd, it has 
been ncconiplished only in the female, where the anatomical relutions are 
Kiicb fut to oppiMto but Httif diHiculty an compared vrith the &itiiatiun in the 
roal^-. Simon lir»t pructisi'd tHvthot^'rization of the iiret^T, lifter dihttatioD 
of the urotlira. Ho performed UiiH luaiiipulatioti on seventeen womeu, 
and in all but two oastis HUt^ceeded in readiing tlie pelvis of the kidney. 
Othen), h<)wcvcr. vfho endeavored to repent the operation found extra- 
ordiiiiiry dilficulty even aft^T Uio urethni nas dilated up to 2 ctiu. Thua 
WincUel and Kut<^nborg failc<l entirely, the former Jissertinp that he could 
not even recofifnize the orifit-e of the ureter. Moreover, the piehniinary 
dilatation of the urethra constitutes a seriouH objertion to tliis method, not 
only because of the necessity for unirsthesia, btit also and especially Ixicause 
of thu ill eSuL'tu uometimcs cuuaequvul thurtiupou — iuooutuicnue of urine, 
eelluUtiK, and fatal peritoidtia. 

Tlie next eueoeBafiil attempt to cathoteriw> the ureter in the female was 
made by Urunfcld, By nieana of a ahort, wide endoscopp, the inntT ex- 
tremity of which wiLS oiosod with glasB. Grtiufeld n-as enabled to bring into 
tho litJd ct vision the opeuin^ of the umler, aud then to introdueti into 
tbiH a Hoimd of Hperial construction. He has in tJiia way pamed a sound 
into the urotor to the depth of 1 5 ctm. Thiis method I knovf by experience 



DKTBRMINATIOIT OF TBS UKKTUBAL CALIBKE. 



93 



to be «xtr«mely difficult ; it requires, on tlio part of thn opnrntor, considei^ 
nblo fcuniliarity with the inBlruuietit. mid iiinuh [»iti«iice wnl pr&ctic« iu 
order to diHtingiiUh tho opening nf the iiret«r from ihtr. iimncrone folils 
tad dt!prc3sit>ii» preseiiled bj the nnicoiiH m^iiibrane. It is impracticable 
eseept when the bladder ia diBtend^d. whereby these Tolds are t)l)htBnited ; 
and the opacity of the iirin«, ng^rftvntcd by tbc cloud of inurtiin which soon 
wpean u the n»ull of tbv irritittiuii CAiiined by tlie iiiBtruiiK^nt, reudc-rs 
tuis inAnipulntioD tAdioiut nnd uDrcrt^iin oven after loag practicf>. 

TU« siitiplest (ind nxwt practicable method yet presented wiisdeuion- 
Btrat«(] in September, 1881, to the '* VeraiiuiinluuK Deiilsfher Nalui- 
(oracher " ftt Salzbiirg, by Dr. Carl Pinwrlik. This depends (or its oxecu- 
tioQ npun the foct that the trigouuui of tbe bladder iu tlie feiuale— at 
whose npiffe« tlie wretcn* opea into the hludder — is di^tingiiisbnble liy 
both eye Kud finger through tlie rngina. Pnwlik hnppened upon this 
ntethod of suundiDi; thu uretorM by hie observations in coeeu of rcnico- 
Tftginol fi^t^iln opnrAtcd iipoR in Carl Ilraun'a clinio, where be wnn niti>ist- 
Miti He fimud that by iuLrodueiog the finger through a fistula into the 
bladder, a tjatheter paatted llu-ongh the urethra could be readily directed 
into the ureter; Huimcrjucntly lie obsurvod t!i«t the linger in the vngtna 
ftflbrdcd ttic aeoeeaory na-stataiiw fur tlio saute pui-potte. Aa oripually 
practiced, tlio patient wiia niarlo to assume the knee-elbow po«dtinn ; a 
Sima specnluni retmcted the posterior wall of tlio vfifri""- bo that the oper- 
ator could botb st'f and fi^tl thu projection in tliP niiWriorwall correspond- 
ing to the trigonum vpainm. A ftoiiud introduced thi-ough tiie urcthrR wiis 
then guided by the finger into the ureter. Subsequently Pawtik found 
that inspection of tho imginu wna uuut'cviiiuiy ; by pincing the nuniao 
upon her liAck in tlwi ordinary attitudo for vaginiJ rxnininntion, tho linger 
in tl)9 vagiaa sufficed to direct the instrunient iu tho bladder. Pawllk 
thus introduced Hounds into the ureters in Mereral cases in >vhich Billroth 
performed the vaginal extirpation of the utema, thereby affording the sur- 
geou better tit-ilities for avoiding the ui'eteni. In the suiuiner of 1S62 
Fawlik informed me that he hwl nuccreBsruUy catljeterized tho ureUrr in 
more than forty cases, having failed only once ; this toilura was tine to a 
decided prolapse of the titerua. 

Howover simple this method may appear, ita aiicf^enHful czor'ntion re- 
quires, nevertbeleas, onudersble practi«e and patience. I hrive performed 
it repeatedly on the (.^tiditver. but have not always been HuccesafuL I use 
n flcKiblfl Hoiind, itat hulboiiM iistrvmity having a calibre of not more than 
No, 4 Charri^re. The iustrumeut is straight except that the hutt half inch 
(at the bulbous extremity) is bent at n tdiglit angle with the iihafl. \Vitli 
the finger tii the vagina the apex of the trigonum is recognized and slightly 
raised, ho that the orifice of tlio ureter shidl rest uu the inner side of the 
fioger. The point of the Jnatninient introdnoN:! into the bhuMor can 
readily he detected, and should be guided so as to enter the oridoe. The 
finrt attempt wdl probably ha uosucccaaful ; tho point engages in the nu- 
coiift uX'mhmnc in the %-ic.inity of the ureter, and the mistake is discovered 
only when the effort to advance the iastrunient meets with decided rceiet- 
mice. When finally the inatmnient enters the ureter, the fact can be aacer- 
tallied by observing that while it progresses readily in the direction of the 
ureter, it cannot be muvtd Utemlly without decided resitttancc. 

A catheter of npproprinte fdzc~Dot larger titan No. 4 or No. 5— can he 
aUpped over the sound after the closed end baa been cut off. If it enters 
the ureter, it usually advances without mucVi obstruction until it reaches 
tha point where toe ureter crosses the ouiumou iliac artery ; here a oon< 



94 



DISEASES or THG imiKART ORQAKa 



uderable, eometimra iosumiouDUble, obsttwle is offered "by tbe cbooge in 
direcUoii of tho ureter. 

WliiU' iliiM iniiilicKl is I>y tio mcAiiB easy of execution, iL lit praoticablo, 
requirfiH iii> iirepni-iition on tlie port of l}i« imtieot, and nn itistninienls of 
npcciiil coiisliTiftioii. It hIiuiiM be uiuIt^rULken Ja evcrj case wliere its ruc- 
cessftil cxi^ciition vroiili] \w .-t iiiiitt^r of inijiorluuco in diftgBOou ; for erca 
if uii!tuccen»fnl. Hit- uttnnvt, wlicD carefully aotl jtidiciouKly made, inflicts 
DO injury upmi the jwtieut. 

The introduction of the catheter into the ureter in tbe male luis not ns 
yet been accompli titii<Ll ; the auiitomical r^latioiii! are such as to offer but 
little eiicoumgi<m«i)t to tbe tittt^mpi. Viuioiiit mciunin-R liavo been (leviKccl 
fur the purpose of ftecuhnj:; tbe urine from one or the otlier ureter as rv 
qiiirRfl. Tlieao lueasureH have couHiBted in tbe attempt to obiitruct one 
ureter so oa lo prevent tho escape of urine from it into tbe bladder ; tlie 
liquid which thiu <'ulleL*t8 in tlio bliuldcr, btiu^ derived from the opposite 
kidney. lUI'onlH thn ninang r)f otttimating the condition of thin organ. 

Tlie fintt melhoil devised for tliis purpose was contrived and executed on 
hia own person by Teirhroonn. He L-oustructed nn inHtrutnent reseinbUnK 
a liglit litlintrito ; this vius introduced into tlic bladder, the jaw» Mepnnttcd 
itiid tb<:ii approximated so aa t« romprcstt the orillct: of oue nrt-t^r. Al- 
though the meofnire wns carried into execution by Teicbmnnn upon bininelf, 
apparently with success, it xvas cot ndopted by others, for obvious reosona 

Otbcr phuia biivL- been lric<i. banrd iipoii the ocx'Jtiaiou of on« ureter by 
tbe prcEuuirc exnrtod ov^r itH v^'ftical orilicn ; one of tJit^ nnnt promiaing 
of these is that devised by Bilbermanu, of Brealnu. A metallic catheter 
(No. 18 French) is provided with an openinp one and a half inch Iobr 
npon tJko ttido and vnth «evcrnl nmnll perforations at il* extr«niity. Aftt-r 
the iur^truiuent Itait been introduced, a smaller catheter is paaee<l into it. 
Over the end of this smaller tube in titled a rubb«' bnj?, nhicli, when the 
mnatler instrument iii in positiou. (ills the eye of the outer cntlieter. This 
instrunii-ut ia ho placed tliut tliu L-yv rtinta Afniiunt tlic oritice of the ureter; 
maetmty is then pour(>d into tlio innpr tubo, dilating the rubber bag and 
compressing this orifice. It is said Uiat tliis iustrument has been success- 
fully employed in securing llie urine fi-oin one kidney only; yet there 
flectns to be nftCawmly an elemeut of uuc^i-taintj' as to whether the ureter 
is completely occluded. 

In other cases tbe hand has been introdnced into the rectum. Uie 
uret«r sought out as it passes along the posterior surface of the bladder 
and compri-tuwd betwetu tbe fingcra. Thi» m u tcdiouH uianwuTre, not en- 
tirely devoid of danger to tbo jwtieut ; and after all it nQbrds no certainty 
of accomplishing the desired object ; for the fingers, whidi must compreaa 
tho urct«r for ten or fifteen minutes at Icaot, require occasional change of 
pomtton, during which movement the urine vhich bnK ooUoctod nboro tiw 
point of cotupressioD luay powuibly eacnpe iuto tbe bladder. 



en AFTER IJT. 



rHTSIOLOGT OF THE CRrfE. 



The kidney ia nn n^grft^ration of tubiilcs, each of which Becr«t«a iirini\ 
The (lUicly of tho pmcfiRS wbrreby the iirinp ia BOirreteil conHtflta, thorefow!, 
in a study of ihe anDorjr tubulo ami ilu fuiictione. 

Tlie ttibulc ia a mioroitcopic l-huhI uliicli begins at the pvlvu of tba 
Iddncy (of Tvhi<!h it ia indoed a prolonfratinn), exU^niU t.hmii;;h tho entire 
breodtli of tlie kidiioT, and termiuatvs in an expanded extxciiuty in the 
Mirtical purtioii of the orgnn. The tubule contuata of un elimtic <'ylinder, tba 
inner (voncave) nurfrtpc of which is coverci] v.-ith cyliiiilricjtl opitbclial oeUs, 
whose broiKl biwet) real upou Ihe elwtlio baeemeut, wbile tli«ir Jiarrow eLda 

. point into the lumen. 

The rarioUB portiona of t^e urinary tuhule have been designated l^ 
dilTenriit unmex: the llrat portion—that which procuo«lti iu a alraight 
eoiirso from the pelvw to the cort«x — Ifi t«rmo<l the "irtrftitrht tubo of 
Bellini :' tli© next segment — that which nuia from the cortex into tJia 
medulla and then curraa back aii^ain into tlie cortex — ia colled the "loop 
of Hunl*;" the terminal segment of the tiibHle^thnt wliivh prcnoiitH a 
aeries of short, irrejrohir ciirvtw — is dcoi^runtt-d tho "convoluted tubiUe." 

Tile expanded blind extremity of tlie tiibide ia depressed ; that ia, tlie 
blind ond of the tuba la pushed into its cavity, making a rup-ehaped de- 

^prcHBioo, juitt Hucli na would bo pro«]uccd by pushing; tho end of n glovo 

■ finger into ittieavity. In thiit ciip-fthnpi^d dcprcsKioQ te»t» tliA bunch of 
espiUsries termed the "Malpi^hiaii tuft" or "glomerulua." Tlje de- 
prctncd. blind extremity of tho tubule is closely adherent to the Rlom- 
cniluK, which it nlntrMt nomplotcly encloses, learing uncovered only a small 

. qmce for the etitntnce of an arterv nud exit uf a vciu which cnrry the blood 
to and from the RlomeniUiH. 'fbis portion of the tubulo covering th« 
glomerulus in (icooi'dingly termed the '■capsu!e"of the pflomenilus 'iFiff. 1). 
I'he ccUa liuin}^ tho tubulo differ in form and bIzu in the ditTr^rciit mi^ 
ments of the eanaL In tho Rtniif^ht tube of Bellini nnd in Honlca loop, 
distinct cylindrical cells are diHtiu^'uinbable ; in the couToluteJ tiibulea, on 
th«; other hnud, the epithelium coufunta of a jelly-like miiKa ill which ntudei 
am iml>o(Med nt r«i;ulnr iuterrala, though no sepai-fttion of tho miua into 
distinct oelln is posaihle. 

The cellii con§titntinp the blind extremity of the tnbiilo — those oorer- 
ing tlie glomerulus— are thin, flat acales, apparently identical in form with 
the endotiteliid ci-U* which line ttio twroua aivitica of the body. They are 
therefore entirely difr«ront in appciimuce from thoxe eoostilutin^ tho rcBt 
of Uio tubule. They appear to lie dire<'Oy iijtoii tho cu.{iiUiU'ic9 of the 
gloinirnilaa, there being no hnacmcnt mFmh'raiip inlerpn.icd. 

Tlie tubulo in surrouoiUd throughout almost ita entire length by capil- 
lor; owslieB. The brnnohe* «f tho reuttl artury paw ftvui the hilus of tlui 



90 



DISEASES OP THE URINARY OUGAKS. 



kidrM^j* bciworn tlw Htraif^ht tuhtih-K, uliri^ )hi*v (Uvidc into two wit* of 
reasrlB. One wt diride Bt mice iiitotliR rapillarips nhHi HUiTound the 
straiKbt tiibules : tbe other set of m-tt-riea pi-ocped between the slnu^ht 
tnbiues to tlic corU'X of tlif kiilnoy. wltcra oaoli t<inniiintc8 us n {:liiiiirriilw8. 
The vein omergiiig from tlio bIoiii<,tii1ii8 cori<luct8 tUe biood to the iielwork 
of <!apLllari«ii fluirouiiiiing thft coiivoluted tut>ulea. It is thus euiliut ibat 
while all the blouU wliicli enters the kitluey pibsses tlirougli Ibc intcr- 
ttibiibii' cupilhirint. ou\y n portion uf it n'liclieH tlie {^Umienili. 

Ill tliiH coiiti(!(-ttnii it m intnreiitin}; to unto tliiit in ccrtiiiii unipliiliiiiTiw 
there w a iiiftrk<-<l diffvi^iive in Ibe blooil-Riippl.v to the ploiiieruli anil tit 
the tubulea ; llie fomicr receive bloorl (lirectlj- and only I'rom the renal 
nrterj-, while tlic capillaries fiiirruutiiSiii};; the lul>i.i!r« nrc wijipliwl iiIm> 
by A renni portal vein, whtrh ti-imsfera bluod fioin the uJiiiuutary catial 
to the kidney. Henf<>, in man on well an iti th& lower animals, the 
tubules are siipiitied with more blood tbau rvarh^H the filomeruli, siuc« 
tJiey receive the uloud nliich hsH pni^Ked tliruugb these tuflit plus nu nddl- 
tioiinl qunntity wliich iitHupplicd ilimt-llv from the runul nrttiy, or from > 
reoal portal vyn. Thia imieaBed blood-miiiply to the tubidca would in* 
dicute thiit they ])erf(^irm a fuuctioii diflertint from thut uf tlie (^lunu^ruli — 
nil inff-nmire nhnHO corrri'tii'-Hs biix Iuh'Ii <lr!ii<niRtnd<'(l by tin: rewnrrbi')! 
of the laat decnde. The Ufxtd-mipply of the hnmnii kidney is derivetl 
eliiefly, tliouRh not entirely, from the renal artery ; for there is free auaa- 
tunioKis bdtwcrn tlic vr'sirU of the kidney and those of ita r-Apmle, iind 
this l(itt*r is Inrtrely «iippiit'd uilli blixtd by bmiich**!* of IIil- »iiprfirftuiil. 
lumbar, ami Kpenn:ilic arterii-31, Tltn supply of blimd fniiii tbew sources 
is quite cou side table : for Uenuann has buowii that the eecreticn of urino 
iiuiy conlinuD ia »ppreciubl» quHiitity even after the reuul urten,' hnsbL-eii 
lignted, EiiflicieTii blood bein^ ^Icrivvd from the Kuprnrenul und H}iemiAlio 
iirterifi) to niaintrtin tbe function of th« kidinev. Litten hne nliown that 
tile Hpermalie arterj* alone fumisliea an appreciable amount of bloc<l to the 
kiduoy ; be fcmnd that after tigntion of the renal artery «iid %<!iii and of 
the mipmretial rirteni', tlicre owiirs n lraji8i«ut pcricMl of mifenuA of the 
kidney, which ia, liowover. «oon followed by decided coQf^BtJon of the 
organ and even the formation of infarcts ; by liKatiQg the ur«t«r, inolud- 
ing the Hperniiitic arl^ry (in nddition to the v^chi already named), iKnnn- 
ncnt aniRinia of tlie kidney vrns seciiri'd, 

Tli^ t'uiirliimn of Ihe Titi'-dr.—'Vho lower portion of the tubule — the 
straight tube of Bellini — biui. so far na kuuwn. uiily the niediauicnl ftiutMiou 
(if a duct, n channid for the prtssngo of the tiriuc. Thia part of the tubide 
deeins to be merely tbe coiitiuuation of the ureter. 

The reiiiainin;; jKiftion — the loop of Heale and tha convoluted tube — 
offiectB the true secretion of tbe urine. Tbe epitliclial t-elU in tbin portion 
of the tiitule perform the oriUDary functions of a gltavX in that they »1> 
Ktnict froR) the blood which ciri:uliiti!gi nrouud theui certain iagredienta 
which ore then transferred to tlie lumeo of tbo tubule.' 



I 



■ 



' Tble ipcralorr aaliviti of tliv celU lining the eonrolutvd tnlulei and loop* of 
n«nT« wM flr*t sultifiu^inrll'.v ilemmintriiU'il liv Ilulilvnliitiii. In 18T?I. He Infcclcd into 
Iho mrouUtloa a ioIuUdii of Ihn indigoEntjiliaie ol E9diiini. and obsorvptl tiiot in tkv 
owiinse of a few mirmlM the urino ootjUiretJ % blue eoiot, iti<lknili>!; llial lln' Indigo wa* 
b«iiig eitrvli-d IrDinlU«l)imnlby tliekiiliif^B, Tu tletermiliv wlijit jmrt t>( llievntan wm 
lusttamenlal in lUl> tiiL'reilou.'lIt'liteiiliuUi kllltii ihe niilmalit nl vaiIou* prtioiU alkr 
tbe appear ance of ibu blue 1I11I in ttie urine, &n<] i>xiniinudlliM kidn<-VK mioninooplcally. 
Hafnuiid fun id Im of inrtiit'> Wuh in civijit numbi^w In lh« cell* lining" the eonToluted 
ttibulvs. and in uanllct qunutit/ in llic ovIU of lluclv's loops, Wt nover in those of tiM 



PnyaiOLOGT or tiie trine. 



07 



Tiiftt these scoretiuff cells separate from tlm blooj not onlv the solid 
cotuditueata but uIho Home uf tlio vrutcr. must bL' wlmittod witbout actual 
demon slrntion. siuce oxcrolioii of KolUIs n-itiiout wiitoi- im iticouceiTable. 
But Nuri'ibuuui 1lii4 furulstiml in the foUowiag vny no elegant tlcitioustrA- 
turn o( the fact that the cigUd of the tubule separate from the bloorl tmiuo 
of itit watevy coustituenta : in amphibintiti. the Mnlpighian tiifta are tiu|i- 
plied with blooil by braDchca uf thi^ ivuol artvrj'. wUili.- the cupillaries eur- 
roundinj; tlio uriiiat'y tubuleH obtain an ndditioniU supgily troia the rsnol 
)mrtiiJ rt-iii, Iji^.vtiiro of the reual arten\ therefore, while cuttinf,' (itlf llio 
l)iooil-!«ippIy of the SlalpighiflD tufli*. dut-a not dtrprive the tut)u!p3 entirely 
of blooJ. Noasbaum observed that. Hgntiire of tho renal artery in aiDpbib- 
taiw wiw foUowvd at oaco by iv i>iippru>ciiciii of the iiritiar}- m^(.-i-ctioii ; but 
he found that this aecietiou roiiitneiiced ngain in njipiBciable quantity 
after nn injection of urea iuto the blood of the auitua), even tlioiigh tlie 
Jiif.iture on tiie artery remiined undisturbed. It in endent, therefore, that 
the well-known diuretic effect of the ui-en ynia eufficient in tliiu case to 
•timtilatv tlin (ri.'llH of th(^ tiihiilcH to a conaidc-rabl j extirolion of wnt^r. 

The functional activity of tliefw cells apppara to l>e limited almost en- 
tii-ely to cscretion. since "nearly all of the uiaterinJa foimd in the urine are 
produi'ed in thi.> body trithout the iiitcivcntioii of thi.- kidnevB, and exist 
preformed in the blood of th« «_>!.t*iiiic circiilnlion. Tlie kidne,^-8, like 
other nr^iiiH, priKbici- nri*a and uric acid, but only iii relalividy kiiiaU 
c|iuuitity. Tlierc is, howevei-, one siilwtauce which is produced cbietly, 
if not Biilirely, by the seCTetiufj cells of tlio kiibicy — hi]>puric ayid. The 
reociit rTuit>tti-ch<!i4 of Bungo luid S<^liniiedelit-r^ UaTi; d«Rioi)Ktrulird that 
heiizoic m-id is Iranflformed into hippnric ncid in the living Rniinol by tlw! 
kidneys ; indeed, thoy were able to seciire this triiuBformation in extirpated 
liidneys by passing through the cxcined organs blood eoiihtiuiug beuzoic 
ncid.' 



* 



Dtralfht tubutei. aor in Ilic cai^niilei of (he glomeruli. It wm tbns d^moaiit rated llmt 
tlie oe11« of tlii» oonvoluti"! tiil.iuli^aaiiil ol Hi^iiltt't lonpn prwiwin (lie power of supiratliig 
oiiK ■tilntaiXM) itt ImwI from Itia blood. iioh»iic|ii«nt rcK<ati;li Kho«r<>d Hint tliv ui'ittea 
KliJ tlu- bilikFi- pigmvnU Alto are vxcrctad iiy tlic>si.> minio I'pitlielinl eelU ; mid it imui- 
HUiavil tliiliill Iha othvr auHJ iugr«dieiit»i>f (liv uHiii^ ntv it\inlnuittii froiu llic blood lir 
III* lujtivltv or ili«w lanM <ietlR 

SIneti tliQ piibllutlon oF IIrld«iihalii> m-.-nrch"*, numi/rous luv^stigntMi Tiarecon- 
flnwd 111* nisultn. It Iim twen found, furitn'rinori'. Mint the injection of ocrlain sub- 
Maacen, such lu oIitoiuIl' arid and GBiillmrido. !> follimrd by n«rri>«is of Ibu cells In 
Uie oonvdiutud liibnks, vliile lliu remulmlDr of llio kidiivy r«inalii< iiiiii'Ti-rit'd. Tliii 
tat't iiluo drirooTiBlrat*"* ttin deimtrtry wlWity fif ih»«» flla. wliich abAtract Ihf chroiaiiT 
Acid froni tKi> binod, uid am thiimbT rtindori-d iici'mlic ; wliilo tliu oolla lining IIi-h rml 
of iliu tubule. Ihcmim) thvy pCHMW iio Mcretorjr ortlrlty, Axpnionro iio ilainiutv friini 

tllt> IilXif >Wj<:^llt 

' Aiii-inpdi liaro Iw^-ii tiiitdi) ta uetfrlain wIk-Hit or luit this poircrof tliv kidnrr b> 
traotforoi tiMuolo acid iiiio lilpiiiu'li.' ncid ii inipiilrvd in rarfiiuH rrnitl affL-itians. 
Jasrsvrld and SIoWvIh iitinrl, lu thi- r*«n!t of botli cIlnipM ttHil pxpertmenul at«erTs> 
Hon. lliit auch iiuinirniuni diMW ix-uiir, and ran ihtIiajim Ihi miulf> a factor of rtiiHrn<iKllo 
ImporUiuo In Ilio roco^iitlan oT Icldnev' ditoOicL 'Ihow ohntirr^r* indiK-ni) livmo- 
MtnulBllciii and lo'tihritis Iii rnLbits by llic in'-'i^tion of alycvriuv ; they found that snch 
aaiuala esarHtitd no lilppiirlii acid. B*tituiu «cM oJmluiHtvrvd In ihifHC tMbbitttu- 
|»*red ts t]i« urinn nnrhan^d : vlills )ir«1tliy rabblti to irbicli lii>n«>iR acid v» od- 
lulaittarsd anrvtod hi the tiritu- iiotis of this (obatAnco. but ■ cvn-cHpondiiig 4iuui(lty 
of hlDpiirie n«l<t. Esttrcidinif lliuir oUwrvaUoiia (o Uio Iwdnldv, Jmnvrld and Stvktin 
(ounn (tut Iha eicrelleii of liliipnrlc avid itm dlmlalihed lu mrUlu comb of rvnal din- 
BM* M fnlUiwn : In two ruK-a of |inren(iliytnBtoiia M>phritis one ninite and one olimulc, 
IM liipnnrle Mid wo* fotind In tlia iirimi ; iMinioic arid adiiiiitlniRmd liy the monlli 
appearn.l in iht urhio nnohanged. tn two oIlnrtouMof U)« aanu) afiooti^n, iWvmrw- 
t Inn of liipi'uricacid waaiaarkvdly d«Dreagvd ; alaulii two •tauetit uinyluid degniMiatiiHi 




9S 



DISEASES OF TIIE URINABY OKOANS. 



7%« Futu^itinii nf Ihrr OWmertthi*. — Tiic aiiiitornirni HinicttiKV of llie 
gloDwrulua iailii-aten ite pLiyfiiological limctiou ; it sei^iua to be a pui-ely 
mechanicul apparaluii lor Ojh Kt^iuiratiuu of the wnterj' couiililuenis of tlm 
blood \ty liltrntion. It in ko iirnuig«il Uml tlto blood fxrriM upon UiewnlU 
of tJic cupilliirtctt n>nj[>oHiiig the glouienilus mu^-L ^Tt-alcr prei«ui-o tliiui 
vi cxr-rtod upon i\\a caplUiirit^s ela«wbe» in the boilv. This 'trnuipomeiit 
ooiiNUtit tuerelv in tlio diriston of tbo arteriole — tb« vas nSertua — iuto n 
IftVKe number ot rapillarics. wiiii-h KiilMetiiieDtly wunito into a niiigle wiiii]! 
vein — ^tlie vaa efFeroos. Siiic*: tli« c(dibr<i of tliiH (iffcrciit vein is muob leas 
thiiD tliu cunibiui'il oaliVre of Uie capillaries uhicli vmptj iulo it, llicre 
inu8t neoOHfuirilr octnir an unusually ijreat pressiiifi on t]ife wnils of tlit-so 
oapUIoriea. To fa\or the pi-ocess of liUnition still jiiot-e. unu.iually nliglit 
resislaDcc \b offt-nni to tie escape of fluid (roiu tho ciipillaiicH of tlie glom* 
«i-ulu«, KJnco Uio blood in thtm ia s<-pa]'At«<l from tlic lumen of the tubula 
oiilj- by tho (papillary wall and tlie hijer of delicutv ctils cuvc.riiiR the 
glomeniliia. Uniler Rucb conditiotiH n inucli lai'^r jiercftntn^e uf tho 
wat«ni' elenientfi of tbe blood rrniet ncoeesorily osca[>e. lu all the <tBpiUnri«8 
of this body a ccrtiiin amount of the blood serum uuiwi'S through the tu- 
rular u'alls ; frnni tlintu! of the kidney not leas tlian fifty ouiiCM of fluid 
usually eHoapc durint; the twenty- four hours. 

The sciwration of the wiitcr (and of tho salts which nafurally a*^c<wn- 
pAiiy it) M ^'ciicrally regarded, thoreforo, as a procoi^H of purely tnechaniral 
fillirttiun. Upon this assumptioD we can undei'staiid tb^ vurintionn in tho 
(joantity of urine observed in clinical and cxperitnentnl cases. Th« qnnn- 
tily of wftt^r filtered tbrouph the plonieiiili. and lieuce of the ui-ine, will 
be incrciMcd by tiny oim or more of the foUowiiig faeUiiit : 

1. liirrenxe (•/ liliiod-prfjonaf: in (he (ilomei-uli. This may be due either 
to increase of the (jeueral aiieriul preHnm-e. or to obatructiou to the return 
of blood through the reaal veui. Pigitalia, for eioinple, causes an io- 
creiiM^d Hetrrelion of uhuci by misint; the geii(>ml Uooil-prttMure in tho 
arteriuH and heticv in the i^lomrniH. Obstruotiou to the return of blood 
flora the kidney riirely orciin* clinically except as a result of enfeebled 
action of the henrt ; a few cases ai-e, bowcvei-, on recor<l in which n local 
impediment cxislod which interfered with the oinruliition tlircnifrh ibe rvual 
vein without affectin;! the kpupiiiI blond-pn-ssure. In tlicae casex an in- 
creaHeil secri'tion of urine liitR been i>bserved, 

2. in'TfOMfii rajiidtl'j (•/ tiir blood-cHnTiit through the glomeruli. Thia 
miuftlly oecunf as an aceoinimniment uf inert^at^ed blood-preHSurp. since the 
influviici: wliicb iucreattrs tlie pressnri^ ufliitilly iii('renM>ti alau the iiipidity 
of tlio circulation. Tot we kuow fmm the laws goveraing BItraLion ot 
fluids, that th« effect of increnfied rapidity is, cirtene paribus, to increase 
tho rapidity of filtration. 

3. Dilution of the Jiitvring fiuid. The iiifjcstion nf laj^ie quantities of 
water in followt-d by h profuee secretion uf urine. This results not froiu au 
iDcreaHe of blood-prewtiire (because no such increase occnri*), but simply 
from the increaaed diffuaibility of the circulating Quid. 

of th« kidiiej'. In tliroe em-a of (>irrho(i<* and one ot Ti-nouii congMtton. <m t1l« ether 
liMi'l, iVin •xiirt-lloit uf liippurfn iK'ld wu) nntinpittreil, WiiToir •u.'itl ■(ImilllBlpred \>y iW 
mouth un-lorjjotn^ Ili« •muo ii'niiifnrniatton u ooRim In htnlthr jwniont. Alllioiigti 
thv numbpr of th(-«o oli«^rvii(iouii b too mikll to jiirtify a cvnobulon, ib«y crriainljr 
aftorJ • prvbumptjoii tliAt llii' t^scrcrlion or lilppuriu ncId by Lhe kidneyn may liRcotn^ 
an Imporlaiit Item In deienuEiiing wliether or iiot the renal' epltliellDm is n'ffcled In 
ciuw* [iC kidney <l)ieu«, or wli'^thpr tho a^Tection i« Itmlleil talhe intenlltta) eotjoeoUva 
tiMua aiiii iliv blood •VMM Is— In uthor wordH, whotliiir Uiv nujihrltit In jiarvnelirniatoni 
ui'liit«ntttUl. 




PlIYStOLOGV OF TJIE ritlNB. 



99 



i. Tfirrmml permmhiHUj of the mjtilUirif tviUh. Upon Uitu point we 
have but little definite knowledge. It !a knnwii thai an uicreaseil lluw of 
iirinc often ucciirv in ciuiv» of pure unijlotd tlcfronfratiou of the kidae^ ; 
and ii is mL*o icnown Unit tliis «if jr<-nerution ftfflfct*! (iqKicidlly tli« OApiDonps 
of tbe olomenili ; lieuce tbe uif«r«iice that tlieae df^jfen crated oHpillnn* 
nalln offer less resutaoce to tbe escape of Uie contoitieil tluid. 

That u t]il(k«nin^ of tbe filtering membrane would retanl the esonpe of 
n-at«r Ivvm tUo bloud u) uut oulv i^litusiblu, but m nctuutly dcmonHtratcd iu 
(he nejihritis whicli followH Rcnrlet fevor. Diiriiig this affpfitinn the <]Uftii- 
tity of urine excreted in niueb diinini§bed ; indeed, tenipomry anuria mav 
occur. The rconoti for tbis ia npporcut upon microHcropit t-sntuiiiatioQ i.f 
tliR inflOiitipd kidiH'V, wbicli r«voiii>t n proliritrntion imd tliickctiing of the 
flftt et-lls covfeiiug the ^lonii-rulua, and ii ibivkeniog of the tapillary waU^ 

There are caaes in wliieh variation in tlie ([uantity of urine secrelcl 
eecme inoxplicnble br the l/tws of sirapU filbradon. Tlius in nifiny in- 
staiK'cH an tiicTi^iuwd wccri'tion of urine eeeniM to rcKiilt dinii^tly from iier- 
TOiJH intlucnc* ; such i« the jmiyiiria which imiiftlly follows a byslericnl at- 
tack or an epileptic convulsion. It seetiis Uij^ldv probtble. however, thnt 
Uw ucTvouj) luUucuce ufict-'ts the kidney not directly, but indirectly throuj;U 
tbe splatichnic iiPrvo», wlunvhy tli« cnlibreof the rvatil nrterii'8 in in<rppn*fd 
and a greater amount of blood circulatei* through tlw kidnL-v. It la at ajiy 
rate (Icmonjitriitcd that tlio imiount of urine secreted can be increased by 
pnn«ture of tbe floor of tho fotirth ventricle, whereby (through the ngei»'y 
of the splanohulo iiorves) tho circrubitioii of blood tltron^h th» kiduoy ih 
increA<teu. ' 

hi tbe present state of our knowledge, therefore, we most regard tlio 
nriuo u tbo prvduut of tnv distinct proccSMB ; 1, the "pccijic ach'rify 'f 
the cetU lining the convolnted tubule and tJip loop of Henle, wherebv tho 
solid iugredieots of tlie urine and Home wttter are separated from tbe blood ; 
ukL 'i, ^fillmtiiftt Ihrourjh tka rjlomcniU, whereby the liquid iu-^rodicntii and 
cflrtain salts Mcape from tbe Uood. 

It aeems with our present knowledge that the aolid contitituenta of ttie 
oriDe — upen. uric acid, creatinin, etc — never escape from the blood in ap- 
preciable quantity through the glomendi : tbeir presence iu the urine iit- 
dicjtl<r)( utid mtiKMums ttut funntiunal nctiTity nnd inlc^^ity of tltci i-jiitlielinl 
oelk of the lubnleti. The cxcrotioii of water from tho blood, on the otli^r 
band, is not iiionopolii:cd by tbe glomeruli : a certain ainoimt is aeiiarated 
umlur ordinarj- cirtumstuncca by the aerreting cells of the tubulca, ariti 
thi» amount con Iif, inidor estiiordinary eiiyiimstanceR. much iin'roaned. 
The experiment of Niiasbftiiin, Bln>ady rclalftil, hIiom-k llmt the presence of 
uren in the blood sUmulatea Uiese rrlli to the secretion of ronaidfrablo 
mttor; it i» possible that tho diuretic effect of certain solittee ie exortcd in 
like DuuiDer through the oelhi of tbv- tiibulcK, rather thou through tlie 
gtomeroU. 

■ H«ld«Dlialii hu Tccvnlly uffoad upva tbwrallnl grouiKla tli&t tliv twtpv vt ivntvr 
from lb* ilomirriili i.i not a purely mfiobanloal prootw, liiit in iiitliivncod largetjr liy iiie 
trtUiiy iif thv rvllK cuimriiig tlm lufu. Dib eoiuiideratJoiia aidTuiuBd in sapport uf thin 
vl«ir w«iii by no msaue oouviaulug. 



CHAPTER X. 



PATHOLOGY OF THE UBD^E. 



Tax tolid ooutftituentH v( the urine cumpriec; almost all tbo producte 0( 
deoomposition nf tho tiUiiiriiiiiuiiH )tiit)sl»n«'es coiitainiKl in tlio Uti8n«e^ So 
loagas the kidnej-s perform tlmir function proiwrl^-, but littl* of these al- 
buiniaoUD pruducts Dsrapcs tltron^h tho skin, liiiig«, iui<l iiiLvHtini.-. The 
iiri&fi iH tb(-roforr> ui iiidM to tlio Tnetnti)on)hoHi9 of the albuDiinoux in- 
(^redieats of the tinnuea. Conwnwlv, i«ii loiv^' a» the other organs of tlie 
budy pt-rfiinii tht-ir fuuctioas iiorniailv, tli(> solid coustitucutit of the urine 
COllBlitutfl ftn iiliiox to th* activity of the kiducy*. 

Vet sot all of thu ttolids found iu the uriiic ore to be rcf^urded h» tJiu 
productd of tifiKue metaiDorphoidii ; for lufttcriidti introduced by ttie moulli, 
Bucb IIS «g({ albumea, an rapidly eliuiinatad by the kidneys, and snbHtanoes 
producecT tu the miaU intcHtiae, midi as indictiui imd cju-holic ucid, ore 
M)piimt«d frtJm the blood by the same orf^im. Evpii thn excrfition of ures 
— which ia pre-euiinently Ajiroiluct of ti^iuo laetamorphosia — varies hirjjely 
accordiDtl «» much or little nitrogenoii» food is trousutucd. Hciicc a. proper 
ioterprctiition of the information derived from im nnftlyHtB of tlid iinne 
iniut he baaed upuii a kuowli^go of thv uidividual'a geuerul oouditiuu, 
diet, etc. 




VAntAnOMH » THE KoBKAL btOaEDtSSTTB OF TBS UltnK. 

Notidb] urine may bo rcf^nrdDd. for pnctioil purposes, tin a Rohition of 
uraa Utd of the chloride of audiuiit. These three diief ingredients — water, 
urea, and i^hloride of sudiiim — nre lU'companied in thfu- exit from She 
blood by orrtnin otlitr solid injrroiliGnts of tliat fluid, organic and inor- 
jjnnif, w well ns by rurioiu fuiiigu muttcn which have been introduced 
iulo tile or(^iiniiitn. 

For i-liniuid ptirpoees the most important ingredients of nonmd urine 
are the following ; the average nmouut excreted duly (acoordiiig to Sol- 
Iconiiki) is uliio given : 

Urea , 25,1)0 to 36.00 

Carbohcftdd 0.02 to 0.05 

LidiciiD 0.06 to ao8 

Urobilin Undetermined. 

Cbloridea 10.00 to 15.00 

Ewthj phosphates. O.SO to 1.40 

Alkaline phoKphatee ISO to 3.S0 

Sulphates 1.50 to SlM 



PATHOLOOY OF THE HRlTfE. 



101 



TJsiA. — TUis, tbe cliief mVui ingredient of tli« uiiue, is derii^I oxclu- 
ravvly {mm allxinieii. Wliether or uot it i« fnmittl dirontlj' from atbuiunii, 
ur LudireoUy after esistiiiR in the shape of other coiapounds, is etill nii ua- 
wttled queHtion. Tii(« iilU<[Dpt» tu |)rudiiL<i> ureit iirliticiiilly b; <lin?ct ou> 
dation of iJbumcn \iavv 6iil<id, though ii Kiibiitiittcc vcrj- Kitiiibti- to arm. — 
gnouidUio — htwt b«eu pixxluced l>,v the Acltoii of tlie ])(.'i'in»it^i)at« of j}ota»- 
Rium upon olhumflii (UC<cluunp, Ititler). It HceniH probable tliat urea is 
formed is th« boily not directly bxtm, albumen, bat from one of the Bub- 
HtonceH whii-'b ame from the decumpoHitioii of tl ijn , Hi^bult£i>ii nud Neucki 
have nbown that nlbuiiicii iw cbftngcd in Um (irgiiniwii into fiitly a<^i<lw, mid 
that tbeno aro tnHiBforiued into ureii ; vol it i» bv no lueiiiis <!ei'tain that 
moat of the iitca in prodiiupd in thin inaQii^r. It lins been lUiown by I're- 
richs, Stolctiti, nod Neiibniier, that uri« arid tnlraduced into the atoiawiiU 
is tniusfortiied and excn-tud us urui. Prububl^ hoiuo of tbo luic acid pro- 
du«ed in Um' organism iw th(' rrKiilt nf tiseue chnngr; ig hkcwisooxidizftd 
iuto urea. Lt-utiii UiUeii into Ibc Bt«uiach ia entirely eouvtrled into urea ; 
heiice it ia conaidered certain that the loucin naturally produced in the 
tiiwu«s (roiu tbe m^t&iuorpliosiA of All)uiuiuoais duhatjuiuufl i* uorniftll^r 
%liU4form« t and ewretod as urea This traiwfonoation aeems to w 
Bfletrled by tlie liver. 

It is quite [waaible, and indeed probable, thai urea originalex id still 
QtbiT wayji ill thi^ or;;aiuHm. 

Many attcmi^ttt hnvo been nuulo to oacctrtain whore and by wliat orpitiff 
the tranafomiatiou of these various intermediate albuminous e^ibetanceH 
ioto urea ia ac»]iupliaheLL The cbksiitcuL nud ufLeu-rrpeatixl fixpcriuitiit u( 
PKvoit and Dtiinfw— the «xtiq>iit.iou of the liidneyit — sliovra that thotio or- 
gana have litth- i( any aj^ency in the production of men ; for tbia subsiantt. 
IS produced in the umiiii quantity alter the kidneys have been removed. 

(Jren is constantly found in ccrtAiii tiwiiicH of thr iHxly, particularly in 
tliu liver, thu lunt^is and !<|)k-uu ; it in al.Ho c-onataitUy pieeeut iu thci blood, 
lymph, nqiKioiu hnninr, and aernUH Huiil. There ia, indeed, one rcuaoii for 
believing that tbe organs named arc largely concerned in the production 
of uiea: this rciiBon ia the ;;L-ucndly admitted ulMcnct; of urcu from the 
mntwlcs; ultbonghone woubl mippoMo that the muHciibir a^'iitt'in — aocxt«D- 
aire aud ao ri(?h in nlbutuinoua mattei-a — would neceaaarily funiiah much 
of the urea, yet no trnstwortliy observer liaa itH yet beeTi Mucccssful in dc- 
t«cltng Uiia aubel'Mice in the muscles of healthy animals. Volt, it is true, 
found tluit the- mUMClet) of n do^,' from which tlie kidneys ha<I betm remored 
contained innre than twice an miioli urea na the Moral, nnil hence holUvM 
tli-'it the muscles must, at least under these abnormal couditions. prodnoe 
uruik. So too ibluui been found that the muKelca of jiaticuts dco^l from 
aholem contaiD«d liron in approHnblo qmutity — in fa**t, mom tlinti th« 
Uood. 

Tbe alM(!ui% of urea frora th» muHclea and ita constant preaence in tbe 
liver and itplern indioat« tliat tbe Utter orptua ar« inRlrutnental in pro- 
ducing thia subataiifxt. All oh«er\-«rv luivv found tbe liver n)]>emlly ricli 
in ores, and have uaually ohw'rred that it I'ontnina a lari;er perfenlagn of 
tbu mib«tauco than the blood. A fact lii-st observed by Prenche. and sub* 
sequeiitly voiilirnicd by otliera, ))oint« strougly *" Hi« "inio coDL-liiaion : 
be twtioed Flint in a cam of acute yellow lUrophy of tlio li^*er. tlio uroa 
found ill the ni-iue was mnoh decreuaed in qunulity and even diaappcercd 
entirely, vrbile on tho other linnd certain intcnnndintcprodiicta in Uie de- 
OOtppoaition of albiimen — loucin and tyi-osin pinticularly — were excreted. 
I Jtalio beturnni 7WMe AlflamwyhiMu ufi l/rtxi.—T\Mt qunulity of urea 




103 



DISEASKH OF THE URINAKT OKOANS. 



excreted in the urine VKtim in dilTerent. condittoiiK of henltli and diseKse . 
and sin<'e it is ft product of tbe deoompoaition at aihuinen, Uiaiiy (■fTortit 
luiTO IxHJii nmdu to dixcovor imd detormtuo for p^tholo^iunl purpowJB a 
quantitatjr« relstioQ betwetrD the amoiiut of this ^ubtttaiicv fuund in tbe 
urine aud tlie decompaction of tiie nitrugeaouH uleiut- iit.i of tlic tiusuca. 
Tbo nctiutl amount of urau excreted in tho uriiio cannot, of course, repre- 
80ut nocuratt'ly the nlbuuiiuouti deuorapoBitiou. becuuBe, tinit, only a jMUt 
of tin- wrtai fiiruHHl in t,lio lM>dv » extntlfd hy the kidneys, tbe reiDsitider 
bc>ing eliminated iiy tbe Hkiii, liitesUne, and luti^; second, urfui in only 
one of sevei'ol Hubslaucoii into wbicb tbe niti'Ogc-nous «lenieiils of tbe tiit- 
ifiU'-s nro dsconipoHod ; b^nce its quantity does not fully represent the 
atiiuiiiit of Hudi d(4C4iiiii[]o»ilioii ; tbird, iiiucli of tlie ima excreted is de- 

id diix'ntly frum tlic* (ouil itiid not »t iiU fnun tissue wu«t«. 
_ Yet it b.i» been found by Voit tlifit ftii approxinjately arciimte index to 
tin deouiii posit iuii of iilbtiminouH siibHtfUK^ex m the body is furnished bv the 
urea and i>lbi-r idln><;iintnis niFitterB oscrctcd in the mine. It Kam been 
nacertjiirnd thiit KKl grin* irf imisciiliir Iis8uu Mpiinitcd fi-oiii its fat and 
connective tiBBue contain about. 3.4 ^in». of nitroyon, Rorrcsponding to 
7.li8 Rrm* of uren. Every ^nuime of urea found in the urine would 
ttierefuru reprvtwnt u ilecompositiou of IS. 72 grnin. of uiwicuUr tisKue (or 
ita ei|uivali>iit of otlitir tiiisite). 

NilrG'jeti HiHuUbriuiii. — Ure& is excreted so lonf; as Ute persiate; Id 
starving uuintiuiu there ia an iippreciable ex<!retion even until deatb. If a 
fiLxting nnimul bo KUppUcd witii nitrogonouK fimil, nn iinexpectedlv large 
exi'retion nf urea is obBened. For it is fmiuti tlmt Ibc mea excreted rep- 
renenta not only the albmnitionB siibatances of Uie food, but also almost 
n» niuob body waste an occuned dui-iiiR tbe period f»f fastiiiR. Tbe lutter 
<]uaiility in. however, » triHe \vs!i tbiiu funuerly. :uid thus theiu occurs a 
;{raihinl ficcuniubiticm of idhnniiiious iiinteriuls, and bi^ucc^ iTtctvaRe of 
weigbt in the botiy. This repair couliuuea uutil tbe body weight is re- 
slorwl U) ita noniiiil ligiire. afler which tlie quuntity uf uiea excreted oor- 
rwpoiidx exuutly to th<; amount of lUbumiuouB mulvriaJM in the food.' 



' Thai a futinf; doK uxcretoe, esy, 10 RnnB. of nnm por day ; dncv ca«tt fCTuama 9t 

loaliulirr (lOx 13,72) gnm. i>f llnnli [Mir day. Now it UiU iitmiuiii— HIT eniu— of tii«M 
be «atiiliiiitcr«>d hi the dog «Ull.v. wu wuiilii #«p«ot thai It woiilil tie used U> ftiipply tliH 
lewi Mid UiAl aa a retuK tliL< Ih>0;- wiwit- woiilil ceoav at oii<i<', vrlillo tKi> dnily I'urntion 
nf ilroM would, rvitiitin ID ii;niin. Kitrli 1*. Iiowuvcr, nol tbn cooo ; thv rxcreljoii uf urva 
WmmiiaalmaBt ilLuugh not qiiiti>)dDul>lii wbnt llnudurliigtiuiting— nv l^tfnns ; lliii 
rei-rvBuiila tliv araa furinoil frum tlic FoliiI [Lii in^it ) p\u» tliai dvrlvril iriitu lli>^ ttnanra 
(HgruiK). rii« Ually lu.-a ur flesh i» diiuiiiialiod. Ijui UueB iwtcea^ mitroly. If iiowlho 
i[iiAnttty of tftoA b« doubled, that ia, II 'J~4 f,rias. of meal Iv rIvi^ii, ilic niaDiiiit of urea 
esrrulBci bfcnniM about iweulj-llve urfimiiiitu— tli»t U, 211 pniis fn>m tin" fixxl ftud 5 
Hrini, frimi thu timuKK. Tlim aiiiniiiil of fund i* IhtirKfuru uut tmlGcieiit To re|ilaoe tbs 
ftltiumun couiiiiTned in Itii; tii»u»» ■ Um aiiiinul (niiticutfii to (■niacUt*. WLnti ih» 
amount of food in iii<itvniM.-d mi llial It hIoiih fi>riilKli-'M sliDiit/iiur Uwit lU muoh iircn U 
the tvniiig DTiiuinl uxtTrt-ti-s. (liu <I<>^ ■'>>i>ii><i< tn I'oioi.iiitii. aikI U in found (hat iIid urwa 
oxorolad now cornaipoailii unnctly (o tlin amount coiuuiucd nItU tlie fuoil. Tliw aaf< 
lual'B wvight rumninH luivliannvd from dav t« Any. TIlib Is " iiitTDgvn *qiilUliriiim." 

By Mill lurlhiT birmaalJi^- tliB miidliiiL hT fiKid, It 1» ftiiind tlint duriniji Uiu first foir 
days the iiiiAnlltv of urea uxerult-d Is leu lliau tlinl *iiiit»lii(id In thn food— m oIIht 
wnrd*. Kdiiiii of C\iif nlliiiinliinLiii ciniKlitiinnin of i)ih i]ciiirji<liiii«ut ant xtored away In Ilio 
body. AftM «nnii' day*, haonirtr. tho rijiiililirinin ia aualii rnrtorod — i.t., llie ainouiit 
of iirc.i i-xtTotvd U'iuuIb cxuctlj' lliv qiiniititv aupiilivil by tliu Swui. 

If. oti til" utlior Iimid, lltv ijtiBiilU.r of fuuil iiidiiiliilnt»ri-d to a woll- iioiirlnliiid aaitDJil 
bo auddQuly dlmiiittltiid, It la at tint obanrvad thot thn uroa rxarstvd rupruaanta mil* 
albumiuoui mattvT th.an Ui« food coutiunii ^ In otbvr words, Iti« llMuea Iom a oertala 



J 



FATUOLOOY OF TUB UltlKK. 



103 



P 
* 

n 
¥ 



II fciUowa from UieM facta that the hcoltlij' orf^auiam poNSCRit^ a cerioin 
ACCommodHttTe power, hy vUtuc of wliicli it is enabled within certain 
liaiits lo adapt ltd «uiisutiiptiou of tilbuuien to the iiitiount i»ippli^>], 
wUctUirr lliiti be large «r touoll ; so li>ii^ lut tbo budilv fuuctiuus 111*0 
iionii'LUv iM-i'Iormed, tlie aniautit of nlbuiuiiiouH rotttititueutit cxnixiU'd i» 
ji)Htci|ual t« tbat AuppliiKl bv the food. Tbo uimimuiu nmoiuit of uuimHh- 
mcMit ivquirud to siutUuii tiiiii ** mtruKOH t-quilibriuiu" mtist cuutoin inucli 
mure iiitiiigi-ii Ibiui is uotimlly eoiisiiiiit'd by tlio liBttm-t*— piubiibly nbout 
four tiiiitm an miirli. It in furtlivr cvidt^ut tliiit tliu ([untitily nt urfi\ t'oii- 
taiRRi) in the uriii<! attoi'th no (due tn iiw. nmoiiiit of tiwiiie nielAinoiplioiHa, 
utdcas tbo quantity of fUbumeo coutnincd iu tiie food ia a\ao known. 

(Jaanlitii of C'rea iVrrcd-rf.— t'l-oni wbttX liiw bccu said, it i» ciident tliat 
tbe exeit'liijii of tireu uay vai-y iu tlie mun^ ht'dltby individual from diijr to 
day iicoi>iUiii(^ to tliu kind and atiiount u( food vouHumtHl. Hcutiu ohnw- 
r-AiioaB made upon ditferent clusacei of people bava given difergeut rc-sulta. 
Voit and Rubtier found tbitt the average dmly exultation of urea in well- 
uuiinttbuil CJiriniiti lubimti-Ji wiix 30 lo 35 grinit. This wim «t the r»te of 
.C to .0 (frill*, for *iicdi kilojn^iume of btxly weijjliL In cuiirtileut iodiviil- 
Uftls tbt! pei-ueutaRf ia somawliat sniail. ttiwee tb« uxi^etM of body w<iif[bt iu 
sucb pei'sous ivprcueiits iin ucRUiuulatiou of fat rather than albtiiuiuous 
tiasiiett. The pcivi-iiliti^(> k ]*•»» iu fciuiLk'H Uiiin iu juuIuk, but niuch 
bi^btir in (diildntn thiiti in lululta. 

CM'iifoi Eittmati'm uf IMm. — For dinicAl purixjMia the detcmiiiiatioD 
of the c[iiiuttity of tiien i!i;c.Teti>d iu thti urine liiMHeldutu iuui.-h vidue an an 
iinicx lo the amiiuiit of iitiiui! mclnnutrpkosi*. Fui' Miico tlir ur«» \n fui- 
niHhed iif)t only by the deooinposition of ti-tsiiest Iml also directly by the 
food, the quantity derived from the tiBaueacun be ascertained only when 
tliat fiirnlHlind by tim fuod in estiinnU'cL 8uch procedui'o iit too coinpli- 
cat«d for clinical piiqKMi'H ; Lvucu tbs dtitenuiimtiuu uf urc.1 n |>i«ctically 
raluubln oidy undix (^crbiiii I'ircumabuiuea. 

Thua iu acute fobrde di&eauea tlio jtatient rarely i'eceiy«s any consider- 
able quiintity uf nitrugeiious fuud : beu(.-e thd lunuunt uf urea exurelfid — 
beinj; dcrivtd nlmoxt oxrlusividy (roni tiasnu wft8te^rtfpr«.<!H-nU foirljr UiA 
ftmoiutl of thin wtuite. Yet even here we aro not siue that all Uie uron 
prodnccd is excreted ; in fact, we know aonie circumstanctia which retai'd 
lIio eliiiiiiiali'm uf ui-0.1 through tbo kidneys. Among thcte ire tlio ro- 
teulion iif vinl«rin Mia blood— a usual uix'iirr»Dci> iu f«brilu conditions ; 
tlu: foriitHtiun of ti'itustiiibitionM in Ibu (iiib(!ut:ini'oii!i tiwHui; und in tlio 
sdfoni^ civiiica (for tbeae trnumidatious contain ui'ea and albumen) ; ab- 
uuruintly low urU<ruLl pretmtni?, iin occurs iu tjiiboiil mid typhiui fever« ; 
profnsn [M^rMpi mttoii, copiuiiK dLirrhwii, inlhitninntiuR of tli« kidney — nil 
divert, niffi from the urine. On the other hand, there are viirious circuiii- 
fitaucea wliich may cuuho nu incireaaed amount of urea to ap]>enr in tha 
un.n«, without any incix^iuio in LI»»iie luetnniorphoiiia ; thua notive diurcsui, 
whether fiuiu the iii^utttiun of wiitur or from a riitt: of bluLid-prumuic, may 
rdKult in vriuiliing ont of lh(> blocid ui^M whicdi bad iu-cumuliit«d iu Ibtn 
fluid, ^o, too, tlie n^eorptioii of trnnaudatiouu briu^ into Uie blood a eon- 
aiderablv amount of idbumon coiitainod iu tho tnuunided tlnid. Tliia al- 
bumen id at once trniiHfontHid into uron, ntid being oxcrct«d by the 
kklucym rai&ca conmderably the auiount uf urva cuulAuxcd in tbo uiiuu, 



poRiiMi ol tUoir nltroicoaoiu coiistltuMibi Tbb TeUtlun Iiubi, Iiow«t*p, but a (mw daya, 
a;Ui> vrhfaih |i<.»rlod thu una oiccrulad oorrafitanda to tlui diiuiuialtud anMunt of ii««r> 



IrtllaTUt. 




104 



DISEASES OF TOE DBIITABT OBQAKS. 



though there hiut lieen no .iticreaa:! itt tiasue inetaiiiorpbosts nor in tlie 
(juutiUly of tutroReDOUH food iugeated. 

If thcrefoi^ w« lire tu derive Accurate arid reUablo iofonsfiiion Of lo tkf 
QmoHitt <^'li'*Jtu': dianif. fioiu tho quiuitity uf uri'ii excreted by the kidDC}'s, 
va miint. <ihuiinnto thn posnble Eourcos of rrrnr already enutunntpd bv 
tAkiiig into account the iiifltwiicea other than tb8i]e Wftste whereby the ex- 
crctioti of urcu is nffcctod ; but tliis i* practicallY inipinwtibli-. ' 

It is cu nil \mie.r fo Iho fif'turi/ iftU'ih/ of hf hdifijs tlint the deter- 
tiiiuulioii uf the un-a udeii furiilHlioil iiufiDrlaiit iiifuirimlioti ; for, niiicc thi- 
excrptioti of urea is perfortiied by Hir renal rintbeliuni, tlio deficit in tbp 
amouDt exci-eted in casea of I'eiiui disease indicnles i" a ijenerai ira^f the 
<logrM! of inipainiKMit of lln^ rcniJ function. Vet oidy in n gciicnU woy ; to 
Hecui'e e»eii ii;>{)ruxiMate arcuraiTy, it is iiecewwjy lo cciiiip«re th* urea 
excieteil by tliti [nilieut with that excreted by a Iw.'ulthy individual nour- 
isbed upon the same diet and ospoiicd to the Biita« cotiditionG of cserciBe, 
clotbint!, teniperuturt!, etc. Such caui]>ftri)u>ii is in ])nvnto pitiflioo at I^ast 
UMUnlly iiii[H»«ib1i'. Himicu tlic iloU-rmUmtioit of urv-ii dh ttii iiuhix lo tJie 
comlitioii of the kidney is pi-artieally valuable only nhen the (junntity is 
found upon repeated exainiamtion to be markedly less or uioie than the 
av«i-(if{e amount excreted by bejJtliy persouu.' 

/mfwri u-hv'h IkiUu-iuv (hr Prvtlui-dun and £roWion of i'rm. — The 
(jiiaiit)ly of men x^hiih iippears in iht; urine can be perceptibly iiu-rca»ed 
williout au^meutin|{ tlie luuount of nlbuuieu iu the food, by Tarioua 
lULouiiire); wtiich iiiuretiHu tissue (.'liiui<i9. The aitviimi-livHou of pniHipkorMS 
— in dosuH Huilicieub to eausi; dAiith in eight or tei^ duys — iiii-^njeiitd Ihp 
qitantjtj of urea excreted to tliree or four tiines its nominl amount. Otlier 



'FortuuatDly wcmky ofti^n d«rir« v*hialiUi Infonnftlion bv^rtrm faring th« ^mntity 
Iff urtii ifitA (Aitf v/tJie oimmvH mill cjrirlrii bf tbo kidiieic. For it U fuviiiil in bfahlijr 
indtviJimla tli«i sail ext-mUiil kiDiiiniia tu nbonl ono-hair b.v wclitlit of tliv ur^^n m Ibo 
mini* iiritiir. How tinae th» wilt h dorivml cliiefly fmin tli>' riiml, n comparinon of the 
two iKom irhother \h* twun i» dui-ivud l»rcL-ly ttota tlic food or frt-ni the tttsofii ; far 
it nu iiierpaM iu tlia iiuuulity of uri-a t-xcrrletl 'm u^mmipuiiii-il hy a curri-rpondiug in* 
tn-asu In tho iiiiiiiillt/ tit huU ••litiiiutttiiil, i],^ inferviit^i- 1^ tlmt tliti urcn is iJcrivcd 
Inr^julj' frum lliii foorl ; it tlin i|(iiintilj' at Htll Iw, »ii Itiu colilrnrv. uiiii'li leM T]iaii 
normal, mi uxi*«bb of utva, JiitliiiilcB mi i-x<^i'*iilve tiaaup clini))ir'. In fuvtT Um <iiiiin(ltv 
i>r hlU i;xori-t-;d in the uriiiv in very auutlt. pArlly Iwcauw! but litlk natl h ootituncd in 
Uie rood, rvnd mrtly beuaii&e tliena ta an actual rotcution oC salt in Ilia li^iio during 
((ivi-r. HiMcn (hiring conrxlisseeince from ftiver a considerible portion o( the utbunii-n 
i>r thu fowl JH rvtnin'rd iit lint liwimii tnr r<>iitnrins tlii'in to tho iiortnal mniiitir.n. r1ij1# 
tht* olitoridi.- of nodiiim is not Ihiu noudud nur retained, tl fifti'ii Iin|>pi:ii]i Clint dnrinji 
oonvalesouiK'u Ibu <iiiaiility of bbII in tliu uriuu maj- clotwlj' njiprc-nimair or won ei|ual 
tliai "f lh<> iirniL. 

' IKiru too aa alinuUion «f rhr rhLiridm in Uio iirino taay aflnrd vutiialili- ilitonna- 
Uou. Thtfw Mlta probably <i»c»p« from Hiu blood by siniplv flUnition with Hit »atiT 
tliroii^li till- gtomcruli niuf nut liy tlx' wicrrtnrv nclitity iil ilu' cells ; nt any rntr II is 
wnll i-illibliiitivd lliiit thu I'tiloridea iis i<X(;rulvd iiuitr if fruuly in tliH tariun* furniK uf 
cilirnnlu ni'iibilliB *t br henllliy ki'lnuys. N'i>w In heallli t'tw quaiilliy of cliloiidvi in 
tliu iiiiiio i« muallj ftbtiiil bair llial of tho aron ; lt"ticv iC. in n rniu> of dirnnlc; Hri^lil't 
dln'oiio, thii quiuillly of cililaridun in Ibu uriiia ia rnnKlunlly ninrn tlioii oiw-half tlial at 
ihL- urm. »-ii may inPer tUnt the Utti-r iiul»tiL[ica in not compli.tcly L-xcrvtcd— in ollii-r 
iTOrdH, tliat Llie inti^grity of t1i« kidnvy* Ih iiupxlrud. 

It la iiiti>r«i*tiii)( l« noin thnt varlatloiia in Ibo iixprotlan of mva in RrI|iIit'H ditewc 
■ra aocompnnled tiv timilar vaiintlonsin i1k irxiTntion of ph(M|>liorl(i and cnrhuulu actd. 
Fl«ijKh«T foiind rurlbi-rnKire Ibut ptjinqiluiHo miid ml mi filtered by tliH miuiih w» hx- 
erelud It'sa n-adily by ilisuiised ilion bv bcullhy kidneyk. thoneli nosncU difti-rHni-ti w« 
obMri'«d ill tlieeioretinn itf nth^r 8a1t«— bromide And iodida «c potuaitun, for (.'xamflv. 
Tkc itnanliUtJTT- onlimnlion of jdit.iH|'boriu wiid in thu urinat ia, howovur, m ooiupUol«d 
a procGM lliai ihv fuel moiiUoiivd Liu but liitiu uliiu-cal value. 



PATHOLOOT OF THE URINB. 



105 



BuVxttADoes. MQODg them arienic And aicokol. exert a similar thoagh Iuhh 
prutionnoed «ficcL 

Limitatioii of th: v.tyjrn i*«*/)irrrf iucrciwcs nlwi the cxrrctidii of uii-ji. 
This linH beeu deuioiistmttnl by Fiiteiik«l, whn iliiniiiiHliril thi^ qiittiitity of 
oiriDHpircd by oonHtriolJiif; ihit tiiulic-A iii tlng& He fouud t lint the titi?tv 
excreted roM to tliree oi* fnm- tiiuee the ii»rmiU iiinMUUt, pAtbologicul 
!ttatca at^comjtaQied with dyapDiea in the liutnati subjopt also tixhibit in- 
croiuorl excTvtioi) tjf upm. 

fui»(m>fi(f wUh i-arljonk- ai:iil also augments the araoiint of iirca exweted 
— probably, a» Fnn-iikt^l Bu<;(^est:A. by dimintahiui:; the (luautity of osYgen 
BuppUed to the tismtea. Lora of blvod iuduc-«» tbw kluio result, npparoutly 
becauK^ it decreuHi^s ttiL> umouut of uiygeu distributed to tli« tisiiiiva. 

Ariijiriitl i-Jritilinit -il Imn^ii^aluTV, by <ix[x)Hiir(! U) M wni'ni liaUi or iTsnn 
lur, liaa been olmerved tn imu'eaae the ninouiil of urea excreted. Hchltiib 
found tbiit aft*r one hom-'s iiimiei'siou iu tt bol halb whtreby liia tempera- 
ture i-otM> to 89.5^ C, the qiiautity uf urea cxcrotud wtui incn-iuwd inuro tluui 
thirty-thrw! per cent. 

DiureMn tavitrn, of couiiie, Uie excretion of urea ; tbd iucreaste does 

I)<>t> bowerer, appetir to be tlic result of no au^rin«Dte(l tissue ciisur^c, but 

■DCCUTH ttiiupty fi'uui t)ie iiiurv thorou>,'h ri^muviil ut the urE^i frxtui tbo liHKUeit. 

r Ttlio con»umiiti(/n ofaiiimal/oud niitiir.dly iucrunocii tlta ouinunt of urea 

foriuiid as well ns excret«d. 

Div^nie rcAiiIta bave been obtaiaed iu the efibrt to answer the quostioii 
whether or not rtrwwiiv: mntcuiar actitm causes an inen-iitkMl jirodui-iion 
aud excretion of ureii. Voil, Fivk. WiBHiiKUiiA, and Vrietzke wei-e unable 
to fiiwl any iiioreafie of thfl ui-en iu the urine aftfir prolonged and escetMBTO 
L^xercise. Fhnt, Porkcts S>.''lien<^Iv, nnd recently North, oii the othvr hand, 
bbiien'ed a niurked iucreaxe under Hiiuilar oircuniMtuui^eH. The diventity 
Kit tliMe rcsiilbt KCOinM l<> bn RXpluiixtd by Inter obiti'rvnlioiiK. Kellner ob- 
served that the ui«.i bM:reted by hoi'ietect fed u]>ou a diet rich iu nitrof^en 
inoreaaed deciiledly nfter proloujjed ewreiBe : but that when the diet cou- 
nat«(l chiefly of hylroiMrbons, but nliglit increase ntiis obsorved. Tin- «!x- 
ptauAlioQ iippcirs to be Ibut tmntf^nUr activity rt-quircs llio couBuniptioii of 
fktii uid bytiirncarbonR ; so lon^' as tlicse aiw s\ipplirid in fiuffieicnt quantity 
the niti'Offenoiie tiflauc^ nre not consmned ; when, however, there is a 
flenrth of liydro-carbunacnou* niat«riHhi. the albumiriouit uubslaiiceH in thfl 
timuM nrv ^^oaAumml, imd a eormi^iouding increase occurs in the ureA 
produced and excret«d. 

X second tnoiuent senres to reconcile the conflieting rcsulbi above 

Buutioned. Onpouliettn found thnt iiiuiktuUi- nctirity, nuiouipnmed with 

dyBpuoos, was followed l>y decid«<l ini-re^e iu th» excretion of urtn, vbile 

ttie satDA amount of work perfonned ho <lelibf mU^ly an not to embnrrass the 

ie8|iit%tioD, did not increase the exrrctiou of urea. Hence be infers tlini 

hlbfl uxtfCK«;vc proiluction of urL'a ubsiirved dunii(,' luusciiliir nctivity in the 

nosult, not of this aetivity, hut of tho iiiijx-rfci^t mipply of oxyf^en aeeom- 

hwaring it, wbicb, oh alreudy ntated, is Iuiomii to be a KulQcient cause for 

ran iDoreuHe iu the production and excretiuu of m^a. 

Tlte observiitioiis of Senator nud of Bauer upon cases of totanas, buiI 
otFleiMoher upon u case uf iueru\iriitl courulflionis bIiow that iu thcac con- 
ditions, not withstand! nj; tlm finomious amount of uiuarular utortion, no 
increaae in the excretion of ure& occurs. 

No a({vut. pUj'Miuluijicid or medicinal, is known, ■wLcrc-by llio amouut 
of ur«n pro(1iiM-ii in tho body can be mwih deoreoMd. Fnumkel found 
tlut the re(i2>ii-.ttioD of condensed air decreased slightly the f>roductiou of 



3 



lOG 



DISBASin) 0¥ TIU UKIKABY OltOAHS. 



urea, vbile the 8iil>ittitutioii of i-arefied air had, aa might be expected, the 
Bame effect as the abiitiuction of os^-geu — a ulifibl increiise in tli« uiuuunl 
of ureii proiiucctl. 

Ea-rvtioii i.<f Vrea in Vinmne, — In febrile c^onditiouK. from whnlaoerer 
e&UiW, the excretion of m-ea Ih nlmosl iiiroriablj- iucreaaed. Tbia mcreose 
is obeerred duiiug th« hi-i(^bl uf llic fc^er iu tuget ini^tauc^s, but is scise- 
lixaes Dolioed Im-foro thtj ns(< uf tL-iiipt'i'iittu'o bi'^iii». Iu iiiuny cumis 
this iiMirv-iutuil itx<'retioii cuiitiiiui-H nisi) for wmii- time aftpr the critical 
UH of t«itii)erature ; thla is es]>eciall7 oftea noticed iu cases of croupous 
pQGumouia. 

It Una beoD obsert-ed tbitt after ibc ndnainiBhntiou of quiDine, ID CSM* 
of coutji)U(;il fevora, tbc iuti^r^itl uf reduced tcnijK-rJttiirL- id ocrotupiuiied 
by an <>xof^s9ive cxcretinn of urea. It is fiirtbor lumiil tlmi Uxi^r induced 
artificially \>y the injection of piitiid lunterial^ ia (like tiif cliuicnl aepti* 
otemia and pyaauia), acconjpaiiied also by an increased excretion. Sur- 
gical operations do not prr m affect tho production of iii-ca ; b«t, llic cir- 
currcuce of fever, uveu if it be uuly Uie oauptic wound Uwi; is uccuuipaaied 
bynn inn-c-asod prodtiction. 

The only a^^ut.e febrile coudilion, aside from renal diseaae, in wbich the 
urcu oxcrctcd is less thmi normiiL ia ftcutL' yellow atrophy of tbi- Uvcr ; in 
tliift di«('ne« tho uroa nifty CLtircly liinflpiKiftr from tlic iiniw'. In noii feb- 
rile conditions there io ^tvnt. diversity in the boh«vH^>r of iirea ; in many 
casee acnompaniod by auir-mia tliei'e in an ind-ensetl pioilutition. con*- 
aponding to the obser\-ntioQ tltnt n aiinilar iucreaae occrurs aft^r artificial or 
mtturul liciuorrhuj^'e. In ])uruicii>ua ibuicinia and IcucocytbiL-uiiu the exoi^ 
tinn of una in afU'n 4)xcc»iiivo. Tbo ^rrcwtest excrolioii oi>cura in diabetes 
uiellitus ; here there ia not only an uiiuautilly larg* I'oummption of nlbu- 
minoutt food, but also au exoenive melnmorpliosih of tho albiiminoiM oou- 
ntituent« of tho tiKHUca. Th@ result of tlu§ double pro'diiRlioti of unui is 
Um «xoivtiuu of Ml vuunnuuit ibiiinuiit., Moinrtiitirii l'2ri i>r cvt-ii ISO giinuniea 
per day. Knileptic attxckH arw itlflo followed hv an increased excretion of 
urea— -due doubtleaa iu part to the dimiuiahi^a supply of oxyj^en nhich 
OCCUi'H an ti fuitture of the iitlock. 

llTrtorption of exiidntott mid tmnetidatos, Bitch as dropnical ^uida, hiings 
into the blood a quantity of albutuen, vrhich is traniifomied into m-ea and 
excreted, thus increasinR the total nniount found in the uriuf. An iii- 
crooito in tho ororotion of urdft l\r a dropeical patient Willi Brijfhfs diRoaae 
does uot therefore ueceaaorily iutlicate uu iniprovijuieut iji the i^nal func- 
tiuna. 

In CAMS of gout, chronic rheumatiatu, biliary cohc, and various disoMes 
of th<] livur, thv cxcrctiun of urea in diuuniiihcd. Id varioiia ht-pattc dis- 
oaaps thiR dimiTiutioii in tho vuvji cxiTTt^d in accompiuiicd by an increoHed 
exci-clion of intermediate pruductfi, pnrtii-ularly uric ai-iil. In such dia- 
ordcrv, therefore — of tho uver, bile-<lucta and duodenom—Uic uriiiu in 
often loiulod with tirid^'H. 

It beia been re[>eat<«tly noticcil that tho <lcT(-loi)nient of cancer ia ac- 
compjuiietl by a dcf^iileil fall iu the excretion of urea ; in one cnae the 
ftinoiint frll Ii-om 29 to 7 (ji-Hiuniea in twi-iity-four lioui-s. It luus been 
proposed to utiltKo this oboonatlon for diognoiiiQ in cosea of Hu.Hpected 
cancer of internal orgnna. ' 

It ia evident from the coiuacleralions meuttoued in the earlier |>art of 
this ohnptor. that but little vnlue can be attarheil to many obeenrations on 
record oa to the ox<-rotiou of urea, since in but few cases hflvo tho coadi- 
tionH noceaaary to accuracy of obsei-vation been fulfilled. 



A 



PATHOKiOOr OF TOE DRUrS. 



lor 



¥ 



"Whilo in tlio coDditious already montioatxl Uie ^limiimlicil exorvUoo 
aeenis to d«pon<l upon a diniininhwl |)rodii(!ti(>n of ureK, th<!re ore otbeni 
111 which tliere appesrs to he the ubu&I production, but a failure to ex- 
crete ; Lbeau iw« t-dpcciiilly uufti of renal difKHuw, Sir Audmw Clark lias 
rfttenllv tk'Wirilx"! uiufcr the luuiid "riMiftI iniuUfiuiioj* " n cliuw of cohok in 
wliidi itic osRc^tioQ of ui-ea 'm Lubituallv Iohh tUun normal, though there 
is uo 6vii)enr-(^ of ktdii«y diaeaae. Uric acid and umteH ai-e nlao aeficient, 
tlie urin^ having a low spAcifio ^nty. Thui couilition is osaidlyoburvAd 
in high Urcrs uid is corrected hy reguktiou of thu Jivt. 

HiPPimo Acid in tkino .'■ oouHtont ingredient of tlie urine in miui, though 
it occuTH in niiioh tuiialler ({uautiiv tbau in tlmt of herbivoroiui animals. It 
ia produced, in part at least, by the dccotuitoaitiou uf ulbiiinftu ; under Um 
influeii'Ce of paiicn<alic juiue tliore is produced iu th« idimcutitry canal b 
RulHUiDfio which in nhMirlinil ntid iu Uio circulatiou is oxidised lo heiizoio 
Add ; this is subsequently transformed ^by a condiinatinn with frlycocoll) 
into hip])urLC acid. The benzoic acid which is coutaiued in vegetables and 
fnut>i, Hiich aa crnuberries and pJuioii, or ndiaiuUtorcd by tiui luoutb, is 
siniihirly ctlumj^ed iuto liippuric fii^id.' 

CViiiiDUi' ,\i lu.^ — Tliu jnilrid di.-roiii position of atbumiunuH hmlieo— pu- 
trefaction — pntdiKHH nuiuproiis amnintic ftubBtancpn. TiiiH deroniiMwition 
is ponstantly occiirrini; iti the lover portion of tbc Htnnll itiU-Htinc ; tii€ pu- 
trid produi-tx iirv in {^.-ii piirt vxpelled with tb« ficc«B, yot a sniidl portion 
Is nlwurbcil by th* iut^^xtiue. 

Amon^ tlii^ proJucta of thia albuminous decnomjKMtion in tlio bowel 
are two subHtauces which aro eubnequently etiniinaled by the Udney, and 
soineliiiivs poMsvwi gnat clinical aigiufli'iuice. TheHu are plieuol (L'lU'botio 
Acid) luid indol (th^' Mourco of indicnn). 

Althoii;,di norma] urtne coutains no trace of carbolic nciil, either free 
or combined directly nith an olkalL yet there ia preacnt iii »very uriae a 
certain quantity (.(^l to .05 frratnme) of the acid tU-rivcd from the inl^atine, 
and combinLii wilb nu]|>huric iidd an a vulphucartoJate of polasnium. Oar> 
holi^t acid tjikiiii itiU) the xtoiniich or inj&i>t«d under th« slciu idno appoan 
in this form in the urine. 

Circiiiiititanceti which favor the decoiupcjuitiou of nlbuminoua BubNtnaceH 
in tht! tnt4-Mtin<.-M, aa well an tliow whii-h iiiipvdv tlio eviuruution of (ho fie««B, 
tnuat, of coui'Be, favor aji iucresHcd a'b»ori)tioD of carljolic acid. Aocord- 
intfly it bis been oltaerved that %ature of the intestine in dogs and tntes- 
tiiml obstruction in tli« human subject is followed hj an increased eliioi- 
untion of oivrboha acid (iu couibinatiou) in the urine. 

Carbolic aciit ia. as ia well known, a toxic agoot; the comhinatioQ tu 
which it appear§ in the urine — the aulphocarbolateof potaaKium— U, ou the 
other hand, iuuocuuua. So lonn as the blood suppUea Hufficient anlnhurio 
ftci>1 fur Uiu forniatiou of tlie «ulp]iov&rbolat«8, tho oubolic m-id which may 



' Oaeot th« molt tslor«<tini; phj'Klolof^ck} facts oMaIiIUImiI in ro«*nl,T*«ni i* tha Atm- 
onrtrattoH bjr nmieK anil KolimWvbKri;. Ihat tliu fanniitiuii uf lilppurio frotu bcniula 
•efd In MHMmplliilinil hj till) I'ells oX t)>^ ki<liii>j. Thiy foiiiiil tlml ariTllitii-iitirfialiou 
«f ItM Udn«}'« or lb* Mgktiini of tha miiiil v««i.>lii In 'Inii*, tbeHp KiilinnI* lixtl ttio jmwm 
of coarertiiig Wiuole into lilp|Hirio (Mid; U^ion oftlio uretcnouly. an tUw other 
hsndt did nol Inleifere ntUi lb« prudiicAion of Ihia add. Tlio Minn tnuwfnrautioa 
WM efTMl«d by paaln^ btood eonuinlnn benxele aoid thrcniBh frMlily exetMd kldrntj. 
Aflor thn \»\m» at nomo houn the utrlKCI ItlilneyH lost tlifa pover. It It therefor* de- 
iBonilralutl thkt Ibu kidiioy cnUn br» tlio iu<mlU wh^ri'liv IwiixaJc i* conrerled btto liip- 
purie Bcld. l'liai» obanrrcr* found ll»l tlje ftildition of qiiinino tolba blood |ir«vwnted 
tkb tranaformallvn (jimbablj' bj^draUxi/liiii tbn proluptnoin «t tliorvnat oolla] ; oubouio 
•eld liad > alntllar ulrvet. 




108 



Dl!4KA8E8 OF TIIX I'KINAltY OROAXS. 



be absorbed, either from Oie inleaime or from tiio mtrtiMe of b vound. ia 
oculnilizeil bj & combintitiou into tlic hiu-mless sulpliocarbolate. So soon, 
bovcver. ns tli« aDiouiit of cnrliolic luud abaorbed is more Uian enoiigili to 
oombiue uitli the sulpburic acid coutained in tlie blood, nii excc-BB of tli« 
foiiuer must ri'muiii as free a«id, and exert its iiijuriuus eBerta It is 
h«tK-« oviiknt Ibnt an eiMninfltion of the iihiiR r(?vcn]js tho approach of 
<buig«r from cai-liiiUc acid ]K>iiH>iiiut; iu Uiohc who are ci)ij>lii^itig Ubia agent 
either intei-iuUly as a tnedjdiie, or ■>xt«riiallv as a dreHsii|;f. 80 kng M-' 
the uria« CODtuOB an ftp|>re[:iabl<> amount of sulpliiiric ncid (aud aulpbates) 
it may be MsaniMl tlutl thcn.'^ in du dtuiKor Irvtu the vurboUo acid ; while 
the dlsappoaranea of the Huliihau^H frnni the urine )ii(1icat(« tliat tlt« bloud 
is eaturat«il vdih carbolic acid, and that no more of Uiia aubstiunv i-jrn be 
obfiorbud without dan<;cr to the uaticiit Baumnnn aNccrtJiiiied tbnt the 
UQOunt of nvntliiblf sulphuric itcid in th« blood oad be matennll^r increased 
by the ndtuiiiitiiratioti oi the Hiil|iliitt<! of Modiiim ; hcucc Ihiit itidt tnav be ^ 
Iffoperl^' adniiniKtered as an antidote to carbolic acid poieooiiig. preoent or 
prospective. 

£ix:retK/n in Disease. — \& yet but few obBervatione on the pathological; 
sif^iificanco of CAi'bolic tund iii the iiriue Lave btcu unde. Au iaereasedi 
exvn^tiuu haa beeu ulwerved in cnsva of iLnictirit;!' luid olMtrURlion of tlie 
ioteetine, ititUHKUiict^ption, periioniti^ j)prit\p)iHtiK, atnny of the Ixiwrl. 
Since, moreover, the nbaoi'[>tioii into the btuod of the ppoducta of albntni- 
nouil d<*ctiKip(n«ili"ii friiiii wljatover Bourro i» followed liy the cxcrctioB I'f 
the acid by th*' ktdnejK, there ocfiirx an iticrwiwi.1 elimination iii cam-h of 
pulitioiiat'v t:;aut>Teiit-, [lutiiil biiftii-hilia, fiiipyu'iiio. dilntatiou of Hit-. Mtoin- 
Bch with fpi-mcutivtiou, cancer of the woiub, rectum, bi'eaet, etc." 

L\i)k'\s.—NurmiLl uriue cuntimui a substance which, iipou tbe addition 
of bydnN-lili)ri(! acid, f.xhibili^ a bluv color idriiticnl with that of indigo. 
nii» indign-prodiiring snbAtaiioe has long l)een known and haB been 
termed icdican. Only cecenlly, however, has its origin and composition 
been nsportaincd (by BiiuttiauD and Briegvr). 

ludic^iu i» di'rired from iudol. which, liki' cnibullo acid, is n regular 
product of tho dci^onipoHitioii of albiitueu. Itidol is, thr^rtfor^. coiitttaiiUy 
produced in the email inteatine ; some of it is evacuated with the fii^ces, 
while a portion in absorbed hy the iiit«Htine, and ariinut^ iu the blood, it 
ootnbineii (like carlwlic iicid) with milpbiiric acid and {Kilii»Ki)iin, nialtiug 
(he i&dox)'lHiilpliato i»( tiotaHHiuiii, or xMlumt. Tlw amount is increaaed by 
an exdnsiroly llesb diot, but it docH not disappear eutirely durint; fasting. 
Possibly indicaa is formed in amoU quanli^' by noiiual tissue luetamoi^l 
phusitt. 

KrrTetirm m Dixnoe. — Indican is aii ingredient of norinnl urine, derived 
by abeorptiou from the intceiioe. In alt patholo^fical couditioas in which 
the evBcuation of the fieoea ii retarded, the quanUty of iudicuu iu the urine 



* A fact whlota tNMsanaoi gntt pRlhnlogical jntorMl, though bnt lilUe cliiiteal import 
taaov. nt Mlablftliivil by Brieiier. He rouud tliat wliilw Ilia ainouiit of oarbolie add , 
*xer«t«d in the urinu U d>Mr«aa»d in fwbrile oondltloDi in traneral. hicIi u jtneamonlai 1 
actlt* rli«u)ii»linn. ttliJ ni«>li[nf[itl«, yet in four lnf««tlnii> dii)«ast« an ex«*««ivn ainOBRt 
of )ilii>n<>1 (■ tlitiH rxpruUid : thvw dlsuoM* nrw Jtplittiarln. ii'AiUt fopur, «>ry>ip>'1ns. Knd 
prn-mi^ In oiUvr infection* ilWucs. avcn thougli Ibe ti-mjii-rotum be oqiinjl; blgh^ 
•cn»31-fHix. l^pboicl HiiH iiitvriuitti'iil ti^yrr — tll4^ ■uiuitiit cf i-nrbulic ariil is icsB lli«ii in 
h*«ltli. Brl4's«r ilitrHtorv lufcn llinl Iliu t:>ur iitvutt iikiueil liavu b «uuunuii cliolutf- 
ksml Caclor- ilie Htiforpltpn of puliiil proriiii>iJi— nnil be tomif thotn " jiulr^rnrtivi' riiii- 
HM**.' Thi* (ituwrraiion arti>riU pfTtodly witli lliw im«nt invMtlgnlioiiti hiii> thv vli- 
olugvof ihuBrptiediMnauin inhlvh t)iuw iliulihi! i titrodtiotiou lut» tlm body ot putrid 
ptMUetfl Indiiov dlplithurta, <>rTe1i>«ltu<, p.va<n)i*, and tuptii'ieiiilii. 



PATHOtOOT OF THE tIBlNF. 



10& 



is iDCreased. JoS*^ otmerred an ciiornioiis nmouui in n fata] ease ot mcar> 
c«ration of the emtil] intMtiiM, nnil Aohii>Tfi<l the samo rottult <^s]>GrinicDtaUy 
hy Uj^iting lli« iutCHtioe in dogs. Inaoa&« of incKTcertitei.l kemift, retluced 
tvrrntvfoiir houra later, a similar iucrease uf tin? iudi(.-;\ii in the urine 
was obnerveiL In awM of diarrlicFii, purulent [ivntoiittiK, hikI in huMtu&l 
(.■onHtipution. iiii vxoeBsiTe excretiuti hats l>eeii notcil ; u»<l it hns long been 
Lnon-ti tlmt in cJuvlitni tho urine (^nutnitiB aa exccKM a{ the uinie substance. 

The vxcietiou of iDcliean, like t)iat of carbolic tici<l, is iDcrciimd in coMttt 
of pulinonarr Ki^i'^E^fo, cancer of tliu Ht«iuiicb, nud tiiiiiilii.r conditiona 
wk«r«iii putrid pi-oducts gain Ji«ccw4 to the blood ; yet hricger found that 
itidtcim and tln^ lu-id nru not alnuya iucreuaed ia tlie Bame degi-ee. 

Senator foiind that Uui urine of new-boni children contaios no iodican 
—a faH quite in accordauce with the obsfrvation tbat putrefaction does 
not occur in the fcctol intcHtiDc, nuU thai uu izidol is diacoveniblo io the 
mecoiiiiiiii. Hu a8H«rt»> tbnt tho gnmuliuntrnphyof th« kidnsya is loarbedl 
!>y an inntPiisttl esi'retioii of itnU<Min, while other forma of nepluitis anil 
the ai]]yloid degeneration of the kidiieyn arc not so accompanioa. 

Id rare ca^s the indioan becomes oxidized to indigo in the urinary 
pruMugrH, so thiit the iirino iit blim wh<'n ovAcuntrd. In otiu;r &wai a 
Rpi>iitan«oii8 transfonuatLon ialo iudi^^o on-iir« 8oaii after emianon. 

Ford reports acaae in which a nloue c-oui^tHtiog of blood-clote^ pboepltataS) 
aud indigo was found in the pelvis in a ca»c of Hurcouia of the Iddiiey. 

lu ulditiou to it« uceurreni^ iu eaaeu where devoiupoisitiou products oi 
albunitin are present in t)iu IiIchxI, iiidioun baa been obaerred in BevenJ 
pathoIoi^caJ ronditiona where ito presence cannot oa yet be explained. It 
ttfls been found iD cases of cancer of various orf^ans, eBpecially of the liv&r ; 
aUo in n cnm: <>t nn^uuitw. ciuieer of tho ui'lut. Ttosi-tiMtciii obHtirved an 
increase in clevt-n out of twelve cawJt of Addison's disease. Itobin has 
usually found an inereaae of indiean in the urine of lTi>hoid fever patidntfl, 
and cousiderM this a valuable item iu dilTcrcDtinl di[i<;nosis from conditions 
preseotiut; similar symptoius. 8ueh itn aeiit« iiiiliary tuberculom Urinss 
eoiitainiug luiu'li indicnut, when heati^d with utlnc neid, exhihit a bluioli, 
groeniflh, or reddish tinge— a fart which doulitlcss eAplains tlie existenoe 
of tbetio tinta in the urine of diiteuae ; for urines eoutauiin;; much indiciD 
arc atroiigly neid, deponit uric acid. »nd d<'CoiiiiK)>>i> copper wUtn. 

Ua()Rir,ix. — This pigment (variously temiej^l bydrobilinibiu. urophain, 
aud uroliieumtin] in coatmnad in normal urine in small quantity, and f^^- 

CoatH in larger amount during febrile conditions ; it is also found in too 
ile. That which np)H>nmiu the luine ut obtained by absorption of the 
bile fiiiiii the iiitcHtino ; the ^rcjtt^ir pnK of the coloring nialtcr remaius 
in the aliineatory canal, and cnlom the ftecea 

Urwbihu is derived indirectly from the colorinR matter of the red coi"- 

EusuIch; iiuUti^d Hnppo-SeyW btw obtiitned thin pipniout dir«-ctly from 
lemoglobin liy treatincnt with hydrochloric acid and tin. It is therefore 
inereaaed in all tliooe pathological conditiona wliiph are nccompauied by 
dcnLriivti'>D uf rod corpiiacles, such as fever. It has nti^o bn4^n found in 
the urine iu lar^ quantity iu caaes of jaundice from iut«8tjual catarrh. 



IjionaAKic OoKHiiTmeNTS of the TJrixb. 

All tlie sulubla and some of tbe insoluble isiltt) coulainod in ibo nour- 
itdununt appear in tbe urine ; Uie quantity varies imtutidly with tliat cod* 
Bunisii let tbe aystem eridently stores away a certain portion of the 
aalta, aiooc it is found that on auitaol fed upon a diet contaming but littl« 



110 



DISEASES OF THK URINABT ORQAKS. 



of tlipse snlls exrret«s iievert1i<!le«a n cnnwileimUe qunnfitv more Uinn is 
coulAint-d iu Hm food. That tlioy conntitute an esMntial pfirt ot Ui6 footl 
IB Rfaawn by tho impiiimaent of h^&UL aiid ev«n f»tal insult which nttpii<I 
their ftbeeuce from tijc Oicl. Onliaarj- fgotl contains &u abiimlfuice of 
such saltM; it is only uodor Hi>ecinl ooiMlitiwiiH (auch iis tLo tmusition froni 
niii-Hing to cftting), that some of tlietialUi — liiuc «.-t«i)ei;iiilly — inaj- be present 
ID itinulticic-ut qwiiititj. 

The (.'AnjittiufM nrc for diiiicfd purpo»«H the most importnnt of the in- 
organic coiialitueuts of tlit- uriiif. Tlinyiirr derived cbietlj- froni the food, 
and in health the (luastity excreted in the urin^ vanes with the uinuimt 
conBUTu«d. 

In fubrilu oouditjon^ the chlorides ore retained in Uie tissues; th« 
amnnnt contained iu th« untie constitutes an index to the coutw of the 
diticuao, siuc« this atuount deui-eases nvd increne^e ncoordiog ii« the patho- 
JogicaJ process in more or letm aggravated. 

The (iiiantity of chlo^rideH in the urine is intrenfted hy the abtwrption 
of (IropHiciil fluids Bnd in^iimmntory exudateti. Iu di.-ibetes iueipiJiiH 
there ia, nccor<Iii)y to Vogel. on exwsaive eicretion. while in diabetes mel- 
Ittua th« ijuantit.y in [loriiitil. 

In caece of Bright o dtsense the estimation of the chloriden iu th« 
tuine often furiiisheB infurtoBtiou of much dia};noBtio value, as hiis been 
already ttxpliiiiwd. 

Tus pHOHfRArts excreted iu the urine amount ordianrily to two or 
thn>o erammea Since the bonea contain lar^e quantities of phoBphntes, 
-it woiud he eipected that diseases involviug disintegi'ntton of bone suh- 
stani'c would Ix? ueconipiuiicd by an Increiused t-xcrt-tiou of phuspluitCH. 
Tot in tDO»t caiiCH of racliitin and onteomAlacia the amount of phofiphAteB 18 
found to bo ]ees than uormn!, In gout and chronic rheuiuati&m the 
amount in also decreased.' 

Tho term pfi'ifphaluna htiB been applied to nn excessive excretion of 
the «»rlljy pl)<iHphate«, the aiiiuuut beiug sonitUniea iiici-eat«'d to tli-ee 
IdineH the nonniil (juantity, I'he amount of urea mid the quantity of urine 
are also luiicli incrciispd. ho tbat the condition has been termed "" plioppliatic 
di«bctfs " Nutwi th stun d tug tlie largf amouiit of phoHphfttcs prtseiit. there 
may oeeiir no precipitation of the^f^ ttaltA. Rince the urine remnina ncid. 
At some period of tlie diaease, however, the urine usually becomes alka- 
line, and then heai-j' white sedimentH of iimorpliouH ndciuui pboBpijHte ar« 
pretnpitated. This excessive olimiontion of tlif pliowiibaUrs rtiaj be only 
temiximry ; or it may perstHt, iu which case phthisis ie eometiiuee derel- 
opeo. The cause of this noeuliar exci-etion is uuknonn ; it is observed 
ahuost exclusively in iudiriduals suffering from (frneral or iiexuiU exhaua- 
tion, nnd sometimea iippears suddenly Mter the patient has undergone a 
aerom ntental strain. 

Au exi-ee&ive excretion of the alkaline ptoBphates of eodium aiid potas- 
aium is obsened more frequently ; it ia usually accunipanied witli some 



' Then? no«nrs a Tnitrki><1 nii<l cnnstant dlmlvnttrm of (ho phnplinlM tn all foraaft of 
paronchvmntDiin nij.lirllis— npiilo and phroin>, with «iicl withmn iimvl.)iil ■3w««iii»r- 
ntion ; dje dimitiisln-d eicrelinii of phoiphork »*id III IIr'Hw alT.'cliiiii* wMn» In run 

pntnllvl with tlie dmrniBeil etlniliiattuD ul uren. FlcliKb^r liu rhnirn tliat phonplioria 
ociA n4miiilnl>>re>l lo patients sutTi^rini: from iieuhrliis li not iixi:rKl<;d in Ihu iirin«i ai 
it hhx hvhllhT inilirMiHilit. It in nrobsbl". llirrf fore. lh« tn tlieae renal alTpcllonf lliere 
If more or Icm retention oC tliu ph(Mipliuti-!i in tlie body. Tliis fact In Imnortiiiit In nr 
liHoii to iho ellnloatf »f iiriFnU. sloco reci-nt #TpMlmpntB make it pmbihl" Hint tli«e 
rotainvd phi>«i>liBtuii i)lay ah linfKirlvjit part iu tha proiiiictl(>n of urxmio poitoniug. 



PATUOLOOT OF THK URINE. 



Ill 



polj-urin. lu many cnaeB fch«sfl pliosplifl't^a are depoaiteil aa aii amorpboua 
Mtltmentf tbc unitt.- bviiig pervisteutlj ulkntino. This coaUitiDU of the 
urine is commonly obsorved in connection witli ncut* iiitlamuitttions of tlie 
bmii) »n(] Hjilnttl cord or Uieir membniuea, nfttr actito iuauw nud iiijiu-ics 
to tlie U&v.\, ami in mtmj nervoua individuaJs where none of tbPBe morbid 
coiicHlioiin eicist : it is ft frequent eirraptotn of neuraHlhonia nnd of sexual 
ilerau^nieiitM. Tbiri [jeixiMtent »lk»liiiity of Lhc urinti and vxctnsive do- 
posit of thy alkaline phosjthatfa — often improperly called plioBphatiiria— 
in frrrjii'-iiti.v iiti'fuiipiiiied witb iri-itubility of tlie bladder. 

Til K Sn-PiHTD-. — ITic deooiiipyi*itiou vt albumen funiiabps a consider- 
ablo quamity of Bulplmric ncid — from two to two and a liiilf (Titnnities at 
stroDR acid daily. Th» uinuunt of tbe aulpliaU-M in tbKrefonr iiicruiiMid by 
uiiiuial diet. Ttie sulphiirin naUl formed in tJie titiaiieH is neutralized in 
cariiirorous tutimala and in maa by combination %vith ammonia. It is 
foand that by itcbniiiiMtiTing frpo Kiilpbiiric atud ti> di>{^ a largo inoreoae in 
the ummonia Ktdts of the urine i» produced, the auiiuiU meanwhile suffep- 
iDg no impairtneut of health. Uerbivorouti aiiiuiola, on the oUier hand, 
obtiUn but little ammonia from their non -nitrogenous food, and cannot 
supply it in sufficieiit quantity to iieiitniJize free acid which may be ad- 
aiui«t«rvd (o thi^m ; nuoh iui<l in itrntnilizcd by liio fixed alkuhi.'M al>. 
^ trftcted from the tioaiiea, and thpae miller n correiiiKfiiding iniiminnent of 
function. A fiompnmtively Hmall amount of free Bulphurie acid ia there- 
fore sufficient to dcntroy a licrbivorous nniiunl, \\'alter found that by 
ntfutnilizin}; the acid with carboiintc of sodium inj«ctii>itM. th« hfe of u 
nd>bit could be »taved even when th» niiiriiul lay at tho jiuint of driith from 
poidouiug by acidn. Herein is tbe esplouatiou of the fact Ibut berbivo- 
rouH animulH caniiot tsxiat u|X'ii a Avnit diet unletw it he oocoiupunied with 
sufficient alknli to nvutraliiee the gulphm-iv ncid <loriv<!d from sucii food. 

HerbiTOrouR animals ordinarily excrete au alkaline iiriue ; when fnst- 
ing, however, their nrine bowimea acid. They are, therefore, evidently de- 
pendent upon t)]«ir food (or the alkalies neceaBaiy to neutralize tbe acid 
formed by their own tissue metamorphoaia. 

The excretion of the aulphatea has hut little clinical fdgmficnncn ; it Is 
uaually parallel with tliat of ur«n, since the sulphuric acid and urea ore 
derived from a commuu Huurce — albumeu. 

Ahmomia. — Tho lunmoiiia fniiiid in combinntion in the urine in derived 
in small part oidy from tbe food ; the greater part proceeds from the de- 
flomposition of K^bumen. Much of it nppcaiti in Uie nhape of urea : the 
amount wliicii ix excreted oh n simplo salt of ammonia is always small, the 
quantity varying with tbe amount of ncid which is to be neutralized. If 
au exeeM of odd be contained in the blood, a large amount of ainniouia iit 
required (in man nnd the camivoro.) to ueutrnliEe it ; if but a small nmount 
of tad be preseul, a limited quaality of uuimouia may appear in the urine. 



CHAPTER XL 
PATHOLOGY OF THE UltlNB (Cosrwrro). 

AmOXVAI. Lc(tKBt>t£NT8 bp TllK TJ&IKB. 

The following RuTiHtancea Fippear in the urine chifflj- or Melii8ivi.lT iq 
pathological couditions : 

Tbe albiimena : senini albumtij, Hcnini Klobulin (pnrnglobulin). pep- 
touo, prdpepldiie. Siignn* : gmpo niifrni'. milk swpnr, iiuiMte. IJiUaiy 
pigiueiiti^ biiiaiy iKnJs, hiemofe'lobiii. Iiit, Buljiburottfcl liTtlroKcD. 

Albukex. — Siiice the mine ia obtained by filtration from tlie blood, tlie 
moet nppamit unci (reqiiput eources fov albumen iji it are tlic nllTiintinouB 
couBtitucnlM of tlie blouJ. Tbe term nlbuminnria is, itide<?d. pi-oinrly l*- 
i»trict«d to tliFit adniixture of nlbtimon with the urino 'wkicb occiub iii the 
kiiln«j — renal nlbuiiunuria. Tbe adtni^turc of [iiih, IJouil, ot'tim^us brings 
■Ibumen into the urine, a condition deHignated for convenience " fttlise u- 
bouinoris." 

Two albuminous couBtituents are conatnutly present in tlie blood — se- 
rum ulliutiic-ii and ncnini globulin. Yr^t IIicrc «rc not iIhj only fumis found 
ill Oh: blooil, nor arc Uiey the only idbuiiiiiiou» oubHtmsi'Cit which filU-r inlo 
tbe urine. The two tisnal test*, upat and nitric acid, detert the presence 
of tb(>H<! two ouly : b^nr^o a uo^itivu remilt with tht'iKi tev^s ducH not neces- 
Kurily provo thn iibscn™ nf all fornm of iilbtiincii fnitii thv iiriDe. For 
thera is contained in the blood^coipumles tut albntninoiin sid^stitnce, htrmtt- 
ylobin, wbidi ia uuder oertmu conibtiuua liberated h^ui theiu. diKHolvf^il ia 
tbe serou, and then inimeilintely liltvi-n into tbo urint. In ndditioa to 
thtiea r^irular (.'oustilueuts of the Uood th^re nro ccrtnin aJbumiuoua 
matti'i-H wliirh ittultrr Hpccinl rinniniatAuoes ai-e found in tlin t-iicMiIalUig 
fluid, and )>enoe in the uiirif! nl«n. Foremoat nnjong these in fnyiione, 
imJ a KubstJinM intormediatc between albumen and peptone, adied ;)ro. 
peptone. BLchanip hn« fiirtlier drscriljed as a coiiHbitit iiij^rcdicnt in nor- 
mal urine an albuminous substnnce Lfillecl ncpbrozyiiia»e ; this is. accoitling 
to Leube. a Jiiixttiro nf two aubstiiiiees, an filbumen and q fermfnl. In 
addition to these soluble forme of dbiiineii thei'e is occneioually found in 
tbe urine a sohd ulbuminutis EuliHtiuice. fibrin, &s well m ihv cuaguluteil 
luaHses of albumi-n known ns " tube-aiale." 

Scrum albiitneii is more coiDcuoiily found Lu urine tlmti any of the other 
varieties ; indeed, we hnve coine to regard albuminuria sa m^rnifying the 
presence of thi« aubatance in the urine. That the olhtr varieties have 
been so seldom observed is doubtless due in large part to the fact that the 
testa genprally employed for deteeliiig albumen do not rcvcol tlieni, Sinco 
the blood (-outniua ^'lobuliii, and since thia substance ie more tUlTusible 
tlian sernm nlbnmen, we would ea^pect that it would idso he present where 
the albumen is found in the uriivo ; it is, iu fact, actually demonstrated 




PATHOLOGY OF TIIE CKJNB. 



113 



tlut in RtofA catieH in which Herum albumen can be detected, globulin is 
bIho present. Ueat tiad nitric ttcid coagulate both of tlteni, luiil do uot 
tiKireforo diilcrviitiutt butwccu tht-m. EmIvIIo hut dcriiwd it utcLbud lur 
■ejKUutiiig (.'lobutin from sptqui nlbunieu ; the applicdtion of tlii« niothod 
to tbo oxniiiinatiou of albuiuiuouH iiriue sUowh that sometimea one, somo- 
Umes the otticr forta is present^ tliough UKuall; both ate found in the tuuuo 
spedmcn. Iud«ed in mauv iuatanc«s the coaguluui produced by heat and 
nitric acid is fouml Ui couBisl chielly of globiiliii — lui obxervixUoii quit« iu 
acoorduive with tL« frict that globuliu exists in the blood in largor (|Uiiu> 
titf Uiiui flentut lUburacii. 

la certniu patholoj^ad ooseR glnbuHn nJone iti found in the \uiiie ; this 
IB true, aceordioff to Strnttor. in casea of luujloid degtntratioD of the kid- 
nt>y, tliou^h this »Ut<iitictit tixodi) ri^WiitoEi.' 

Whether or not the dijttinct iou l>etweeu these two forms of albumen in 
thl^ iihiiK i»ny potMoiu diiiK'nontia Talu«, lias not oa yet b«en deteruiinod. 
It has been shown that heat and nitric acid ore b^' no tneouii delicate teutti 
for Rlobuho. siucie they often fail to reveiil minute qufuititieti of it, Siik-d, 
morx-oviT, ^lidniKii in more dilTiiBiblc tlinii serutu (Ubutn<m, it iwoms quito 

grobable tliwt it nm}' be ofteu present undetected in iiriue which seems to 
e free from albumen. 
Within r<>ceut years it hnii been demon atmtexl that prptorte frequently 
appears in the urine ilunn^ pathological couditioua, and Uint it tMinetiuHM 
pOMHOMMu <hiiipu>ittic importtuiOb Peptono 0«capea detection hy tli« onli- 
naiy clinical teats, since it is not coagulateil by heat or uitrio acid. In 
some tDHtauceii it in a^Muciatud with Berum albuiueii, wlule iu othem the 
lattvr Kubsliutco in Tibwat 

Thai thuro u«t:d bo no osaooiaUoa of the two is evident txom a conud- 
cratioii of it8 aonrnc Peptone in pntduced ill the aUuieutarj' cunal during 
di^^tion, hut in h-aiiefoniied into albumen Iwforo it r«aclies the circultk- 
tioB. Heucv the bloo«^l contiiins no peptuue : even tbo jKirtal bloud t-xhib- 
itaooJy a trace of it for a abort time after diffeRtion. This fact explains 
lis sbfleace bom the urine tinder ordinary conditions, since there is nothuig 
to prerent iLh escape through tlie kidney when it ia preiient in the blood. 
For it hiw lieou oftou (h; mo nitrated that pcptonu injected directly into the 
circulation or into tlie snbcuUiueouti tittsut, ruitppoiu-s in tho urine at once. 
It may Uierefore he laid down as a generiil principle that neptone which 
ffUDB nccesH to the circulation by any other route than tue alimentary 
SHMtL will appuu' in tliu urine. 

Now ii\i:iv. in At Ipoiit one othor Bftumo for peptone bendn digestion. 
It has been aacertaiued that peptone is a constant product in the putrefao- 
' ":>a of albuRiinoua HuhHtanceu, and is moreover containe<l id every itpeci< 
l«n of pus. Evrry collection of pus in tlio VhxIv is, thorcfora. a depot for 
lie tonuatiou and nbhHjrptiou of ij^ptone, which immediately nppt^iuit iu 
^the urine, lliia fact has betfn already employed for reco^iizing <leep- 
•cnled EUppurntiou inaccessible to tlie b'ocAr or hypodermic needle. Thus 
T, Jaltwh detected the bur»titi{; of an ovarian cynt by the appcortmce in 
the urinii of pt-ptonc derived from the pint of the consequent infljunma- 
tioa 

It in highly ni-ohable that suppuration is not the only pathological pn> 
LceM wherooy afl>uniiDOUS Kubfttimeeti are transfonnGd into pc^ptone ; for 
" isubatanoe is produced by the action of acids and olkiUicu upou albumcD, 



' A DIM of Klebiiliunrla doHog Muta iwpLiitU is reiHirtvd In Ibe New Ycrk Medloil 
B«oord. Ntx 8. 1W4. 



i 



lU 



DISEASES OF THK CBIKAIiY OROANa. 



Mid also by Uie isiIiigiioq of pancreatic jtiica It HocniH platioiblo to suppose 
that Tflrioua patliological Btnt«s c-nn 8o modifv tissue metaixtorphoeia ns to 
cluuigc olbuuico into peptuao iu tlic botly. HTule this nssiiiiiptioEi ia not 
n* v«t doinonstmt«)1, yet it ifl n well-oMablislied fact thnt tavbr ia uHuiUly 
Bocotap&oicHl by the apiHiarauce of pepUm« is the urijie, without regard to 
the ongin of tlie febrile condition. Furthermore, different ngE^iils wtiti.'h 
ctause a pronounced alteration lu tissue change &i-e also produclivtr of p<rj>- 
tuuiiria. ThUH piiptoue has bt-ou obKerved Iii tbti urine in canes of ptioet- 
phonis poisoning. dipliLbcrin, pneumonia, tj-jdioid fcrpr, and ncute y*-Uow 
lititijihy ; aiid it ajuji-iirs to be aUuost constantly jireeeiit in caises of fwnito 
and chronic liriglit'a diHeiise. 

Lassar recently mad«> an obscrvntion indicating the proLablo origin of 
pc;|]touo in the Ussul'b under ti[Hicinl aircumstoncps. Ha«nR obsenod that 
fwruEu nlbujuen npjieared in tiie urine in couHoqu^uee of inum-tiouH of 
petroleum for scabiea. he ex])erimeut«d wiUi rabbits to (titcertain the effect 
of tlie sotne subHtuuce upon them. He found that inimclionR of petroleum 
r«{jiilarly itiduced in rabbitH Uio appeaiiince of peptone, followed after a 
Kbort iiitvrvid by nlbumon, in th» urine, 

Projx^ptone ia one of the iiit«rmediAt« pixxliicte in the tnui^oniiation of 
olbmneu into {K^])tone iu the tiloroacb. It is fount) in the blood dimng 
digestion and in pue ; also in the medullary tiubetance of bone in the 
healthy condition and in OHt«<ouinlucia. Leube delected it iu tbe albumi- 
nous urino of a i)nticnt aufVuring from urtiuariik, luid Netdv ubtwrved it in a 
case of bffimoglobiuuria 

Senator tnaintAinB that the preBence of propeptone in urine ia much 
more frequent thou tna boeu stipposcd by writvm niid investigators. 
Within four years he <letectcd this Biibittujice in sei-en difTtTfiit cases — 
tttrtinrj- HA-phili*. hfcniiplepin, dipbthi-riu, caneer of tlie Oisopliitt^a, pn«u> 
niouia, ami luiieculw nlrophy reapectively. 'ih© Inst case w«8 remarkable ; 
the patient bad four yeai-s previonsly Buffered from liemorrhiijjia nepliritia, 
iJt«r recovorj' from which tli© urine for ii long time i-ontained utbiinion.. 
£ligbt«flu uioutbH liitL-r the ulbuuieu disappeared, but octriiKiunaily reap- 
peared tranaiently ; the subsequeut diw-'overy of propeptone wiis quite ao- 
CJdental. The patient bad nei'er bad (edema, and exhibited no cardiac 
hyperti-ophy. 

Sinoo propeptone is not coagulated by heat, it is usually overlooked ; 
indeed since propeptone is albumen at a certain stage of ti-onafonnation 
into peptone, it would not be strange il it were found in juine in many of 
tliose conditionK which induce jteptonuriii- Lassnr, in his esiwriniontH 
with petroleum above referred to, found propeptone ia the urine at a cer- 
tain Rtage of the inunction. 



CHAPTER 5IL 



ALBUMiyP Bi A, 



Phtsiolooicu. Albtmdiubu. 



Jx order to d«k'miino tbe imporUuiod to b« afctAcbed to the pr«senoe of 
MCam albumen id the urino in patboloKicul caaca, it must b<u dctnOod 
mider what if any circumataucus. iinJopttiiiJeiit of diseftsed conditions, nlbu- 
BMD ix prcsriti It wiM formerly' aup^Maed that albumiiiuria was u(>i^eft- 
Mifly iiiJicrative of diHease of the kldiioy ; furtlicr iuvcHtifjution showed 
that it occurred in variotia pithulof^ttnl couditioim otlicr tlian rcuiil diseaeo. 
Id oourae of time it wan diHci>vi-ri-il Uiat allmtiieii i« uccamouully prrspnt 
io tbe uriiie of uppiu-wuUy lienllhy indiridiinla; tiiis occurrence, at tirBt 
regar(](!d ns ii pliyHtnloijiatl <'Utiosity, was soou [oiiud to Le by no meoQa 
rare. It bt>caiue further apparont that the urine of tliC wamo individual 
u-ftH at differeut titaeti, evQn at diff«rei)t liours of the saaie day, soiuetiuieH 
Ireo from nnd Motnetitnea iniiod with Hlhumen. 

HiuH Lfliilie «xniiiined the urine of 119 eoldient He (ontid tbat in the 
morninj* 5 individuals (4.2 per cent.) bad albumiDurin : at noon, after the 
military exercises of the morninj:;, 19 (lit per cvtit) ; in the vvcnin^ after 
restiiig for twvenil hoiirx, the uutuber vna i^ecntntted to the original fi indi- 
ndonla. Muuu found amoiij^ 200 upptu'cntly ht-olLliy applicants For life 
insimuice, H <:iis8a (12 per coat) of aJbumiiiuria. Flirbringsr found albu- 
men in the urinv uf i out of lil iieultby childriiii (II. 5 pvT cent) ; Kleudgen 
in 14 out of 'i2 Itnaltliy [X'rtunH (44 pur c^riit.). 

Chateau bo ui-g liaa roceiiftlv reported luiniRrous einniiimtions of the 
urine fnjtii appitrt'iitly hcuJtliy iigi-bodh ; he found albumen in the urine of 
44 out of 98 mildii-rn, tho s|:)cciinen "beiug pAxeod three lioun after dinner. 
Another tent ')( the urine pus&ud tire hount after enting, revealeil albumi- 
nuria in 76 out of 1)4 tioldinDt. In iitill another cxJiRiinAtiiin, he fitiiud nll>u- 
minurut in 201 out of '2'il cases, tbe spedmen having been obtained after 
tbe perfommuca of fatigue duty. These teats -were nmde T\ith e^wcially 
delicate reagents*. 

UenaU>r made an eziteuatre ftcries of obsermtions upon liiiusolf niid 
three aasuiliiDta all in the onjoyment of perfect lieolth. Care was taken 
to obtain aiiiniKO<l luine, by usin^ for the emnaiDation only that last voided 
et each eTaeuation ; in tJiis' way tbe urine was obtitined free front the Be- 
cretions of the urethra, wliich Vtlwaya contAin albumen. In onch of Umm 
h«altliy individuals, albuminuria was occasionally detected, usually during 
digestion. 

Ill reociit y<'i\rH Ihix fitrt — that albutnon is often present ia tbe urino of 
mrfectly healthy individuals, yrithout oiposure to unusuul infliicncc« — 
naa been eeUbliaUed by nuuieroos observers, among tliem rroriebs, Cltz- 



1 



11« 



P19KASKS OF THE URINAKY OROANS. 



raaon, DeMuaey, Vogel, Oull, Moxon, Lepiiie. In sQcb cases the smouDt 
of iilbunien is rnrelir more anil usually less tbfui 0.1 per cent 

In A still Urger number of cases, tronaicnt nlbnminuria is obscmtd aa 
a consequeuoe of c«rtaui gpeciol influeDces. TbuB it often occurs after cold 
butha, severe muBculiu- eflbrt, and the rambiiitttiori of tliese two factors, 
prolonged sca-biithing ; after profTUH* i>erspimlion, itit«D»e emotion. FUr* 
twin^L-r i>bnon-«(.l jjiowt <Mue/ully for a long jjerioti a healthy younK jjlij-fiician 
vho, uiiilei' t.ho iutlutincB of mental excitement, repeatedly ovncimltid uriua 
ot higli ajjecitlc gravity, containing an much, as O.C per cent, of albumeu ; at 
Bocb times he experieuced dull piuu in thu rt-i^ou of the kidney. No casta 
nor other inthcntioiis of renal (iiaeo&e wero di80ov*red ; in tlie intervals be- 
tween these [>crioila the urine was {{uite free fnjin &tbumeii, imd nt the end 
of a yriu-'h ohaen-abion the health was unimpaired. 

The ohser\titioiifl of Virchow. Eugo, and Martin show that in a large 
pcrcEiDtuge of ciuee the urine of iLfauto in lUbumiDotui during the first days 
of life. 

Awuiniug tliat some of these apparently healthy individuals in whom 
temporart" or j»oi-sinteHt albumiDuria has been observed ore tlie subjects of 
unrecognized renal disease, it must bo admitted that tliere remains a huge 
coutinectii in whom the presence of idbuuicu in the urino must b« tXr 
plained upon some otiier grouud. 

Senator argues that by the use of more doUcale reagents a much larger 

BircDctogo of cusos of albumiuuria ia healthy persons would be revealed, 
ut asBumiDg that the roKults obtained by tho ordiuaiy tctite reprceeut a 
fair avoruf^, it fcdlowH that oixi out of ercry seven or eight inilividuahi ban 
at leaBt now and tbea albumen in the urine. To e:(p]ain this we must 
aoBiune either that albumen ie present in erer^' urine, or that it may iwcur 
in every healthy person under si>ecial plivKiolugicnl circumiitnnces. In the 
former case we must b«lt6ve that the nmoiiut of nlbiuut-D varies, being 
sometimes reiviguizabie hv our ordinary teat^, and at other fitues too 
sUgbt to be thus detected. Senstor concludes that this is actually the 
case, namely, that tbe urine tdways cuuttiius albumen, though ufteulimei; 
Ln audi soinll <|uantity as to esuipe cictcriion by the reagents oommouly 
employed. The epitlieliiil cpIIb crtvehug tlie cnpillaries of the glomenili 
ore similar to the endotheUal cells of serous memhranee : lience it is rea- 
Bonahle to asaumo (in tJie nbsencve of demoiistmtioiiri to the contnu;j) tlint 
the fluid which passes from the blood through the cells, coveriog tlie 
gloQiemli, lins the same (jualitative comjioaitiou as that vi'hich eiicapcA from 
the blood into serous cavities. Now it is well known that these serous 
fluids contain albumen : the cerehro'Spinal fluid contains, for example, 
from one t<i three-tenths p^-r cent, of albumen, as well na a due proportion 
of the salts of tlie hloo*). Analogy woulJ therefore suggest l^at the liquid 
which escapes from the glomeruli into the renal tubules would also con- 
tain not only water and Kidts, but also albumen. The percentage of iJbu- 
incn would of cour»t; be lc»» than that cootiiined in tbe eerous tiitids, since 
the blix)d-press\ire is greater in llie glomeruli than in aii^' other capillary 
system of tlie 1>ody ; and it is well eiitabliabed that tbe greater tbe press- 
ure during tiltration. the lai'ger is the amount of filtrate and the euialler 
th« percentage of albunwin. Hence the litjuid filtered under great pn-bmurw 
ttirough tlie glomeruli, while having the same (pialitalive com)>ositioQ as 
other tranaudations, would mntiuii a Bmaller percentage of olbuineD. 

The objections to tlie nsEumption that tbe urine, like other transudates, 
contains nlhuuieu uonniUly, are chiefly three : first, that the ordinary din- 
icnl tests usually fail to reveal albumen in the urine of healthy ]»rsons ; 



alhuuinubu. 



117 



mcoiut, that the nhsemitioRii rjf Posnc-r, who ooa^al«tecl the albumeii in 
tntAi 'ki^Dey» by boiling. woiiM seem tn inclicATe that ftlbnmen is not fouud 
in the Mft]jii(,'h!ftii oapsulta of tlie iioriiial ki'lney ; Uiird, tlint the gkirmriili 
we tho only capillaries in the bodj direallj covered willi epitlieliiiin ; liciic* 
tlii^ itiffri'euce tiint Ihe^c opitliolinl collt; have some Bpeoinl futjirtioii. poaai- 
bly the power of prowutiiig Iho uacupc uf Duruin albumca from the rap* 
imriea' 

A« to the finit — the (ailure to detect albutaen in tiormnl urino by (ho 
ordinary teirta — the answer is plata ; there in ample proof that thesR testH 
ore iiKApable of rereaUngf miuutt^ trae^a of nlbuTDen. which may therefore 
be ])roMuit in niauy cMoa uuHutipectxKl. lit fuct, ob«orvatioD« minic vtiih 
«si)ecinlly delicate iiiethoda, micb a» tlie potaasin-mercuric iodide, rpwiil, as 
hm lievn alreaily statiej, the froquent predenoe of albuiueu iu healthy jK-r- 
sons, in case» Vihere hoat uad uitric actd sLuw none. 

Vomer, by Ijoihiii^ pieces of Crsdi Jnduoy, con^tUftted the albiunen, and 
vnut tlitiM (!iirLl)1iKl to dnmoiiRtrato that in caitett of lilbiiininiiriii tb» albumen 
escapes into Mie tubules from the glciiiiflnili — a fact wliich had been preri- 
oualy nasunied. but cot demonstrated. Innfimuch as Poaner failed to tind 
»lbumtiu in tliw dijBtidri* of normnl kidiicyn tri^iatcil in this wiiy, ho iwaerta 
tl»t in LOriiial kiiiney« no albumen onrajtea fiijni the bloud-resseU of the 
DlomeruU. Hia cotmlusioii is not, however, %vflrraiite<i by his ohaervation ; 
ror minute qunutitiea of albumen ctut be present in the capsules without 
b<iin<T diat'ovt^mblo by the mieroButipp. i>von ttfl*r toHHulatiou by boiliog^ 
Albuminuria eiiii be induciul in nibbitn very rnjtily l>y rapid clovation of 
tein{terHture. or by tlie injoctinn of miall ({uantilies of pha»i{ihoras dia- 
flolv»l in ohve oil. Such albuniiniuiu ia accumpamed by flr'""dar tubo- 
ctmta Btid by rcmd opithcUum in the niiiic ; y<>t eoc-lions of tho boilcil kid* 
oey frequently »ltow no itlbum«n whatitrtevcr in the ciiiisiilot ortubules. \ 
aeries of experimentu condunted under Cohitheini s direction gave a sim- 
ilar absence Qf albumen in the captjuleti iu caaen of albuminuria induced 
by th« injection of e^g ulbtimQu into the oiroulution. The exiilaniition is 
sunply that tlie mnount of iilbiatnoii in these cn&cit ix iio hhiuU that «veu 
when coagulated it ia indistinguitihahle by the microeoope.* 

It ia therefore deruoastrated that noi-mal lunne may and frequently 
diMtn contain wcmin albumen ; indeed, the recent exIeuHive employincDt uf 
delicate rcngents (espectfdly the iwtAssio-uiert^tiric iudidu) furuish results 
irhioh tend to support Senator's belii^f that altnimcn is just na iiortniU a 
coiwtituvot of the urine as many of the ordinary ingredients. The ro- 
aSHTobes of recent ,vears httve shown that sevenJ siibetauces. formerly sup- 
pOMd to ba ocotiiioiml auid nncideutjJ constituentB of the urino, lire cou- 



'Haidenbiio, ColmtKiiin. 

* Htl<i»Dhftln utd CuliatiAlm h*ra reMntlr arg«d tho lirpatliMis, slroftdy rury pop. 
qIm tn 0«rRMiir. lltat tli« ejitUiaUAl oovciiiiK ot the gloniatuli powumcB Ibu powvr ol 
imvantlti; tliu .mcajm of MFan albiuunn ttata Hiv Ulotxl, kiiiI uiaI tliu apnuruioo nf 
kDiiiiBvu in tlumitne tiiuftIlyliidlc*t«BUiln>pBlrinnnt of funoiionof iIium cuW Wlicn- 
•v«r (nuu alt; cause ilicw o«IU mnt itapurtvctXy cotirfiihiHt— w ooeurn \a ■iin.'iois i>t tlii» 
kldnvy, slovBMa of ihe riivuUtloii, ift-hnniia. rlc— thej pennit •Ibninru to eK»iM 
from (bo blood Into ttie tubules 'ihia ilivury liuk*, u jet. e](p«rliu«ul<U. foandAtlon ; 
but it It «xlr>inplir oonienleDt for «x))lBluiii)i lh>> albuminuria uf in*iijr ol)nl««.l cubm. 
Sonv of ila adTOcnl** liaro avnn uunmf-] n coukkhIuI mntfonuBtSon of IIiom aipiUialiol 
cwll* f«T th* pxplknolion of eiuoii of p<irifiiteiil albiimiiiiirU Id Bppdrcntir bMltbf in- 
(Uvklasls. TIiIb hj-polhfitis faili to uxpUiu »U.iatactoiilj tha w«l1-linowTi fkol t]i»t 
otbor form* of >lbunii'n I'liwulj' allUd U/ iliiil of titv ■eniiu— "(Qf ftltiuintn Mid pQjitaiiw, 
for InjIUMM — Duiut no inipodiinvDt In iwrnpliiff from tli<,i i^lomiirull, but u« U, onoe lat 
irreM t»j ■wrmkl kiduuyt irhitiivTitr iulruduoifii into tliu blwd. 



118 



DiasusEs or tub crisary oROAira. 



•Uul and norcDKl iiigTe<lioDts ; tliiit hMM been proron, for oMimplo, of iDdl% 
can, carbolic adil, hiripunc and oxalic acid ; aad after niucli controTersj 
it haa been establitilieu that (n^p&-siifriir is Creqoently excreted is tnmuto 
quanliticK bjr uomini kidn^VH, atttl mity won hv preaent in appreciable 
uuoimt in the uriui- of Leultfij- iudividualtL 

Tlw! time haa tertuinly orrivi^d wliftii Oie iriin/j/« preaenct cf Mwir^n in 
the urine cannof be regariied as prunf of any morbid conditi'j'i of (he hUIitei/t ; 
tiie queHtiOiii is no loD^r, i>aei the uriue oDotain olbumeu ? but. How inucA 
nlbunMii is preseut, u it perKi^ent, nud art there any other ifulicaiiont, nit- 
erotct^ical vr cliniad, of reiiai dumee T 



Ai^iMixtnuA JKOM pATUOLumcAL CowirnoKS othib than Renjil Duulihe. 

Many iiiTeetigatious, clinical and esperimental, have been made to d»- 
tcnoine the various inltuencea other than diseoae of the kidney which cauee 
Uiv •«CB|>« of albumEm into the urine. To enuiuenilfi these would exceed 
the scope of tluH chiipUr, wliich iiLall iiiiii luurelj at sunimurizini^ the re- 
sulta Blrea^ly obtained. It luunt bo admitted that the subJE-ct is but 
partially clucidnted ; the explauatiou of the olbumiDuria obaerved in many 
olinicol ci\aes ishiill uncertain and muHt so remain until the phrsiological 
relationit of the kidney to th« general bodily functions nre more thoroughly 
asoertwDed. At prcyeut w« aro uftvu luiable to trace satJsCsctorLty the 
efliects upon the kidney of ilifTei-eut diHturbiug factors involved in the aaue 
dimcal or experimeufol couditiou. 

It IS, LoweriT, deSuitely estubliabud that nibuniiiiuria nay result from 
any one of sGvcrnL jnllueiices ; thei^ will bo brietly dincusBed. 

1. Tticrease of' arltt'ial i>re^un:. There are various methods for itt- 
oretutiu;' gcueral arterial |)ret4suro wiUiout iDdictin^ injur}- upoa the aui- 
mat. FJnt among these is tim-ecntar achvilt/. It haa been itinply shoiix 
through observations with iho kyiuogruph that every musctdar contractiou 
teuds to iuci'ease the general artpruu preswure, arid that violent muscular 
exercise may ensily nuHo tliia prcafeure forty or fifty per rent. Now it ia 
eatablifihed by (-Uuieid obaervutioua that idbuuiiiiurta occurs lu healthy in< 
dividuahi with eHpeeiai fretiueucy after muscular effort. The observation 
of Loube ak'eady referred to, iu xvhich the percentage of cnsce of albumi- 
nuria ill lii'altby pcrHone rose from f(>ur to Bixteeii por ctiut. diuing muucular 
exertion, in nn instnnce. It is also known that convulsiona, t«tanic and 
epileptic especially, are followed by albuminuria in persona whose urine ia 
at other times free from albumen. Esperimentally it has been obneTved 
that tile struggles of animals while being bound upon the operating- tabic 
lire followed by the excretion of albuminous urine, ev«a though the uriu« 
evacunt«d just Iwforo IMb niuticular action was quite free from albumen. 

Another metliod (or itiereiwing arterial pi-eaaure esperimeotally without 
interfering lUrcctly with the activity ot the kidneys, is arlij'n-ial e(i:va(\on of 
temin'ralure, griKhially indueed. An inerenBe of temperature of one or two 
degrees Ci-ntigrude euunes an appreciable rise of arterial pressure and with 
it the appearance of albumen in the urine, Eianiination of the kidneys 
immediately afterward, by means of Poener'e mctliod of boiling, shows 
that the olbuiuen Inis escaped as usual from the glomeruli. 

Tlie injection of ittrt/chivne or of ijotiiseium nitrate cauBea a marked rise 
of blood-pressure and the appearauee of albumen in the urine. The latter 
BCemB to lie the rutuU of the incrensed pressure. 

2. DwreiMf? ef arterial pressure ia a (re^iuent condition, wliich reHoUa 



ALBUHINDKU. 



119 



in general renoufi ^j^ncmia. It Dbtaiiui Booner or later in most fsbrlla 
couditious, ID cAKeH of c(iltn[>se ironi paiii or hemorrhace, Aod in Talrular 
h«ikrl tUsMiiiw bvfuru Luuipeusatui'y hypt-Ttropby ; io aJj of th\MO albumi- 
nunii i» ft fre(|neiit oocurrence. 

Prum nu expeniaeiital iuvestigation iato the conditiou of tlia rvtiaX cir- 
colation duriug febrile couditiotiB, Mendalson oirives at the foUowicg 

1. Tbat in dogs with fever the klUa^ uiul«i:^«s n dimioution in its 
buUc. 

2. That this diminutioit is due to a «ontiscticai of the wbUs of the 
hiood-vemela. 

S. Tliat it is constant sud progreesiTO, bciug proportionato to the 
iulKiiNit^r of tliu fnvcr. 

TJieae observations nlTortl a denionBtmtion of the fact tliat the albu- 
miuima aa we<U oh tb@ oli^^iuia ugufiUy ntt«iKliuit ufioii febrile conditions ia 
atlribiitAblc, lii purt »t IviMt, to the dt:cTea»e of m-t«Hul prviwura in th« 
glomeruli. 

It iM probable Umt a v«r}' large uuinber of tdinioal onaes of albumiuuria, 

■side trom febrUe couditiona, aro to bo cxpluned by Uio diminished nr- 

[terial jfreHHure in the lutUiey. For miitiy 8ubjoct« of luifoiuia and uorroua 

nxhaiutioit, vHjxicifiJIy duriug youth when the phyuotd dev«Io}fUieut ih very 

Iv^rid, exhibit aUght albumiuuriii, which toay be ti'sjinit'iit and t^miKirary 

MW may oceor intenuittently for years. Such patients often conipkin of 

HiQtdnolio and listlcmiteHS, ore fre(|Utntly uorvuuit tuid »ii>:uv times Miiflor 

from dyapeiiNia aiKl even iiiarrh(wi. Owing to the pr«val«nt n*;gliyeiieein 

«samiuiut; urint-, the albumen unuidly reuiaiiia uudiacovered ; if detected, 

liuwfvor. it usually aroUHoe tbe graveat approhGiiHiouH. Such anxiety is 

noixllvw^ (uulutifj indued there be evideucuu of reuid diuease) : fof the aJ- 

Llbuuiiuuria i<«oiiiM to r^^Hiilt merely frciin the diuiluiHliL-'d blood- jvciwurft in 

Ftlte kidney as a pai't of the gt^iieml anii^niia ; ami it disappeai's so eoou as 

the patient'a general health w improved. 

Til thu Ham*; cauiw must be roferrvd the tilbuminuria often Been in 
nmsting constitutiounl dimwieii, luuka-iuia. and couditionii uf general 
noiaraaraua ; alau after prufuHu Iiumorrliiigv, in i-ollapHo and in Uio IiMt dayx 
of life duriug exhausting diseasee. The albuntiuuria which frequeutly 
nppenrx during a febrUe diarrhtBii, luay be iu i»art due Ut Die accompa- 
nying debility, though largely rjausuil, doubtlvm, by tbo abxtmctiou of vmter 
from the blood. 

8. /wCTty*.' of iimnus prensure occurs either ii cini dccr«(uo of the orto- 
riol proMura or from impediment to the retui'u v>i' blood from the kidney. 
It hnH boea found tbut atriiple pressure upon Ihe renal vein of a dog pro 
duces albuniiuuria ; thv tiauie result is (Mniiwd by pliuring n ligature around 
tbe Tviu for ten or twelve iiiinutea. If tlie kidneys be at once removed 
and boiled after Posnor's method, coifcgulated albumen is found, not in tlie 
capBuleH, but in tlm tubidps, c.sriocially Ibinso of the rDedu]hu7 portion. It 
appcan^, therefore, that the uieiltdLiry part of the kidney eufjers especdally 
during veuuua hj'penrmia. ThiH is readily explained by the obaervationB 
of Luilwig, who found that this temporary occlusion of the renal vein (the 
arterial pretmurc remaining uuehaugvd) cuutuid tiucb dintentiou of the veins 
in the medullary portion of the kidney nu to rompreiw antl clow coinpleti'ly 
rthe tubidcs surrounded by tiiese veine. In short, veooua hypenniuia 
hatues — in the kidney, an olaewhere — iL'dema. j>., the troDHadation of 

' Cartirrigltt PriM £anj, Aawrloau Joarukl of tbu Mgdinl ScIkicm, October. 1889. 



120 



DISEASBB OV TUB VBINaKY OROAN& 



'WOtM', Balta, and albumen (rum tbe smaller veins inta the !(urrnuR(Itng tut- 
ta». SineD tlio timue HiirrDumliu^ tlic rfins in the ld<lney is coiuj)oeed of 
tubiilci, ihe tnusudeil fluid iinittt eudL-utlv escmpe inU) tlicm, wbure it is 
mixed vntii the luiue ; tliu latter, tbfirt^for*-, lH^■l>ul<^8 iiibiimiuouH. 

Venous bypermmia of tbe kidney tx^curs cliDically in auuierotis cas«8. 
Valvular (liumKe and fattj degtitjerKtiuo of tlie heart, impairment of tlie 
reflpinilor^' fiinctiuii, mivli us oocun lu twtliuiii, omphjserttiL, imd coii&umi>- 
tion — are fiuuilinr examplee. In Rudi cases tbe iliuguosis of " Bn;;ht'a 
diHeHHe" — bn^ed upon tbu preacni'c of albumen luid liyAline oasts in tlm 
nrine — ^ia ofteu eiToneouslj modo ; tLe writer has repeatedly seeii 8Ui'b ao- 
CJlllcd Brifjlil'8 diaenao— due to valvulw disease of the heart — cured by 
digitalii. 

The effect of venoua fa^pericujia from local mcchuuicel ubatruction 
•ma demcinHtrated in tlie ffiiiiuiar Pitse rejinrtpfl by Bartcls. Thin patient, 
mifrc-riiig from nsceml svjiliiliii, had ttdema of the loiN^r exlremitaeB and 
eaormoua diliitution uf tliu superficial \ciDH of the abdomen. Tbe autopsy 
nliowed throuibo&is of the iiif<-rior vonn ««vu above the entrnnce of the 
r«nal veiD. lu tluR case tbe )>atieiit erai-ualed more tliiu tLe usual amount 
of uriuc, wbicb ivas liiglih- olbuminowi. 

4. /->t«nn(' and injiiiy iif the urrvmis system are directly responsible for 
albuminuria iu many cuimih. Hotno of tboiw atv traceable to inJuriiM in or 
near the fourth veiitridt!. 

Claude Bernard discovered that puncture of the floor of the fourtli Teu- 
triclu vnut followed by nlbuininurin, and it boK been Biuco dcmonstmt«d 
that injui7 to oert;iin portions of the cprcbolluHi and of tlie enira eerfbri 
induce the same teault. Sul««--<iueiit reaeart'L 1ms uliown that the albumi- 
nuria iu tbcm cans of injury to tlie brain results from th« couBcquent 
pnmlyMis of tiie tpUnoluiic nerves, whereby the general arterial prcMwiro 
(iiU'Uulin^ thai in the rc^uiLl arleryii im miicb r<!diiced. In Bticli oantta the 
idliuiuinurin is to be referred, therefore, dirertly to tbe deci'eaaed arterial 
pressure, induced (through the agency of the fi]>Ianchnic nerves) by the 
injury to the brain. 

Clinieally, such ensea are not inlrcquout; thus Frori(?h« rq>ort» foiiN 
t«en cases of albuininuHu without i-enal dit>«ii8e, iu wliicb poet-mortem ex- 
amination allowed hemorrhage or inflammation involving the floor of the 
fourth ventricle, the cerel>elliua. or the crura cerebri, Jo all of these cnSM 
sugar wan aleui found in the iirtue. 

Various diseases alT«ctiii^ the nervous sj'steia are accompanied by al- 
buminuria whose origin U obw-ure— tetanus, epilepa^', chorea, uieningitia ; 
BO are ps,iFX-lucal distiubancca, emotional oxccsa, and nerrous vxhauBtiou. 
The observation of Fdrxtncr. Weinliery, and Bummhavo shown tlie es- 
pecial frequency of albuininuriu in e-jwi-x uf delirium tremens; these ob- 
BciTcra noticed that the (luaniitj of albumen rose and fell with the riolonce 
of tbe dobrium, while tbe kidneya were apparently normal tu several fatal 
cases. 

Various transient nervous disturbances, such as intense emotion, shock, 
and pain, may also produce albuminuria ; i»ftioij-«ms of pain, renal or bil- 
iary colio, and tlio "gastric crises" of lobes are frequently anaompanied 
and followed for a few days by Kli^rht albuminuria. 

5, Changgg in Ihti C'nmpttKilion of the Jllvtl. — Egg allrainen in jeeted into 
the circuluUou of an animal, soon appears in the nrine. In most cnscs the 
albuminuria thiw induced ceasea so soon as tbe quantity of «llnmien ex- 
eriit^id by the kidneys etpinlx that iiitroduecd into thci cin'uliiiion. In 
otlier iustuucea the injection of e^g olbamen into the blood is followed by 



ALBCKIMUBIA. 



121 



a proloBRecl excnvHon of albuaen by Ui6 kidnej's ; thus Stolnis observed 

ia one case ilint four times ne luiicli albuoK^tt wiw t-xcrtUil an bad been in- 

iJecUii]. This exce&s of ulbuuicii must have been deriTcd (rom th« bluod- 

^Mvm : hoiicB it is deiuonsitraU>d that tlie idmple preseuc^ of egg Rlbiimea 

in the blood can induce album in urio. 

It, hftH also bet'Q sJiown tbat th« injcctjon of the serum albunien of dog^ 
into tb« drcuktion of rabbits ceiUH proloBg«d alhuminnria iii these ani- 
siuU Thnt tbe albumen excrotod is derJTOd cliielly from tbo mbbit's 
blood is tthown by the fact th&t far more albumeti is exci-et««) tbau in in- 
jected, aud furtliermora that a d'oslruction of ths red blood-oorpuscW oc- 
eans, evidoDficd by tho n))peanuiD:] of Ittcmuglobin in tbo urine. 

It is, therefore, woU ('HtabliKlieil thfttiLlbuminurin ean he. indllcod bvtho 

prcMinM) iu tlio Moi>il of foroifjH nuliHtauoex — evcu though so nearly allied 

ta the Mood-aeruin of oilier animals — 'without any aimrecjable Icsiou of 

the ki<.luey. It Ims b^n afisuiued that certain modilicittioDii of tiasat 

LnttamorphoHts iu the body amy remtlt iu tlto production of iiDmiiiinoiu 

nuatATMlfl whicli iiiny act Uk6 e^g albumen or tbi< Moruni albuineii of otlier 

Knimala, uid |ircKluc.o albuminuria. Aii niialo{^y for UiIh luisumpliou ia 

. lound Id the fact Uiat ]>eptone, though normally absoul from the blood, is 

Ru^uced in ILe tiuxues in (.■ertain patbolo^cal stateo — HUppurution, acutd 

'j^Uovr atrophy of th« livvr, nnd ostoomulocia — niid ih lliuu oxoretcd in tlu 

uriD«. 

It has al«t been assumed th&t disorders of diffestion may result in the 
production u( uquhuaI forms of aJbinncn iu the stotnncli, which when taken 
Eloto thfr ciictilntioii limy cnuw tlio kiimjo elTcvt &» «<,'t; albmaeu — thnt ix. al- 
llnuniiiiiria. This idett htm li(it*n a ftivorlti^ ouit aiiioiig English authors 
unce tbe time of I*routk Sir ^Vnilrew t'lark in a Imliever in irliat is termed 
" hepatiL- lUbuminuria." i.e.. the eai-iipe of iilbiiiiieu in I'Linst^queiice of the 
timwoDCo in tln' lilnoil <S .■tllmniinoidit ititunuodinlfl bctwtK^n thii |>R[>t(>n(-M 
rwken fromtiinHiniuiuliruiii the fully melainorxiboFsed »eniin albumen ; Bintie 
the liver is Inrpely oonoerned in effecting thesie transformations, the presence 
of the intenne'hnte album in oii.ts in the blood (antf tbo consequent albuini- 
Duria) are attributed to diHordeni of this oTgau. It is certaiu that albumi- 
nuria i.s obnerved during many livpatii; dinonh^ni ; that the urino m nt the 
oame time loiuled with urates and uric acid ; and that a ]>ersialeac« of such 
hepatic.* derun^emeut may be followed by I{ri4;ht's <liseaBe. 

While tliose are powtible cnuspH of albuminuria, it munt bo ndinitto<l 
Ltbat we have na yet no dt'iuouHtrattou of UieBe theories. All attemptn to 
rarove that albuminuria can Iw of bitnintogcnous origin— i,^., can result 
EBrom a ehani^ in tlio nlbHminous constituents of the blood (except iu lUono 
f<MM alrMdy mentioned, iu which albumen is introduced into the \nMly 
from nnlhoiit) — h-uvc failed. 

So, too, it has beeu ti«»um<!d that Bri-^ht'ii lUscam wa« consequent upou 
the presence iu the blood of nbnonnal fi>r[n8 of albiiiiioii ; but tbua far no 
cbMvrvor luiM boou able to demonstrate the exiHleiice of such unusual forms 
of allvuioeD in the blood of patients Buffering from UrighfB discuM-. 

The only known qiialilativt: change in the composition of the blood, 
tbervforet, sufficient to induce alliuuiiuuria (witliout cauiting diwiaMO of (ho 
Icidiiey) is the jireaence of albuminoUH aubstauceo derired from foreign 
aouroea. Tltere are, howoror. qiiaitliiaiim ohaupfes iu the relalivo ]>ro[ior- 
tiou of th« <liffer«i]t tn^^-di«uta of the bluud, wliiub may doubUeas ptay a 
ooosidunihle rnU^ in causing; albuminuria. For it is a woU-eetablishBd 
LpHuoiple tbat liu^ amounl of alliiiineii whi'.-h jUlrrx thr^iwjh a m^mhrane in- 
\cnaaet, c«tchii poribua, uh the a/bumtiii ami the aaiU iii tiu: ^fitiering Jtuid are 



5 



123 



DI&SA8B8 OP THX URDTABT OBGANS. 



ittcrmeed. In those contliUoiiH, therefore, in whicli the l>loo<3 contoiiu an 
unnsual nmouiit of allMitncu or of salts orof both, or n ddtieiont^irf water, 
albumen is apt to appear in tlie ui-iue. 

Now. there iirt! scvtnil physioloKiail conditiona in which the percentage 
of albumon nnd of sflltJt in ui^ blorn] is iinusunll^- hi^h : foremost amoni* 
th«a<> is tlie proceaa of diijeetifnt. Fi)r duriiifj tliUt proves* llie nlbiituicous 
and saline rniiBtituents of the blood axf aut'nienl«(i fntiii the footl iukI, aa 
a T«»iilt. \he dlti'utiou of nlbuiuen tIii-oug)i the lueuibraue uf the glcimcni- 
lusis favihtutfiL Nuw, o,t a mutter of fnct, it has bean often ohHerved that, 
in thoH« bt<iilUt,v persons who exhibit albiitiiiuimii, the ulbuaien urauni 
wiib I'lciHicial frecgueticv and in {;reat«>it (juaiiLit^ dtiriii^ the procc--KK of 
digestion ; inJeed, for theee rases Uie term " digestion albuiuiimrin " has 
been created. Fiuibenuure. it hoa been ascertained that, tn cases of patho- 
logical nlbiintiDum, the ntnount of albumen excreted is prentest duriof; 
the proc'ciui uf di}reKlion. This iligeHtion albumin uriii ii nhto moHt iiifirketl 
aft4--r tho iiigestiou of higMy albuminous food, huuIi im iiiitut iukI cheese. 

The withdrawal of water Croai the blood effects of course the eiuue re- 
Bolt aa an incrcaBe of the albumen and salts, namely, a relative auginenta- 
tion of the latter. Hence nil excessive excretion of wtiter may be of itj«elf 
autBdeiit to iniluce albiimiuuriii. This has been amply deuiountrated ; 
profuse permiimtioii, even wiiea infhioed by pilocarpine, whereby the blood- 
pressur* remains essentially unchanged, is followed ficqucntly by nlbiimi- 
nuria ; doubtleHS it iif. iu part ut leaat. tlie loss ul watbr tiuiu the hlw)d 
which iuducc« albuminiirin so frccjuently iu cases of ufubrUe diorrhtcn. ' 



AuBUUDtumA fhox Bksal Diskue. 

Honim Albumen can reacli the tubules either from the capilhu^ aet> 
work surrounding them, or from the capiUnries compowiig the f^lomerulus. 
In the former case there v^ di»em)e uf thi^ epithelial ci-IIh lining the Itibulus, 
in the latter there in found degent-rutiott of the cjtpillury widls in the 
glomerulus. In most, thout;Ii not all cases of renal disease both: the 
tubules and the glomeruli exiiibit patbolofjiL-al cbanf-ea 

Albuminitrui from Drfjaicration of' the Tubal JEi.iitln-Uum. — Tlie greater 
DumlK-r of the true Micretiuns uf the body coutuiu tdhumen furiiinl)e<l 
br the cast-off epithelial eeUs of the respective glands whidi are min- 
gled with the secretions. A certain number of secreting glands^the liver, 
the BWMit- and toar-glonda — furnish n secretion which is. in the noi^ 
raal condition, frco from albumen. The Beereting cells of the kidney — 
those of the couroluted tubules — ulao fumieh a product ^ee from albu- 
men. Now it has beeu B&certoined that in abnormal conditionit of the 




' II It quite pofitible llml vftriMiorB in tho Alkalinity of the hlooA m»y ><e n faMor (a 
hvatiajt lti« vMHpr uf Blbtiitifii witli t1i« iirliie, Vcir It In w«ll knawii thai IIid injai;- 
lloii of *ll[aljn«i liuiilda liilo ihfl clroulatloii Indiioa aiigmunted contiBcUotiB o{ Iht 1i«art 
nud nrl«tleB ; Vthiiu dlliilc iLcid lolulitiUE, on ttiv olli«ir liHiid. diniiiiiali llitme coiilrao- 
LiOiiii(Uuikulll. ^OM" tlic vocapt^uf nlbunivii {avw?!! mot ftUfcuT) in tavvrvti hy dSlatatlun 
of the Tuoular an-a biivplit'^t by the tiplaai>liiilc niTVes ; and It le ceitolnly poadblo 
that a illinliilsticil Rlkallnlty of the htnod mny favur inch diUlatiim. anil tiriir-^ nlbii- 
miiuiriii. Kiii-h rnlntH-ti oir'idity (if the bliHid uoL-iira iu (p-uil aiid aauCn rlicuuiiLtlsin, 
whon.' iratiilcjit nlbumliiuiia ii a fivtiuoiit ifhuuomuuoti ; It lioubtlfw exUu alio tn 
diaurrlvn of ihe liv«r aiHl ptJicrt-aq wli-rt-by Ihi' ■llcalitiw ]ii>rrelion4 <if th«(- organa ar« 
mproMinrl ; 1» tliem euiiillltnns, IiM, albiiiiilDiirla la fi«<iuciit. I'oaiiilily Il<» valtiw of 
alicalluu mincrnl mtcn In dimliilahmg (bt albaoiiouria uf Ttriglit'it djauaac, la parti; 
tlue (0 their iulluaiitje in UiONMiug XUv iilltallulljr oC tliv ttlood. 



ALBUUINCKIA. 



133 



pJtTer, irlmebj the outrilioD of the epillielial cells is impfurvd. the bilo 

ItODtduS A ocrtais amount of nlbumen ; this liaa been oliRerved hy l<>enp-li8 
in etate* of hepatic congestion, by Tieniirtl in cases of fatty liver, and hy 
Lcliniann in coses of ^'riuiuliu- oud fiitty liver. Wo might iis»umo by 
Mialofry that imiiy degenoration of the »ecreting cells of the icidncy vould 
uIho b« nccompaiiied by the escape of albumen into the secretion ; but we 

I are Dot compeLlod to rely uijoq iiuiilugy. wuce there in iiioplc cUoical and 
experimental proof tliut nucli in tlio oftae. 

Albumiiiuria uou be induced by the aduiiimtratiou of certain ttub- 
Btniices, especially chromio acid, cantharides, phouphoiiiij, and petrolmim. 
Mow it is eatablislied by the obsorvationB of Wcigcrt and LosHar that 
these various polHoiiH, adniiiiiHttired iu doses uulliaeut to cause prououuced 
ftlbuniinurifi. producw merely n degeneration of the epithelial celU in the 
coiiTulut«d tubules, while the remaining eleiDeute of tho kidnuy — the 

t glomeruli, the interstitial tissue and tbc epithelium of the Htrait^ht tubei^— 

I remain intact. The ceila in the convoluted tubules pro»eut the peculiar 

I condition cidletl " uougulatioii uccroaiti ;" that ia, the outlinvit of tbe cells 
ftre lost, they coiilt^aco into masses, lone their nuclei and their ability to 

' ahiiorb the onUuory staining a^^ents. It in foimd. moreover, tliat ilu: cclL* 
hi tliis ronilitioD are unable to ueparatti from the blooil particlfa of the Ln- 
digoHulphiite of uoiliiitii, which, sm Heidoiiliitiu hiu shown, in iLlwnys aorom- 

» pished by thtisu c^ULh in thi.*ir uonuul couditiuii. KxuminHtiun of those 
Kidneys by the laetliod of Pokier (coagulation of albuuieu by boiling) 
allows that tbe convoluted tubules contain albumen, and that there is. 
moreover, a layer of tJiia subatimce belween the epithelial ccIIb of these 

i tubules and the bAsemetit membrane tipon which they previuiuly rested. 
The iilbumea is found only in those portions of Uie tubulun wliere tiie 
epithehum is necrotic. 

This euuntitutee, therefore, nn adniimble demum^tratioD that serious 

' int«rfvrcii('i' vvitii tlie iiutiition of the epithvliul cellN in tlio convoluted tu- 
bules is suflident to cjiuse albuminuna. C'hnicatly it is also ealnblifthed 
that albuminuria is a frequent accompfininient of pboai)horo« poiHoning 

L and of porniRiouH aua-'iLiiu, in holli of whicJi conditi'uris fatty dejjeueralion 
of the epithelial cells iu the tubules ocfura. The excretion of bitibly ucid 
urine, of urates and uric acid in excess, is sufficient to cauae temponuy iJ- 
buiuinunii, probably from irritatiou of these colla. 

Iu the iJO-calliMl i'liopathie cfluch of uephritiK — Brighl's disease proper — 
it i« u fajniliivr cUniiud expenencu tiiitt albuminuria is moat constant and 

Smnouaceil iu tluil variety (chronic parenchynintoiie neplu-itis) in vrhich 
egenemttou of the epithelium ie the moat prominent morbid clumgo in 
tbo kidney ; in cirrhonict of the kidQ4>y, on tlte other hnnd, in which degen- 
eration of the epithelium meaa to Iw aecouihu-y to increoiw of connective 
liissue, aJbuinen is found iu the urine in comj>arativt-Jy nniidl tjuiuitity, or 
may even be abucnt altogether. 

Albuminuria/roiH l*ryi^iieration of the Glomeruli. — It has become popu- 
lar ui nHW&t jean to luic-rilitt to the epithelial cells covering the glomenili 
the power to prevent the eecai* of albumen from the eiipilhu-irs coniputiiiif; 
the tufts, and to assume tliat iinpaiiTuent of the nutrition of thette cells La 
milfirivnt if pormit nlbiitiii tiuriii. Uuwwcr tlint may be, it ia certainly ce- 
labliahed that a dogeueratiim aOW-iing the capillury walls of the glomeni- 
loa penoita tha eaca{>e of albumen ijito the tubuloH. 

The moat fumiliar example of this condition is the amyloid degcnera- 
tioQ of the capillaries comixwing the glomeruli. '\Vhilo such amyloid 
eb«oge U, in the lunjority of cases, on aocompaniment of nephritis, yet 



• 



124 



DISEASES OP TnS URIHASr OROANB. 



cuw of unoompliCAted tLiiiyloid <l6g6neraUoil ooour iti which tbere is Da 
>D«phriti8, thfl odIU nf th<^ tiilmlett appoiu- tntoot, vhile tlip ii^lomeruli and 
tb«ir vaea nderentia tilone exhibit tho tusyloid dutnge. The pronouuced 
al)>uiiiiiJiiriH which nLiiotrt iiivariiiMv iiccoiiipniii^a thflM caws of uucom- 
pH<-nti'tl uiiivioid ilcf^ciivration muat be attributed to the abtionuol perme- 
ability of the glomerulL 

<Jl)structitx Alhumviuria. — It is to be reini'mbered that albuminuria 
may be produced l>y ii purely mocluuiical iiiiptr<UiiKiit (o the pracuntton ot 
uriiie, provided this cniises an inci'taiied pressure of urmo in tho nmiii la- 
-bulex. Partial ocrhisiou of theitdvis or iireter, thp preBBore of an (^nlnrsed 
or displaced iilerua. prostabc lij-pertrophy, urelhnJ etrictiire, vesical 
xtpasm. tumor or (.'nlfulus, cvtu a tit^lil pliimoaM (in infimla) — in sliortv nay 
''eondition capable of iiKbieing hydronfipbro»i« niftjr nlso eause albumLnuriA ; 
tlie lutler niijptoui may loug preoed« the devclopuiout of a i-ecogiiizuble 
tumor nf the kidney. 

Th« pntl)olog;y of albuniimu-ia m by no tneana comprised in our pres- 
ent kiiowlodf^'o of the subject ; miiuy aistn iii which album<-n appears ia 
thoimn« r^uiain still uiiexplftinftd, while many others, in whiffh rJbumi- 
'ilMiria iloeti not ooi^ur, arc equally perplexii)^. Thua while albuminuria 
''lemiltH from dinoi-craniyjition of the tubular epithelium and from amyloitl 
-degeneration of the glomeruli, y^t efiMt ore knovu in wliich, in Bpit« of 
twh duKT^imizatiou luid dcgeuecutioa, no albuiuexi has tccu discoverable 
m the uriuo. 



CHAPTER srn. 

GLYCOSUIUA. 
pHmoiAKiicAi. Olvooscku. 

Orapk-sto^r is coniftAiiUj' found in mnoiu Uhku^m "f tlio body, uid ia 
a iioniitil iiitjreilieut of the blooil. Siiicp it is very difl'iisihle. it would ho 
especicil tliat some of it would coDntftatly filtur through tlie glomeruli and 
appear in tlie urine. Moeler sIiowpO in 18-'>3 tlmt an exclusive diet of 
mgar and ulairfi priHluced glycosuria in n liealtliv pei-soit ; Eichborst ub< 
Ki-rvci] l,bi^ niktiic pticiioianuau uft«r an exeluaiv«ly milk diet, Hi>lfn^ich 
after ve!;;etii1>le noui'iMhmeut. In llS5>i Br<lck« lutuouuced that uomial 
urine usually contains a trafs of sugnr. SubBequi>at iuvestij^ons Imvo 
shown that this occui-r«uce is by ik> in<iiui» oonxtunt, though fi-ecjuent. 
GlycoBui-ia is, therefore. jLirr «, uo proof of nn orgnnic lesion, if it bo but 
flight and traniiieiit : imieed, pfirsifitent (jiyooHuria witliout any iiKhcAtion 
of a pathological condition ia occasionnlly obirorTC'd. especially it) poreons 
of nervooa tempertmeut, and in iK^uraiithi^uic; ruuditiunH. 

Tliv incrsnaed production of Hii;^:nr during ])r<-^iiiticy and lactation ia 
naturally occoupauied by tlie <.'irculatioD of au iiioreaseti amount of thin 
sabstancQ in the blood. In 18f>G Ulot difK^overDd the frequent prenenoa of 
■agar in the urine of pregnnnt and nurnnf; women^ a statement which baa 
Iwen uftau corrubomtud. It hits uIko been uttci'rtaiaod that an arrest of 
tb« laet«fU eocrfttion, such aa wraning, ia followeil by an ineroaMxl exors- 
tion of suf^ar in the urine — a fact which liaa been explainetl by llie receut 
iDTMti^tions of HofuiciHter imd Kaltenbiich. wbo found tluit tlie substance 
sxcretcd under th<>w ronditionswos notgnipe- butmilk-migar. Tbis form 
of glycusuhu has been accordiugly termed " lactosuria." 

An might 1)6 expected, the urine of infanta nourished exclusively by 
mother's milk haa been found to contain an ap|»reciHble ijoautity of mllk- 
eu£ar (EichliurKt). 



OLfOMaiBU LoiErEKDEST OF DlABKTes. 

Aside trom tk« woditioiiB mentioned io the jprevious pora^^ph — in 
vbich the increased quantity of augar in the urine is the direct uiid nHtural 
result of an increased production ur coumuuption of sacx:barin<i MubHlances 
^thsnAre Qumcruua conditions in which tjlycoHoria oi.'cun without the 
olhor eoniplex of »ymptnmii do»i£rrmt«d " diaMcR." Tbu-i HUtcar limt beeu 
obiervftd in the nriu« — traiisicnlly lunl in coniparatiiiely small quautJIy — 
in rases of intermittent fever, tetauuH, tjiihoia fever, gout, canUnc. and 
pulmonary inthtmninttons ; also after btr^e dOMe of chloral, chloroform. 
Atbort morphinu, CTinira, and other poiaoua. la order to sppreciate the 



126 



DISEASES OF THK UlUNARy OBOANS. 



aigQificanoe of sucL glj-cosuria, it is Deceasaiy to recall tha formation ontl 
luDction of su^^ur in the unitnat tconomy. 

Olyco^tfi i» pro(luc<td ffoni the vnrioufl sncchArino and stiirchy iD;*re(1i> 
eniii of tli« food hy tha action of the 1iver-<»Us. bi ttie liTcr it utidct^oes 
A further tranHTormation into frrape-siigar, probably induced bv a fc<nii«ut 
wliich results fram the breakinp; up of the red blood-corpusclwi ; at niiy 
n-tif, normal blood coutaijiH ti fi'Tincut oii|Hi.ble ol tmiisforming gljcogeD 
into ijiiiiie-augar. 

Uncler ordinari' circumstances this transforiiiation oeoitrs in Kuch a 
Itmitod di'Sicc tUat the sugiur nppcors in tlje blood io only small qu&Dtitj 
and iu the urine tnoroly as trnccH ; under sjienn] oin-uiiiHlniices, on the 
otlitr liaiiJ, tluB [irodactiou of gmi>*'-s''gar ia bo rit])iil thiit tLo blood con- 
tains a roniparutivf^ly tnr^ oiniiuiit ; honce the sugar filters through the 
glomeruli and appears in the urine in npprecinble quantity. 

Aftftr B<TriiHnln dint'ovury tluvt Ifsiou of the floor of the fptirlh ventricle 
causes glycosuria, it -waa ascertained that Uie Uver is an aetive agont iu this 
prooeaa ; for if tii'm organ be deprived of glycogen — byalanfing Uie Rnioinl 
or by the lont^-contiQued iwlmiuiatration of arsenic (whereby ilie glycogenic 
fiiuvtiuu of tlie livor is aiTfsted)— puiioturc of the floor of the fourth ven- 
iriolo is not followud by glyt'onurin. Sugar iiitriKliiw-il into the slotonch 
of 8urh animaJa nppeara at nnre in the urine (nbowiug the abolition of the 
glytogenio function of tlie liver). 

It was at first wippowd. in cxpliuiittton of th« fact diBCOTtTed by Ber- 
iiaiil, thill the bniiu fxerctsed »oine direct and peculiar ititluciic6 ovtfr the 
wcTnttorv rxcti%-ity of tli« livc-r-c.eUs, but it waa Hubsfi|u<'Utly nHtr<;rtiiini<^ 
(hat leatous in other porta of the cerebro-epiiial axi»— the thalauiua opticus 
Olid Kpinal cord — prtxluced glycutnuiu; inaeed, eugar appenre in the urine 
without any other injury to tlio iiorvouH Myiitem ttiaji ainiple srt-lion of the 
ccniud mill doi^rsal sytitpnthetlci Since the only feature ooiumon to all 
th»e Icijoni* i» a dilatation of the abdominnl blood-Teesela and consequent 
increfwe in the quantity of blood circiilnting through the liver, it Koonis 
certain that the njtiHtaiancH of itugar Lu the iiriue aft«r those various leuious 
rOMultM nniply rnnii thii incn-aiitnt i-iri^u!aliim through (At; /io«'; in cona^ 

Sueaoe of this increased circulation, more sugiu* is carried to the livor 
lan can be tmiisfomied into glycogen hy the celht of this organ ; hence 
HOTiio of the siigni' pnsfics tliruitgh the liver unchnuged into the griioml cir- 
ciil»tiou and I'lltt-rs out of the glouienili. The glycosuria which followa 
the ftdniiniBtration of certain tlnigs, curara for example, is apparently 
caused in the same way, sintM) tlieee drugs nre kuovm to induce ddntjition 
of the abdominal blood-TeHsels. 

Numenms lesions of the nervous system have been found eTCperiment- 
ally to induce glycosuria ; among these are imUition of the first dorsal 
nerres, fnratliziition of the central end of the divided vagus, as well an of 
the rentral end of the divided depreHsor nerve. Of far grtuiter luoment 
for clinical pur|>oHe» ia the fact that section or irritation of many spinal 
norvea has the aanio effect — glyeoeiirLii — as irritation of the abdominal, 
sjTu pathetic. Thus it haa been amply demonstmted that Bection of 
Hcialic nerve causes glycosuria in iiniinala — s fact of tspccijil intert-st ^C0 
transient glycosuria hiis been observed ft<'Ponipanying arifttion in this hiunan 
subject (EuJontwrg. Froning, Bntuu). Pousibly the glycosuria which iii 
obaerved. in nuuiy cases of ppripheral irritation, such »a bums and in&uQ' 
mations of the hIuq, are to bo explaineil in the sninc way. 

In the mujorily of casoa in which nugar appears in the urinn in BualL 
<luaDtity, ita presence can be explained by the increased How of blood to 



CiLTCOSURIA. 



127 



tlie lirer aiicli ta occurs after injurr to the floor of the fourtli Tcntriclo. 
Sncli c*8e8 comprise Lho iiuiiiorotis mBliuicm of disease or injnry to the 
bruQ ukI spiniil cord ; meningitia, cerebml ftDc) spitiol, eaoepbaUtiH. cerebral 
heutorrha^, tumors at the base of the broiti, epilopiiy, tetauuti, rabies^ 
tabes dmaaUa, emotioo, and pttj-cbtcal iitTeGtioiia are examples ; and it la 
probable that various dnigrs wLich htp knowu to produce temporary glyco- 
suria cause tbi8 ctt'bct iu tlie Hiutie vfuy — curnra, luurpluoe, uilritv of amyl, 
turpentine, ether, alcohol, chioroform, etc. 

Yet there remain numerous cases in which the explanation o( tiio a«- 
eompaQying ■^lycoHuha is tiot so nppurtiut ; such ore poat, tvphoiil, recur- 
rent aud iutenuitlviit fovorti, niid di^icoeos of tlie pauc-roas, in all of which 
vugiir frtigui'iiUy ii])|Kiim in tJiii unuo t«iii[>i>rarily. Sugar is al«0 oMudtf 
found in the urine iu canes of cb/laria of iion-i»irasitic origiii. 



I 



. OLTOOHmU IK I>1ABET£H. 

Until the palliology of diabetes shaU be definitely ascertained, it mnsfe 
remain, as it is iiovr, iiupnaKible tt eiq^laiu rhe presence of sugar in tbc 
urine as a svinptom of this affectiou. 

Accortbng to our present knowledge the complex of Hj-mptoms desig- 
nflto<l " diftbetCB " miiv bo induced by any ono of sareral causes; chief 
among these »rc, 1. Diaeasu of the corvbro-e).piiud uub ; 2. A pcrroniou of 
ceU'DutritioD. 

The ftutopsy usually shows some disease of Ite central nerroos axis; 
th<!M Itsiuus vary cstn-moly aa to hoUi naturo and locality, tumoni aud in- 
fljuiimattong of tiio bmiu and its iii£<mbmii08 being tlic mout frequent. la 
such cnaea there is usually oliserved polyuria aud albuuiiuuria intra-vitaia 
and oulargcmont and congestion of tlie liver jiost-mortem. These clinical 
and uatomieal f«atiuva justify the assuDiptioo thitt the glycosuria is of 
analogous origin to that induei-d by Bunitu^l's puncture of tba fourtb voo- 
triola 

Tet cases of diabetes occur in which tlie autopi^ fails to reveal mcb 
Imiooh Id tliv DtTvous Hyirtfiiu an would osplain the glycosuria. While 
tbese Icsionit arn therefore by no means constant, there it; aiiotbor imiior- 
taut and coni^ant departure b\3iu the uununl ucoitniny in lho diubtrtio pa- 
tieat : tbe incretmtl ami furrtxrlai liAiur mr^tamoi-jjkoKii. In eTcry cnso of 
diabfltos there occurs an increased excretion of ui-ea, phosphoric ncid, and 
carbonic aciil, tuid a d^urouMMl conxumption of ox^'gen. Uiitkgvus, Fr«- 
ricfas, and Knlx liare ahown beyond doubt that the diabetic patient ex- 
cret«s far uiote urea than a healthy peraon cou>«umiug the same tliet, and 
mom than can bu funiisbod by tlie food ; there is, therefore, OTidcotJy aa 
inonaaod decomimsition of fdbuuiinoiui matters iu Ilia body. Furtber- 
nwre, it is ascertaiued tluti th« uiiiiu of a diubotic patient coutaiua more 
aogar than is furuishe<l by his food ; and since glycogen cau be pitHlur^d 
in the body from nlbiimen, it seeus probable that a part nt lenst of tbe 
sugar exiTjttti^d Ls drrintd from thu dccuin[>oiutJoii of the iJhuininouH coii- 
stitnents of Uie ti>MiicM. 

IiMMtiina. — liioHite is isomeric with grape-susar, and ooout8 in stuall 
(|UMitttiei> in many orgims of thu liody — the uuhcIl-h, liver, spleen, kid- 
neys, bmiu, and hiugs. It iu not. Iionrivcr, fuunil iu uununl urine except 
after tbo ingestion of largn <pinitliticct of water, wliich nj>parcutly waah the 
sngar out of the tissues before it has uudergoae the usual decompmiiUoa. 

Hany attempts have been miide to truce u rolatiuu between the axon- 




138 



DISEASES OP TBB UBnTABT OKOAJIB. 



tioo of inoRle Kod of gnp fl wgt r in casm of diabetes. Brrawd and 

OwBowi fomHl thai Uie {nqurc uocudoiudlr cuimcJ tbr app«aru>ce, not of 

gnpe-^Ktgju, but at inusite ia tLe urine ; H c biJ u eo obwrttd imjfitari* in 

t«n> putMata wifiiiin batn tamoTB ia the vietin^ of tbo faniib veotricie ; 

BmiIcui faoDd botb enqn-m^raad tuoMteiatlM aiiDe of apotteaiBtfBF- 

iag from diNM* of toe Bwdulih On ibe oUmt hand. Phbma nlmiiil a 

tat ot inflummtiod cxtcadiiig to 1^ fourtli vectricltt is miaih aeitber 

1 gnpe-aiWU' nor isoate m dinavenble in the nriDe, oiMvillMtMiding de- 

i tided po^nri*. lDOMleha«lieeBt«{ie*t«d]Tot)Mnttd«Moei*t«dvithgE^>e- 

ifflr m tba uioe of diabetkit and Vohl cav a w mifaWe case of diabdea 

IB wludi Um gii|i»4Bpr gndoaQr dinppfand ind «n nplaoed by iMMit*, 

18loaOgiM»«ao<»yAw»Hiiiili IpTd^- GallMs •abMqDently 

f c h a MTwl a Bimflar aaa. 

Yti than appeats lo b« bo drfaili atinlnpial rabboa ba twaii sItvo- 
anria and inodtnria. Kols fboad that after a ea dajm' £ast (wbenhr the 
rinogu of tba Incr waa «xhaaM«dt 111 ailMaiihatinii of iooaite to rabbits 
Old uut mum gHrnaana : be ^ao tammd tka* tta BCMlioa <tf tDont« did 
aot iiMwaa ibo'iiwaiiij a* wi.m iiiiinil ty^abatk patkato ; iixked, 
in BPe mm of diAalaa ia ^M«MMa^ >g » wif ha wlj narogMMwa dial; 
to aanaa tiw aMtar to danfMr flnaa lt» aaaa caM ph l iV . jet crren them 

Fte aHHiod BHaMM. IhmlHft. i^ pwaiaw! od mocite in the aiine 



CHAPTER XTV. 

EFFECT OF ACIDS AND PIGMENTS ON THE BLOOD. 



TiiR im^mrinnt Rmtfttitucntx of thi> bilo fira tlM> two aRi<1s, gl}-eocbolic 
tuid taui'ocholic, bilirubin ami choleiiteriDC. Both tbe acids aotl tlio bil- 
inrv pi;.'uit?ut are fouuil occiwioually in uonuul urine in tiiiiiutu quantitj ; 
their np^iciu-iLitco in itjijinrcnrLhli^ ninoiiiit iiKlicittrs lui itiiiioriiml comlititiii.' 

Biliaiy pii^nitiil in furuiei) fnim Uie harmojiloliin, the cDlgring loatter of 
the blootj-corpuscles. Tlie tmnsformatinti ol biPinoftlobin iuto bilirubin 
tuk«« jthu^e Tiorniiil];i- in tlio liver, aiid abnormnlly in tlio ci rc.it ]nting blood. 
Jnuiidicv ami llii* )ii<pttm~.i[i(M!i of bilJitry pigiut<iit in Uit> urine iimy, tliere> 
ton, be dm- ('), 1. I)i.*ir<!ers of tli« liver, ojiil 2. IHilurliftin-es in the cir- 
cuIntiD^ duiii ; in the formei' caeo the jauoOice in ttriuod heptittigcDoiiK, in 
tlut latter liii^iuittu^enous. 

Tlic bill- whifli in discbarg^oil into tlio intoittino iw liirgely reabMoriwd 
ami i-etiinii'vl by tliu portjd vein to tJie li^tir, where it is Again Hejiaralcil 
from the blond, oidy n tnuic pansiug iuto the geDend pirouktioti to he cs- 
crctci! bv the kiilntya. W'lienpvcr. from nuy cnuw>, n-n afcuniiilatinii nf 
bile occurs iu Ihu hvi-r. ibt cuustilututti are takeu into tbu cirrulntiuu iiud 
eliiQinntcil with tha iinnc. 

The iDoiit frequeut cause of such accumulntiuu ie an impediment to the 
p!MHn<;i< of bile thruusb the bilidr>' Juct — occlusion by piU-sloneii, by 
Mwvlliii); of tiir inu<^ouH mcuibniiK', by aLii('«roii)(, Hypliilitir. or uiTrbotic 
uew formatioue, by abdominal tumoi-e, especiaUy eulurgeiuente of the pui- 
cruaa 

TrrinBfomiaKon of lucmoglobin into bilinibin may occur in tho blood 
witliout pai-ticiputioii of the livi-r. It lukt bi-eii in I'eirent ye4irs fleinoii- 
Btnted that jniindieo niKl th(v oxcrtrtioii of bilirubin in the urine t»a ho 
iiMulily inducoil by the injection of various ani^nts into tho blood hy ^■^lliG]l 
blood -4?orpiu«clvii ann detiLroyed and their colorintt inutlir trmiverted into 
Uilirubiu. (;h!i)r(>foriii, injected or inluJed, prothiccs tliiH cflVrt— n result 
iwwctimes transieutly obMirvt:d after auwatbt-viiL ; iiijtvlioiis of biliary mlU, 
i>f limnioplobin, ainl even of piu'o wat^r f'an iiiduw jaundiep. 

Hiich hivniitlo>{oiioui4 jauudiee is observed clinically iii cases of septic 
infection — pya.-iui» and suptiea-miji— typhoid [ever, innlnhol inffcUou. ta 
well as after poigoniii^; l)y luwenic, chloroform, ethdr, etc In eucb caius 
tho biliary pigment appeai-u in the urine before the skin is jaundiced ; ui- 



'Thtf appKaritTi'^n nf ilii> bitlAr; twiilt In arinn his nn praclic>) e1lnlp*1 vsUiv, iMnkUM 
the pnMttM for tluir d»taeti«ii t« tno compllAotixl fur rifnical om. It U oiilj' tta* billwjr 
pitpni'nl wlilcli cau lio daleoled so readil^r hi ta ooiuo nltkln Iha nooh of clinic*! vx* 

9 



180 



DISEASES OF THR miNAItY OROAKB. 



(lr«Ml, till' formation of bilirubin ut tiie blood niAy be so ditifat thai m 
jnuiiilico occurH, ultlion);ti tbr [ligmenl vitn he <]et«ctcd ta Uie urinCk 
Cboliiria i>t usuullv ftcooinj)oiiiecl with aJbuminurin. 



HjEMOOIjOBIXITBU. 

Amdv from llie Diinii>roiiR cnses in whirb hlond is foaud mixed with the 
urirn- (in i-fimw^iiocnce of niptur* of bloo<i<veesels) tlicrf an- frcqncnt in- 
RtniKH-a in which the urino oxbibittt t)ic dnrl: <-vlor chnrnrt«ri»lic of blooi). 
luid vet in ft)iiiul iii>ou tiii<-ms(>)i)ic cutDiiuatioD to contain itn blood-oor- 
|>ii«<:W. Tlio pir4-nli:ir color iu tli«Ke mtutt in tinti to tlii* lupmoglobiD, 
vliicli bu b«en geparated from the coffpusdea in tlie blood aoU bsB ee- 
vftpMl info tlie urine withuut ntiy mature of bkx)d veBwIa. 

It iins been effUbtiKhvd (tint liv-nioglobin i« onv of those albuiuinoud 
iabiitaDC«s which leavo tbe blood and ran^w lbn>ii}:h tbe kidDo>' without 
IMtroint. It in ox«<'tfrd largely tliroagti the glowf nili br nimplo filtra- 
tion, but n.]>|)ear8 to be in part ftl«> »b»tr«rtetl fruni tlir blood by tbc epi- 
tht'lial cells of the mnvoluled tubuleft. Vntler ordinnn- cunditioiiB hanio- 
globiii is of course rotnitiivl in the blood -corpvuclea, and tbim prerented 
from piusMiiifi out tliroi^rh ibe kidii<-_\* ; but m won as it i« eeparated from 
thm» coi-pii»icb-s and (litawlvetl in tbe wniRi, it ewapes from tho kidittjrs 
Ijoito SH ri-'iulilv Ml e^-albuioeu or peptone. 

HmnoglotHOBnk is tbeivfon- critfciK-fl ibat tbe blood-forpnt^lrs hare 
heen «tpoMd tosoowuuunul rotidition whereby* ihe b»nioi;lobin i« sepa- 
mted froui tlio re^t ot the cotpuscle. Such Mgiiunlion occuth upon ifa* 
introduction of ornuiu aahstanrps into the blood. It bo^ been eiperi* 
montally asoertaiiHHl that the injeetioQ ofglreerine, niitieral acidi^ chlorate 
of potaiwium, biUwr »Mdt8, pyropdlic acid, nn])htbol, and even of pure 
ivater. is sufttcieDl to eaiue nich blinking up of the blood-oorpusclpH, and 
bence tbe ewMuai>c« of htem<^1ubin tn the urine. TIio nme effect often 
follovk'a tmurfiisian nith tbo bloml of & difffrt-nt nninidl, and MteDaivo 
biimn : itron a pold foot-bath is HotnelimeB sufficient to induce bii?ino^]o- 
biuuria (Ito^enbnrh). 

Cliiiicalljr hR-iiio-^IoliiDiin:% lias been obHtned chicflv in conditioni sim- 
ilar to ItuMewbieh an? found to produno it e^iprrintentally; in ]>oi!loniiif; hy 
dilorrtle of potasauiu, siilpliiiric, bvdrocLluj-ic carlxjlif, pyrojjallic, and 
■iwnioiu acidi*. naphtliol, iodine, tmA nitro-benzole ; in luirns ati<i Hcalds, 
tianafuaion of Itimb's blood, sunstroke, and fnltr cniboUiB, Kxtrcmc wire 
dwald be taken in tbt; ndministrutiou of rhlorute uf potiisb, t<inoe remark- 
ftl)ly small <]iiantitic« of it Imro proiUinrd danperoim frrmptnniB. Even 
after the iii';i-Htton of tliree dracuiiis (tn divided doses) of the chloi'ale, 
tliere have Ix-cn srcn dj-Kpnaui, r iimnll. weak pulsu. cyawosiB. icteniB, 
luenioglobinuriA, and f^ave cerebral sTmptoms; pfiHinl or cnniplcte «up- 
prtMinn of the uriiic and death may foUow witliiii one or two da^-a. 

Many of tbe infoptioiis diseasps are ocr&Honally accompanied byhtemo- 
nlobinnrin — aeptio infepfjon. iniennittent and other ninlariRl fevem, scar- 
Ution, diphtheria, typhoid fever and heiuorrhiipc Bninll-pox ; it has alto 
bo«n w?en in BKuni'y aud piirpiirfi, ns well as nfter exposure to cold. 

l-iioj-al/iic fIi7-j!i'iii!iJiiniiria.^~ln the eases already mentioned the ap- 
peumiK-v of lufniogilobin in tlic urine is ciplnined by the evident prtBtnce 
of ft fiirei«n af^ent in the blood, whereby tlie li-iimoglobin is Hopantted 
from the' ldood-cor|>">'^'<'^ 1 '*■ o<^«»m, however, where iio such exjilatiatlon 
k appareut, tbe patients apparently enjoying perfect health. In these 



J 



>:fkkct of acids and piomksts on THK BLOOU. 131 



the lia-jnonlohin nppwint in the uriou only nt ialemU^ UHunlljr of aev- 
ftnl wcoks or montiiK, luul is found for n. fc;w lioiira or days at n time. 

The attack in preceiloii by fti^'na of cuiistiliiliomJ ditituiijiuiiif — prjck- 
ling RetiKntionti in tli« Mkhi, piiiiiH iu tlie Wtul, liHck, and liiiiliR, a Hiillv 
neiiBH-tion, or even n dei-idi'"! cliill followed hy fever aJid ttweAtlug ; ill liie 
luttvr kUi^ tlic uriiiv CAiiilfittt tlicr liR'nio^luliin ; tbu skin often becnitics 

■ (oinowlint jnniicli(!Dd, aiiimrently from tlin tr»n«foniiiitioii of liii-mof^lobip 
Liuto LIUrubiii ; liuiiAteul eulaj-g«iaeut and BbtiHiiivi-ui-att of tiio livtiruiicl 
M}leen are uhuuJ featiireH of tlio iitturlc 

■ Til© etiologj- of tlii» paroxysmal, intemiiMent ha-iooglobinoria is iin- 
TCrtoiii. The itwcllinf; and M-riMliTeiietiM of lli(> livtr ui>d iijiWn, toj^tlitT 
with the jaiiiidicp, indicnto h derangempiit of one or both of thc^e orgnnsL 
Now since one of the Dumerous functioUH uf IL^ liver is doubtleua the con- 

LTCreioti uf tlio l)aiQO);lobLD uf tliu disuitcgmlud bluud-cvi'pUHdcii into bili- 
j^bin, it hnx bocn nwtiiinrd thnt a d<>rnn^'«mi*iit of tiio liver iiiifilit coiihU- 
tutethfe origin of tJie attAck. Ponfck lia*t aliowii that Iin--uiiiglobi!i uia;f 
exist dinaolved in tlie hlood-Kerum without ftpjiearini,' in the luiue ; ex- 
cessive clisintcgmtioii of corjiuHcleB nmnca firat a swelling of the spleen 
and iHixt (.-iiliirgcmi'Tit of thu liver ; if both or^iuitt t/iirbllicr nrtt uiinbh- to 
reJiiove the hwmogiohin, tiie exceiw filters out of (he blnod inio the nriiie. 

It ia oulj' when one-sixtieth of the entire ttmount of liteimiylolnn iu the 
Uood is diiwolvvd out of the coq>uHcki«, thut hivniot^Iohtuut-ia appvon). if 
tbo ftniouiit he cn^nn grciLtt^r timn paii bo (liKpowd of by Hpldeii, Uvor, aud 
ludiicyii, jaundica occurs. 

The ntt/tck often occurs after oxpoBure to cold, and lisa beeo rcppatcdij 
induced artiUcially, in fawn iiriidinposod to the uirwtioii, by iilticiiig tho 
linndrt nr tvf.t in lold wuli-r. The coinplaitil is iiiitat fri'ijii»-'nt iii winter 
and Rririiig snd rare in summer ; and patients have tliemsttvcH observed 
that tlie Attack oocdn* only when Ihpy leave wnrm rooms. 

Ill oUicr iiisljinwr.H !m-iii(>globiriui'in in iudiiceil l>_y t-illicr pliyi«iral exer- 
tion ill general, or by nonie particular enercisa ; it has alw been observed 
to follow regularlv upon emotional excit«nient> such as accouipanies vene- 

A CAM rcAMFtod by Fleiacher ia eBiiocinlly noteworthy. In thiB inRtnnco 
a robust nofdier obaerved tliat the urine became bloody in appcanuioo 
after ho had been on the ninrch for on hour or two; the intoDaityand 
duration of this color was proportional to the time spent tn marching. It 
vim found thut the urine coutainod no hlood-corpuHclvH, but niruply hit'ino 
plobin ; nnd ciirioiisly enough no other foriu of exercise, no mntter how 
ijioUnt, was followed by hieuiaglobinuna. nor waw it iiiiluced \iy cold fool- 
hatbs -, yot it invnriubly followed after u march. In thin vaao the patient 
liad no foTor uor otlicr diKturbniicv of the fjenerul health. 

In aonio outei hiPmu^lnbitnirlu in wiid to linvc oanirrod (m n rvxult of 

Bfphilta, and t.o have ceawd under the emplnyinent of anti tty|>hilitic Poin- 

eaim ; in other inHtnncoa it haa appeared ua one of the incidenta in an alp 

tnokof rltMiniMtivn), and hdndiMrippi-nred when the rheuinati.- |"iiiiK c^'tuwtl. 

Tlmt the hn'iuoylobin i» a«^tiially diwiolved in Iht- bloiid-ncrmn in tlieite 

ifiasen haa been <h-inonHti-ated in aevenil iiiHtanreK : KuH.iiii-r fonnd Uiat tli« 

[blood removed from a patient diiriuR an attack of hientoglobinuriit by 

Deochee furnished seniin id a ruby rvd mAur ; aud Elirliuh ubserved a siin- 

'ilar culor in th<: lu^riini of blood tiikou from the linger dtirinf^ an iittixik ; 

be aim notit^ed that the red blaod-QSBUScIeH were []ec^olori7.oil, many of 

Ihern disorfrnnizeil. and thnt those wlMfletiuned Iheir bnatoglokin abowed 

B grvat divorsity iu nixv uiui sihitpu. 



a 



lail Dtaujoa or toe trBinABT orgaks. ^^^ 

III llio maJoHty nf iwwi <if birrfno^loliiiniru, nemin aIhntD«n is fouix] 
lii'iiiM Iff IruK »tiiMtnntly in the oriiie, fttx^oiDpnuisil ii<ihtniMy by fa>>iUuie 
inMtN. MiMWM of Mnoriilinaii hfniKiglabin in tlie form of rjutU, uxl (if 
)iiilli<llra eiiat) ofbiliiu-y {li^'intTtils are sIbo found. Tlu! ei>itl>elial cells of 
III* ki^lnity which may Im> prcMtiit Homctitu^i; rontaiii rr>-Blaui uf himiiatoidJB. 

Tliu ttry iitMi^ in which pmit-niortfin rxniTiiiintion nt itic ludneyB has 
Irtxrii iiirvli' nh»w ill thi'Bi' oTgiuiM tiotliiii;; abiKiniml wsrapt liy]>cnEnita BDd 
Uif [ircM-iiro (tf jiitriiioiit in tbn t-pithrlial reil-t, tuul in iht- liim«it of tlin 
lilldllra. Ill thin Mitiiiitioii Uic hi>'n)o(;lo'biii npi^eara as au uiiorplKius, 
hrown iniiM, or ah v<'ll<>wi)ih hrown biUbi. Iti caHcs of nrtifiml hn-ino- 
llhiliiliiiria, ihiHNi ]m(\» mw oflcii present iii mich quimtity iu tiie tuhutea aa 
Iti ]>n-*i'iil. n nidlrtliii;; npppftrnnw. 

lliMii'iuhiliiiiuHn AvoinR hi c»^cur almORt or quilo i>x<>]usiTi;l^ in miUiH. 

Tito frooh iirliiK riiiititiiii^ lui n ni1i.>, only methiFmo^lobm, wliicli is 
nildliU'il to (ityhniiii(i)f|ohiti only aftrr ntnnilini; for houid time. In Home 
tuLNtxi (Ih> itrh)i> iviiiUtliiH rhiellv Itivuintiii, which mvc« Alt <tKp«ctiUIy dark 
ixiliir i lliU liM htroii iilMwrvi-«\ iu owa of dij^diUieria by S^owslii iui>d 
Kutilur. 

OtRunu. 

A linm of flit in (i>u»il in nctnu»1 urine. In vnrioufl nbzuwiiul eoBtIt 
llniia full !■ i<«on'l<Hl in ctiimidonitilo t|uiuilily. Iu cm« danof MMsibiA 
(niiii'l tlit>r<<ii)rlily iiiiii<»l Mitli Um^ urino. mtUtinf; n& oinalsion — cliyliiria; 
ill nit<<llit>ir rlitOH (li<> fnt is not luixwl with the anne, but Honts a» Jmpw 
li[iiiii tli«i aiii'((toi>--li^Hum 

Ohyliiitit MivnrM id two diMUnet el—ao B of rasM; in the one ruietjr, 
wllli'tt iirriii'H tfxohiiuvi'l.v in lni)iio«l oUiuiitcis Uh* pnlicnt's blow! iti tovmA 
\» tuijilalii II iit'iiiuliulci uonii iii t'liiltnro fnnii— tlio fiUrix HnguiiiiK hnmi- 
ftt» i III l1i» ntlicr t'likw*. ii>ii))>ri»iii(; but few nww, \-iirious (taostljr uniii»- 
iiiitiM'tol) lncli>re itn> iiiTolml. 

.\» III thn MMii(\->(i of ih« ht in the tirine. it is eertain th*t it i>i doriTwl 
fi-iiiii till) fitiiil ; for Hriff^r and otliers haie tihown tb»t by nilbbuhUns 
full* •rlH'lcii fnim Ilio ilict. nil fiit tliitapjifnni from the iiriiie in chhcs of 
nhyliirln ; ninl tltAl it roflppeftre ogftin «o nooii m the food igun comprises 
fnlt> >irli<OcH, 

Aa (<i the iimntipr in which the fat eRpnpo* into tlie iiriue. no detinite 
)i)fi>riiiittiiiii hnH b<>cn oblnincd. It hiui been supposed llutt an obatructiou 
III Miu llii>ni('ic duct might n^Milt in dilulAtiuu of Um iutcfiltuid hiuptiaticx 
Mid t)ii> oHlnhliMhitipnt of abnormal <u)iiiiiiitnicAtion with iho iiriiiuT olma- 
iibU; thia nnpposit.ion is supported by thii 6ict llml chylous fluids occa- 
MloniiUy coUfct ill tlio pcritontnl cavity, yet no demonstrntion to thiit effect 
linH AH yot bwn fiiniiiihpd. Kici>erinien lolly cbyluKn has l>e<in induced by 
the iniectioH of ohvp-oil into the blood-vexAols. In one clinical case ol>- 
BurvL-iI by l^'ftfl the blood was fotiTi<I to coutaiti au exrewave quiintity of 
flit, HI) timt ill thin roue nt least tbe tttt found in tiie m'ine may have e^ 
mpetl thri>u)(b tin? kidney!*. 

it is hijjlily prohablf' ttint the fat nstially cticiiix'f) through thf" kidneys, 
ImoniiKP the urine contains in all cases iilbumeii. globulin, und oflen p«p- 
tiino ; iiiort-ovcr, Briugpr found tlmt ■vrhile the fat diaappenml from the 
urine iipmi witlulmwinp fatty food, yt-t t\u- Albumen persisted, Tli* ttiA 
nlno ii)creiiHL-d u[K>n tDorentent. Iu those fiu»» of tro|>tcjd cliylm-in, where 
the Hlitrin ih preaent in the patientM blood, the urine ciinHtantly contains 
Mtfod Aikd occjMional wormx. In theM eMM thei-e is pr«eeot »hK> &bhi>o- 




RPFECT OP ACIDS AND riGMEHTS ON TIIK BLOOD. 



133 



gen, whereby dots are producocl in the urine, even before it leavcw tho 
Uiulder.' 

Tii« few post-inortern examinaUonti wliioh buve bceu maiile upon caws 
of clijluria have usmJIy fAilod U> furnUh any plnusiblfi csplaitation of tLU 
jilMnoiucuou. lu a few iust&iicea there a])]>ear» to liuve hcvn a fUtulous 
opeoiiii,' IjotH'GPii tlio rndieleK of Uie t)ioi-a<if duct aod the urinarv trarl ; 
ID oue tztuie cMii'MV of the btoiuacli mw obsurveil, in iinotli«r tiilxirculosls of 
tliu liin(^ Kvep in tlioHo cuiiVH in wliicli Ibe filiiria in pruscut in the bloctd, 
[iCN;t-mort«m «]uimttintiou bii« fiulcd to {-xpltuD the Qp)K!a,raiice of fnt iu the 



urine. 



Lm-RtA. 



It is domnnstnttotl tliat fnt cfin lip ehmiimted froni thn blood by per- 
fectly healtliy kidneys. UemaiJ foiiml tbat fat appedi-eti in the vaiue of a 
iloR wliii'h hftd liepD fcil fur a wcfk upon uiuttoo fnt i-scluaivt'ly. Witntr 
Bud Soribd further obwiTvi'd Unit itijin^lions nf nil and fiit into thfi bltxtd 
WMv fiitUivvutI liy its upjtcunuitifi iii the urine, and that the fat ceca]>ed 
thiitti^li the glotiieruli. 

The appearance of fat as drops upon th* eiirfaro of the arinct is termed 
lipuri't ; in H'jdh cilkpm nlbuntni in citbor abftt^iit or present <iiily in tiiiiall 
quantity, while in cliyUiria tlicnj in uRunlly a large percentage of aJbumen 
as w-t'Il iiM t,'lobulin ami pc'iiioii*. 

ClinicaVly lipuria is obHcn'cd either with or without diseaeo of tlic 
kidutiy. Ill thii liiltor wwt* it. Iiua hwv notiiMid afcT tlie iii{(C8tion of fats 
and oiiit; in ditHifiMw (if tlje pmiL-i-eaH ; iii caaea of poisoiiiny by pho»- 

E bonis, cil^bonil^ m:u\, ami tinpriitiiio ; iu acute yellow alropby of tlu3 
vpr. in obstriietiou of the bil6-<luct by gjdl-stonca, and in yrllow f«vtr. 

A inoHt iiilvn,-Mliii(; obM-rvalinti in thv iK-rurnmoe of fat iu tho uniio iu. 
ca»e* of faltr embolus I.Srrriba) and in ordinaiT fractures ( Kicdcl). It hat 
tklso beeu seen iu ohronie diseiuH.-a nod tuiuors of boiif't^ uud in long-«oa- 
tinucrd ttuppuration. Iu tho latter cntw the tat aueine to bo derived from 
dv^ouci'atiou of tim piitwoll* ; for Kbstein recently observed « onse of 
lipuria foUox^inj^ pyoiK-phruMH. 

Tlie aiJiM-ai*aiii'o of fat in Uie urine in Miiid to be a frecpient occniTeiice 
(luring pit'^'iiiiucy. In tliii^i (.'oudJIion ua udl as in diub«ti.'», whicli is 
uImo lucrum |i£uii(.'i,l by lipuria, tlio blood contoina on unuaual [lercoutage 
of fat. 

Cbrotkic porenoLymafous nepliritia is oft«u ae«impanied by extensive 



' Willie ittselied [o fhi! medio*! alalF of tlin London UrMiiiUl. I hul t)iir> r«r» iip\i<ir- 
ttitiily i>r onrorull.v oliHirvinir, tor sevonl monlhs. a twe of (^hylnrin with niaria in tlui 
bluod. (For • fnll FDpnrt of th« Aitfc> ann Path. Hiit, TTKimaiitiuiis, tvI. xixiii.. p. 894.) 
Ill tliiB eatr, lu in all utiivn oo reconl. Iho wiiruiH WMr» In b« fulliid oiiljr at iilftbl, aX 
uliiili tiriH* A ilrop i)t blood takuu uiivwhore from Ilia tnirtnea tonuinpd (roin iWly to 
mil) liiiii'lted of (iiHin. Il Is iguili- |-[>Hrlb]« thM thu tlUrift Uiu )h-oii ti.-|'>-uii.'i1lv urcr. 
l«oki'<], bi'cnuNu cxiimlniitloiic (>t tim Mood were mudu vuly b/ dujr. Tli? uriue con- 
tuii«d MI luucli ribriii tliiil 1i Irnqiitmily omigalMed In the bUdder, oniiHliiK rptL'iitiim 
snd re<|ulrliiK iliti iiui of a futliiTtur. Tliu warms were lo I* found in t)ie urinnrv wdl* 
ta»ni iiy ilny u) uvll as by iiigUt. yut nn (mtaji^litd niid hUldi?n In miiNc* of nitriii Ibal 
tli«Y vtt m olU-n civ*rlooki'd. In ihla (>u»l> > luvonjil of llm Ardiimry daily pr<.ii;tiitiiiiie 
— thv Mtlant alvopiiift l>y day and ivTiiHiiiiii^ jiit&ki! at iiiElit — cauH-d a ri'roliition In 
tLs hahSta of thu wnrtnii, vlilati wuru imw fouii'l in llm I>loml oiilv during (lii> dky. 
Thii patlviit — A Ii#a1l)iy j-mmg iwldiur, ju«t arrived frnm lixlla— rt-innhii-il •{iilta wi>U 
{••r MTirral mumliJi, but iiltliuiU-li d.:i'v1opud abtMOKH fu thu joint*, and QtiBJIy dl«d 
of jiyKtnio, sb ut vlrvini nioullif utliir [Im cliylurla wti» fint iinliiH.-d. At tlie punb 
In<^^clu ttiaminAtitiu Um adult wiirm >vm not dIacoTvr«d. 



184 DISEASBS OF THB UBINABT OBOANB. 

fatty degeneration of the kidney ; in a few instanoes of this affectioii, ht 
bus been observed in the urine ; lipuria hag also been Been in cases of 
(^stitifi, presiunsbly from fatty degenen^on of pus. 



E^BBnnjBiA. 

In rare cnsefl the nrine coagnlatea some time after emission into a jelly- 
Uke mass. The co^rulstion is not dependent upon admixture of blood, 
since blood-corpuscleB are few in number or may be absent entirely. 
This condition ie said to be endemic in Brazil, Madagascar, and the Isle of 
iTrance ; as to its etiology nothing is known, though the occurrence of 
fibrinuria with the filaria sangiiiniB in tropical regions suggests the possi- 
bilih' that such endemic fibrmuria may be due to this parasite. 

A similar condition of the urine has been observed in cases of papilloma 
of the bladder, in a few instances of Bright's disease, and after Uie use of 
oantharides. 

HrDBOTHIOiai&tA. 

Sulphuretted hydn^n is evolTed during the decomposition of urine 
containing cystine ; bat it has also been obeyed in fresh urine, chiefly in 
oaaoB of cystitis, where it is produced by deonnposition of pus. In a few 
oases of abBcesaes in the vicmity of the intestine, it has also been found. 
Emminghaus has described two cases of hydrothionuria after BuppuiatiTe 
peritonitie following perforation, and Betz observed it in a case of prostatic 
nypertrophy with dilAtation of the rectum. In these and other cases the 
BQ^hurettod hydrogen appears to have been absorbed from the intestine 
or adjacent abscesses. In one case Dittel observed an escape of gas with 
&.e urine, the autopsy showing a Tesico-inteBtinal fistula. 



CHAPTER XV. 



DAILY AMOUNT OF UEDJE. 



Wniu: thfl BTeroffe diiily (iiitiiititj excreted by an &i\\i\i in nBually bft. 
tvreeD thirty and sixty oiiucea (l.CXiU and 'J.OuO cv.), it may be diiDiiusli^d 
to 500 or inc'n>u«ed to S.OUU c.c. for u duy or two during' porfoct heiUtl) ; 
far ■ucb wHTiitionx luny W occiiMitjnciI by tiMupomry cIiuu^vh in the 
<]uaQti1y of liqiiiil iioiiminit'il an well as in the activity of other excreloij 
orgUDS. i>B]ieciHl]y tlie akia aiid tbi; bowDla. There ore oIho otUiT itiHueuccN 
wbicli iuduno increafied or diiaiui»hcd excretion of uritio ; thv quiiutity is 
luci«fl.>M.-<1 by 

1. All aliuiuiaid nuppltj of aninuil Joixl. Rotiko obnert'cd in ono cMO 
the daily eseretion of over ^,000 c.c, while duriuy a period of starvation 
the niiiuuiit psusKed bj' the same patieut van reduced to TAIJ o.c Si>«(;eu 
HAW tht: (]ti'iiitily ilcrrpiiscid oven to 125 ctr. [>vr day. Thin incrcjisud ex- 
cretion is due ill lar;;e part to the excesuive produotioo of ureii upon ou 
auiiuul diet, the diurelie effeet of which ia well known, 

'2. pK^chi'-al i»fitu;nce*. Beiieke oI>HprTe(1 during t-onditions of ph^'aio- 
logical exaltdtioi) mi iueroniib froiu (iU to 200 ca ]>er hour, nnd during 
pliyaical And mental depresaion, a deerenae from l>0 to 15 c.o. per hour. 

3. litcivan'r of arterial ptv^saurt. Thia results in increased rapidity of 
fiUnitiou lhroii<!li the s^oiueruli, and hcuice polyuria ; digitalin uicrvfiiteB Uie 
reunl esnTtttioii in thiH vnx. 

A decrease in the forue and mpidity with ivhioli the blood ciicuIateB 
llirou};h th« t^lomeiuli uiiiseK, oil the other lumd, a diiiiiuiiihcHl excretion of 
urine. 

■t. Tht pf¥«v(tif! ut the (flood of mme mihiitarire loJncA exritea tha »(vreting 
eelU offhfi kidnei/ to increoMd mth'Hy. Jaboraiidt, atiltpetre, nnd urea in- 
CTOMO tlio uriniiry excretion. Tlio diiiretiv effect of uron Jit often ohsorreil 
iu the polyuria n-hich occim iit the begitmiut; of coDTslesMDce from febrile 
affectioD-s <:uiiHlitiitin^ an iiuportjuit feature in the ao-cftUed "crisis" of 
the case. This critical diuresis appears to be due to the effect of tho ac- 
cumuhited tu'ea ujjon the kidney ceiU, 

The (juiLiitity of unno exrroted in influenced in disenee, nnd iloubUoM 
ID hoalUi, by tlie norvouii aysteru. Beniord obBerred that injury to a ccr- 
Uiu locality in the tfonr of the fourth veutnole causefl marked inereawi iti 
the (jiiitiitity of urine excreted ; the some effect follows section of the 
^jlani'hnic nerves, tiiid it has been deuoDstmtett thnt Uit- diurCHix -nhLch 
follows Bernard's piqfiro in due to tho conaequont paiulyHiii of tlie renal 
artery, supplied by tbe splnnohnic nerves. 

SiioUun of the cervietu cord or irritation of the iloreal cord iiidiices lui 
URMt of the iiriuar^' (;icn'ti<iii by irritatiiij^ the t<[>lan<:huiii ncrvex, wherohy 
ooulraction of the reiiol arteries is produced ; indeed, direct irhlatiou oX 



136 



miSASB or -iHX rsausr OB&An. 



ercD uTeBdn^ the 



urttuir7 excHttoB. 

Uan;r dimoU <SMs of |w h iir m mk «■■*] bv ^ i»Me or iujuF^r ia mkI 
trooad tbe foorlii vcaizidc fa tarn* is wludi tiw ajnoptoms liaie ui<lt- 
e*t«d and tb* aata|»y has pnivvB djanakt kenaahagBB and Iuidor. of tli«^ 
ecntnl auituus «jnrt«ai, tfac mwlnn a , tk* i w itnHiwi, and tLe Bpiual cord, 
pobnria haa baaa a nwituit ajn^itoBL lajaiiM lo tbe Umn awl to tli* 
duu hM» be^ ■monuMtifd hy this auie i^ntplam. 

^ awXlHr dMa a( cMBB the infliwDM of tfaeDerffoaBB 



^ " "rtlMr dMa oT'cMeB the infcitniia of tite n er tow mtnii i» <■ qiuiUr 
•fpM — > tlut^ kn iDleIUgiU«i Exampln arc wai in the exc«BUve ex- 
ualiuu t4 uuie aft^r a hjvtcrica) attack ; in sooa caaes of bv&t«rU poly- 
uria i» aoi ■ tcaaaKut but a ixTsistetit iTiaploiiL la epOe^, too, a pca> 
flMmt mnraani in U>« ^civtion of arue bas b«eo oba m riL 

It Lna bevQ alreaitv Mated tJ»l tlw> i|aaotitv of uriue txcret«I ia tUmin- 
srfwJ *>y trritatiuD of tlie sjaaduiir Dfiuvs wbervbr contniftiou of the 
PNUi artmi-s in inilueed. It wiwild wttm that sneb ixritatioD of tiivmi 
■crvea ocvurx in cilmh of li«d pouwniiig. lU^gd obaenetl tliat lii lead 
eolic the auotutt of iirine <lecrM»<K] as tbe pain and aiterial tennon in- 
<lNa0Ml ; tltiu ivUtiuii wtw «speciiUlv appan>iit where tbe attacka of eolic 
recurrvd 01 iiitLin-als of i^t**™! days." 

Thi^ quiiuiity of urine is nif^ohiuitcnlly dpa-t-oacd by obetmction in the 
unnainr ctuuiu«l — a result wLi*U ia to be nttriLiuteil lo tbe increase of 
prewttre on Uie outer side of the tllomeitUi, aud cunsequeut decreoMi in 
tho m]udilv tif liltrntioii. IIkuuL calciiU, Itttiiora couipr«««iiig Uio urolfirs, 
tilOKwelling uf tlie liliublcr mucous inviubnuie iu crstttia. pAr«*4a of the 
bladder. liyii(>rtroi>!iy of Uie jirostale, stricture, may all deL-reawj tho 
<|uantit; o( ui-iuv excreleit 



Rbactiom or tbx Urucs. 

Tbe reftction of the nriiifi varies considerably in licnjtk oven in Iha 
mnio iierson.und iit tlifl'tTPiit houni in tbv eiiiii«<1uy. ll ia dependent upon 
Hie degree of nlkuliiiity of tlic blooil, and this in turn larKi'ty "poii the diet 
of tbe aDitnol ; thus cwnivoioua animals have a tnarkodly urid iirin*-, 
while the berbivora excrete n coiiatittitly ulkiiUnc uriiiu. In luiui the urine 
ia generally slif;litly iicid ; tho dcgroe of ai-idity is muph increaaed by an 
exceae of aiiinnd food, iind dimini"Ii«d by \i-getable food. 

Tlie alkalinity iuttucud liy »eyetalile food Hcenia to bu duij to the wge- 
ialjle acids theK-iii ^rontiumxl -oilrie, tarl«i-ic. aoftii", ftc. ; for theae are 
ori<liznl into carlHunti acid in tJio or{pn»i>""i producing alkaline carbon- 
ot*n. It isfi>«n<J also rlinicidly thiU (he ml ministration of these acids or 
aaltHCODtninirt^' ihem— ritnilc. tnrtmt*, oraeetate of [lotAseiuin. forinKtaaca 
— iodncM alkalinity of llif uriiip. 

The allwlhiity I<f tlwi lilood (and tliereforo of tho urine) is iucreaiseJ 
Itoi onlv bv the "addition of alk^li^>^ iw ixKiuni upon vegetiible diitt, but 
fthff br the'alwtrtu'lion of acidn. which takes place durins diyrHtJou. For 
tbe **p«r™ti»n of livdrochloric w^id by tbe gastric glanila increaaea the 
aOalinity of Ihp Unotl. It baa been founii both csperiuwnlally and clini- 
cally that Iht-re is n ronatant and diret-t relatioD hfltwwn tbe seowtiou antl 
dapoBtton of tlw Riwtric jui<* on the 00*1 hand, and the acidity of tlir urine 
B OB thaoUHr. It tua be«n ahowu by rxtteriuieut that when tbo gastric joioe 
■ of a doc » pmnittol to Mcapa thioai;h a fistuK the urine (nomially arid) 
I '<t -ifcjt— am] to KDnma oatil the eao^>e of gastxic juice ia pc«- j 



DAILY AMOUNT OF UKINK. 



13; 



vented. Tbe same result van oLtnuicd by Quincke, bv remrtving the 
gaetiiu juice throiigli n Atoninr^h pun)}). CUtiicikllj- it has beeu oft«ii ob- 
served that patit'uta aufferiug froiu pentUtoiit vomiting oxcrobu alkaline 
uiinc 

The oxiibujatioii of ibii; rtlkalinity, obsened in experiiuoiit lut wt^ll am 
uUuicully. is avidcutlj- ihrit tLe iciuovul of tli« Kaatric juice from the IxkIv 
prevents ila i-etiorption into tlip blnoi! and Ibua luuivutits tbe lUkuJiiiity of 
iLLa fluid and tLciefore of tbe lu'iiie Ji'riiod from it, Tlie Alknliidty of 
tbe mine {abitolute or rolitivcl which is pliysiologicaUj- obstfrved soon after 
tiio iiiguHlioii of fooil is tborcfom most plausibly exphiinttd by tbe fitriuii- 
tioD of bydrocliloiic iirid in tlit; stoiiiocu ; for the formatioa of this acid 
■eaniB to be aL-coinpliriied by the st-patatiuu of bydrojTpu from tbe acid 
nIlOHpliat« of HOiliiitii. wliifb iKtuitaieti tbe iiiMilml j>lioK]ibtitc ; aii<] »iuc« 
lie iirality iif Ibi! Liriiio dc])eiidx lar^Iy upon t\w jirest'utin of tbia iiciil 
]>hoKiibati\ tiie ilisupiiBUtuucL' uf tbiu Bflit i-eaiilbi in diminiRticfl Kcidity of 
the urine. 

Dr. llidfc ituj;t.'e»ls that there may be another factor iu the i)nKluctiou 
of this ulkiibnity (btriiig di;;efltiou, iiAincIy, tbn iriuruium<I cxludittioii of car- 
bonic (icid by tht! liiu>;«i. lilwnirl ^jniith has shown tliat during' digfAtiou 
thin exhaktiou is iiicruiiscd, whiJti it it diinitrifihed by fasting and by aleep. 
The iMiidity uf tint urine i.s iiiruiWy imiporljouid to thui cxtialatioD, being 
lOMl during di^'tintioii and ^^rcatfint dorin;,' eJeej). 

Tim roa^tiou of tbe urine is aiTected in uutny lienin^mentH of tlio di* 
gestive and of tlio rcMptrritory orgoiiM. Any ititarferenee witb tbe ebmi- 
nntioD of curboiito ricid, or excesnive ])i-(iductiun uf iho siinr. may be- fol- 
lowod by lui csutaaiTc excretion of tilkoJine earbonntc-H, and eonRctjuent 
alkalinity of tb? uriuo ; Kuch i» atum tlie coee during couruleacence from 
acute diKemtex. 

Tltu fttiliiro to HAonrte uoriniU f^natric juii-o, iih in ci^rtiuTi forinn of 
dy»pe[)Uai or ita removal [rum tbe etomoch by |)ersiHt«iit voiiiitiu^', may 
oause atkaliuity of the urinu. Any condition Hucb ua duodeuid catarrh, 
vhich preventit tlic ili^i-hiir^c nf liibi into tlio intostine, causes nn nccumu- 
Itttiou m tbe blood of alkiUine carbonfttfs \vJ)ir-h would otbt-rwiat- oBcaiKi 
witli the bilcaud, ia pari at least, be discharped with the fi«c«a; heucAanch 
condition may tbu» iuilirttcUy produco nlkalinity of tbe urine. Probably a 
Huppre^iun or r«t«utioD of the pancreatic aucretiou ocLmtuotia tb« Home r»- 
ftull ill n nimilru- way. Feriuentutiou in tlio Rmall iiitcwtino cniiNiit tbo pro* 
duction of cerlaiu fatty acids which are oxidized in the blood iuto oai'bonie 
add, rewilliufi iu Oie excrelion of lUkaliiie rarlKHiates in esceati and ooiwe- 
quont alknleM'^riico of the nriue (Italfe). Hucli fennentatinn produOM the 
syiuptorns of d>Ap<?.))»ia with conntipiitioii imd flatulence, usually lUfiOeiated 
with alkahue urine. Jf thcfie Midst l;itie\io.. butyno, f\tc.) nn; produced in 
tlio smidl intestine iu esceiift, the oxidation is incomplete, producin*,' oxalic 
ftdd, whcnsby Ibc urine is rendered acid imd Ibt coudiLiou termed " oxo- 
hiriA" may bo dcrdopiKl — dy^pepaio, lltitulcuo(\ oud a oojitoua precipitate 
of coloiuiu oxalate vryslula. 



';d 



i-- 



-.r.'j ■; 



CHAITER XTl. 

UBINARV 8EDIUEKT8. 

Fatal Acn> Ubink. Tucnt Auuldtk Ukdis. 

A. VXOttOumKD. 



Jl. Amorpluius. 
Urates of aodium uid potassium. Fbusplmto aad corbouate of caldam. 



S. OrtfOaUma. 



1. Uric iw*id. 

2. Oxalate of eakiutii. 

3. fj-Rtin. 

4. TvrosiiL 



1. Triple phOfi]>)inl» (Ammanio-msfc* 

iieHtutu pli<)!ti>)iat>-). 

2. TTrat« of nniii>oikitiiii. 

8. I'ho^liate of ma^csiom. 
4. PbutspbaLo of CHlciuni. 



K ovassaxD. 

\. BpitlieUal ceUv. 
8. B)ood'-oorpnscle& 
8l Piu-coirpusoleB. 
4. INibfr^aBta. 
6l foermatoma. 

6. Fni^nu&to of morbid growths. 

7. EaloKM. 

8. Futigi. 

9. Bacteria. 

1. Uraf Aniui uro Ubateb. — The aentaal VBtM of aOdiuui imd potaaaituQ 
are conUined iu orery ikmhioI uriu« in pco^eot solation ; tiirongk tbe ac- 
Uou of Itic acid pbusplmte of Boibum contnined iu the urin«, tkcM ncutz&l 
iinit«ii ue, in tb« coume of a fev hours, decomposed into tbe ncid untcn 
mid fr«« uric add ; BiDCd tbese MubstAnves are far less soluble than tbe 
neutrsl urates exrreteil hv the kidi)evH, a precipitate occurs. 

Altboajrh Hucb pn>c-ipit»ti(iii of tlie acid umte8 of eodlum nnd potM- 
nom as well uf of uric acid ununll^r occum ualy euuic licHini ttfti-r tlie uriae 
bu been ™iil»>d, j'i>t in poridiu ststcs. uoriiml iw well a& pathologi<^ it oc- 
cutB before the uriiie faiui Ivft Uii- body ; it ia favored bjr : 




IJEIITART SEDIMENTS. 



130 



' (I.) Exee^noa acUIUj/ nf ihf urine. Tliiii oocum «Kp«c>iallv whaa lh» 

di«t contains an utiduo proportion of nitrogsiiouB (nniinal) foml, eoqco the 

I decotapoeitioii of alhumcti iii the \>oAy ia accompamed bv tlio formation of 

I free acids. In cattcn of i^oal niid v( tLc so-cnUcu " uric uciti diuthciiis." tbo 

iiriiia ■» utturUly decidedly ndd, and furnishes nn nbiuidaiit sediiuoDtof 

urttrx. 

That t.he precipitation of the urates mny he quit* inilipendent of the 
actual production tu llir; l)ody, nud (^^utirely dfipi^ndent upuu the reiuAtoti 
of the iiriiic, IS Hhovrn iti <;x:iuipl(w incTitioncd l>y B«rt«1»: 

lu II case (if (iapilliiry bittntrlii tis Ihe pi*ti*ut (fxci-c-ted iu twenly-four 
houra 920 C.C of uriue, containinK 4.ij [xr M'lit. nf urea mwl 0,123 per 
cent, of uric acid ; tlio rcitutiun niw aUudiuo and tlie mine contuiuod oo 
sedim«DL 

In a caMC of tjphoid fe^'er there vnut ex<-i-«it(!d in iw«nty-four liouni, 920 
cc. of uriue, cutit^niug 4.4 per cent, of urea and O.OOH per t^ent. of uric 
aciJ; the reaction waa acid, and a* a foiisequenoe a heary BeiUuient was 
pi'i-cipitfttiMl. 

(2.) SMiilim^nAofthi^ urine. This occiivs csiwciaUy when the waterv el*;* 
motita of the blood are laifgely excreted by the iikiii, tiio bow«lB, aii3 the 
LluDgs, 09 in cuso« of profuw pcnpiratioit, dtairbica, etc; also in fc-bnl« 
FoouditioriK. 

(.').) JCrc^^iii!,; ¥xcretitm of ut-ic acid, auvli oa hajuxini* at tL« wu-caUttd 
"crisis" of many ft'brilo affections. 

(4.) CfiiAinij of Ih'' xtriiii; Hiiico the urut«u and uric ncid ore leas euluhle 
ill cold tliau ill wiu'iu wator. 

Clinically the occurrf ikvq of a iirir ari<] (1p|>oiiit is an iiuporlaiit item in 

dia^osis only when in fieshly voided uiine and peraiBlent. In «uch caaes 

it will be found tlmt thn uriiin is hif^hly ftci<l, luid that tlic rryntidjt of uric 

acid iiri' rouijh, puinted, and often .irranKed in roaetteB. The deterlioii of 

mitdi forms sujjyesta the suapii^iou thai lije deposit of writ? aflitl nud ui-ates 

(js occurrinK iu thfl iiriniiry pas8ii<^(iif, and Klioufd therefore xtimulate further 

Icxuitniuatiun of lhi) uriiio »» wvU iw of thv pati«iil. Iu micL u(h«h albumen, 

ibluod. p.xt) and epithfliid v.tW* fittiii tbo' kiiliicy and fn>m tlin pidvin rou- 

Efimi the HiiHpirioii that urici add coiicretimis may be fnmiiiig in (tDino \XiT- 

Ition of the urinary tract ; in other oaaoa the vhief syniptom noticed is a 

|BCAMin'{ upon iirinatjun nuggt-Htivo of incipient ROimirhu'ii, Kven though 

poai.^ of thuMi conditions can bu d«>t<>cU'd, a juititiot who hnbttunlly piuvtr-s 

*ery acid uriue, in which rougii and jjoiuttd cryMalst of vliu; atid lu-e sufni 

precipitated, ]>erhai)e ovoo while the ui-ise is still waiin, aliould receive 

olkoliex in order to avert pj-olitis nud ncphritin. .\fter the admin iiitratiun 

of alkaliiK- i-iirbonab-K or vr-gwlitblo acide, it will be found that th« uric 

acid is precipitated not na rnu^b, poiutMl cryHtabi, but in tho uhuaI wbet- 

fituue Hhapea. 

In corliun condttioux, cHpocially gout lUid the so-called uric acid dia- 
thea[». the acid and itrt comjHJuuilh accumulate in the blooil and may fvon 
form ooncretionH iu the akii^ luid around the joints. It batt \it<-\\ cuMtom- 
Hry to regard the^e phenomena aa iudicntiooa of an uvor-protluctiou of 
ttnc acid Ul the titwues : rteeiit reaeoiidieti make it, however, probable tlmt 
thi* Mcuniulation in t3io ti>uiii<-H rcmdls not from excetwivo production, but 
fi-oiu deficient excretion : tliat tliit* iuipei-ft-ot cxcrelion i»ducli>diuiiui.siHid 
oUuUiuily of th(> hlooil. nhiuh in its turn in the r^^sult of addiction to nitro- 
gwnouit foo<l, wboretiy lui undue aniouut of at-td !a produceiL 
, It was formerly aupj>o»ed that tbv accumulalioii of uric ncid iu the 
piBBuea was fovored by inauHicient osygcnatiou of tho blood ; this itloa 



1 



140 DEBASES OF TUB UKIKART OKOANfl. ^^H 

YMtod chiefly upon tho h}r]x>th<wi8 that iircn triw produced \>y tiie oxido- 
ticin of uric uind, auil that a iledcieui^y of i>xy^eii wnuld tliuirfora prerent 
the amud oxidation of the ncid. Subxequeut rfHearrJies liiivc, boweTdr, 
Hbou'Ei, first thnt urea u produced chieilv iu otlier xvavri lltiui hy llie oxido- 
tioQ of urii: ucid : luid Hcuvud tluit di-licicut osj-^oDatiua of the VjIqoiI doe« 
not, mt K mriltcr r>1 fiwt, rliniimlly or cxpcriiiii"iil!il]_v. fnvor the increased 
pruduc-iiiiii and cxi^ruiioti of uric tuud. 

2. C>x*i.uK or <;AUTniM.— This is iifliiall.v fniiiid in fu:iA tiriue in eojn- 

Eany, therefore, with iino neiA and the urates ; it is not, liow<-vor. dissulvwd 
y n slifilitly nlkiJiiip rcnctioo of tho iiriiip. The ocrtohednil cl^■l*taJB of the 
oxaklo usually n|)pt-;ir Li firetitcr quiintity uftvr tlif tiriue hiut Htuud fur 
nettinU litiurn ; iiKlcf d, in t«>iu<i ciuil-h hoik- iif tliL'H<; (■r^-ntiilH ciiii lie dvluctcd 
in the Xrc»lily v<iiilcd uiiue, vhilo thi^y arc found in abundance after tlM 
lapue of Huiue huuiu 

Tho n^itiuiu fur tliiit KubiM^iiicnt iippciinincv of (ho osaluto of ailriiim 
cr^BlalH iu the urine i& the diftapppanince of tJie iw-Jd phosphate of Midiiuu. 
Keubauer Bhon-ed thiit the oxitlute ia held in solution by tho acid i>hofi- 
phatd ; anve thu Inttt^r ^nduidly cniiihiiira witJi tlie urHt«-«, the oxidate of 
calcium is (;nulu:iUy tbruwu out of i«ulutioii nud apixrim in the sediment 

Tlih iiiiportimt tufori-nco front UiiH fiitt in that the cjuiLntity of dxtdatft 
of calcium found iu the sediiuent ia detentiiiied not l>y the ouoiitity ex- 
creted, hut by Ihe reuctitm of the urine. Evmi thou{jh the sCiliiueut con- 
tuin« no crj*it4il« of tho oXFilntc, tlir iiriiir Jiiiiy hold lui oxf^f-wiivc quantity 
of thiH ealt in wilulioii ; and i-or>vti*ely tht' apjieanim* of tiuiiK;ron» <Tyff 
tnlit ol the oxalate in the Bediiuont docn not pi-ove that nil abnormally large 
amount of the wilt is exci'eted by the Itidiievs. Furhniif^eT's iiiveHtigatiuUB 
Hiiuvr Hiost clfju'iy thiit tlRTf is no dttinitf ratio betwiou the amuiml of 
tho iixalutii lurtiiiilly [■•[intiutifd in tlie iiriiie >iii tite one hand und llio num* 
ber of crvHlid)! found iu the sediment on the other ; Ihua be found iu some 
cuKefiMitita Ictal excretiouof ten Dailligramineitagrt.'at(<riiiunber of oxidate 
crvKluls in tho wdimout tliiui oocurred in oth<.-r cases with un cxcrctiaii 
of iit-arly twoiitv miUigmmtnes. 

VxalurtJi. — \huiy of the £ug:liBh autliom have reeofrnized, under thifl 
uabc, a diHliiict patholot;;ic!d <'ou(ltticii), indicAtcHl by nientaJ drjiremou, 
dyHpeptiiu, puiti iu the upi^iLttriuiu uud in the loiUH, i-tuaciution nud diu> 
resiH ; aincc^ iu such fiu*cn, iiunic^rouH oxiUatc of caleium riyotala hnTebo6ti 
found in the oc-dimeut of the uiine, it has been supposed that the symp- 
tonia orifiinated iu nn increased production of oxalit aiid in tlie body, 
Since it is now kuown. as has Ixru fttnt^d, thikt thciT' iw no [■onHliiut roln- 
tion betwcuu thti uinouut of uxidic ucid cxcrL't'Od, aud th« iiuuilier of oxa- 
late prysttaii* in tlir» Rcrliinont, it in evidont ttat there i« no prouud for 
ascribing the sympfouia enumerated to the pi'eeence of oxalic acid in tb« 
blood. 

Clinically the appearnuee of oxalic acid in tho imnc in not associated 
etipeduUy with any piitli(tlc>(;iiTftl conditiiiii ; an iucreaae has been frequontly 
ohwrved in cases of diftl)etes. and Caiitani has recently recordwl u caae UQ 
which sugar and oxalie acid wei-e alternately cxerirtcd in Iiirg<( quantity. 
Furbriu({<-r dctvelod uxidic ucid in tht^ aputiiiu of n diabetic patient. C<d- 
cium oxalate crryiitalH an- Honii^limoH found iuexcesain eases of fermenta- 
tion in the tmall intestine, whei'eby f.itty acids ai* produced ; if thcuc ure 
only pai-tiidly nxiihu'il iti the blood, oxajic ucid is foruiciL 

Tlie qiiantitv of thft acid escretcil ia of courno inorpasod by the infieB- 
tinn uf vcj^ctables cuiiLaiuiug it — beets, tuiiii]ts, s]jiQach, cabbagv, appl<;M, 
omugeti, toiuuttivs, gnipes, etc., rhubarb, squills, vulcriiui. 





VRIRART &BDUISHT3. 



Ul 



9. CTsms. — Thin is a, rnro Mctliinonl, mmftllj- tount[ in individitata vho 
BnOer from eynt'ui trton*»i: yet it i]iaj-oc«ur dbsolved in tlio urine with- 
out tUfl (timnilion of vedicol calculi and even without thp procipitntiou of 
ra^fitnU in the »edimenl. 

' The ftuA tluit wvstin contains Hiitpliur (iml nitrog«ti inilipates itii ori- 
gin in the albiimiiiou-s (■tmstitiieiit-s "f thi' ltiul_v. Many efforts bare been 
niatli? lo iwceHftin whether tlie txcretinn of tivstin is accompnaied by a 
diriiiniition in the other urinwy ingredients eotiliiiniii^ uitro^^en and sul- 
phur; it lias lieen cletenninecl thut t.hrn* is iimmllv, iii wmh owih, n de- 
crease iti tJit! excretiou of uric acid miJ oi the »iLlpb»tes ; fiuther than tbia 
no nonstimt dsrinlion liiw bo4*n obHonoiI. 

Ill one case Maromtky observed cvBtinuria neaociated with » dimin- 
! jahflrd BOtivity of tlia liver (neholia) ; Ebstein nrnl Salisbuiy Imvo tiotioed 
^cyatinuria. during &cute rheumatism, tlie cystin tliMippcnriiig nft^r counu 
leaoeucc from thv AiKCiute. Ebsteiu'ii cuHft wa» cHpevially noteworthy from 
t1i6 fitet tk-tt filbiinicn wm iusocint«d intli (-yfilin, both disapiwarin); 
from tht! urine at the same time. In another case Ebstoin obtemd cj-w- 
tinnrin in a ayphilitio patient; nftei- tlia employmeut of inercuria]!t the 
cy»tin flisrippeared. 

Only onu obsen-ntiou as yet iiulicivtes n direct influenco of the diet 
Mpon IJiR prodnetinn of pj-stin : ICbstein ob8enre<i tliat the quantity ex- 
creted wia tripled atl«r tlie ingestitm of [waa. 

Cliiiicidiy, thcrwfore, the occurrenco of cystin in the urine — c>'Bt,inuri« 
— hiw aa yet no c(»pftciiil tqgnitieiineo. Aa yrt only ststy-one ouseB have 
beeu observed, of whiob fortv-dve (seventy -five per cent. J occurred in ioaI<m^ 
Cyslinuria hoa been noticed most frennently in youth. uccnaionaUy dui"- 
ing mi'ldle ago, but tvitli extreme rarity Aft«r the fiftieth year. It hiis 
)>eeu repeatedly observe-l in dilFeix-ut ineuibers of the atuue family, tbough 
whether from a common ppedispofiition or as the result of eoinnion mup* 
loiuidLuga is not knoivu. Tbiu Toel saw cvHtiiiuria in tbrer members of 
the Kime fiunily, mother and fhiu;:^hter8, and Ebiiteiu dcterted it In two 
brothcrft Host of thcuo itidiridudU enjoy rtpparcntly pcrfiti^t hcnlth. 

4. Leivis AJiD Ty«ofli?i. — Leuciu ia found nonnnlly in aiufdl ijnanlity in 
tlie s])leen, the jwnpreaa. tlie liver, and lympb ^Innda ; also in the scedH of 
certain phiut* It is pi\)di.ieefl in InrRer quftnlity daring the putrefnctioD 
of thi- t^inndq iibovc iiitioud, ah well us by tbo iictiou of punvrL-atiu juice 
tipiin albtiniinoiiR aubatnni^ea ; it 18 therefore evidently constantly produced 
in the aiinientory canal, Since, moreover, it ia formed by Uie action of 
ac'uhi luid ulkalic'ii upon albumen it aeeras probable that it may be fonued 
ill the body oh a part of nonnal tissue nietAnior]diO)ji«. At any rate it hag 
been discovered tliitt during the gi'rniinaliou of plants leucin mid tyrosin 
are prodncpd out of albnniinona tfljlislancf*. 

Tliough ft certAin amount of leucin nuist therefore be preaeot in the 
body, yet it Ki>p<»int to undergo further chnnpc before el i mi nation, RUice 
it i» never found in urine diirini; health. Kveu the adminial ration of ron- 
eiderable qua.ntitiM of leucin by tJie tuontli does not cause its appeai-nnco 
in Ihe uriuti ; there does occur, however, n decided iucrtuee in the iimuunt 
of uron excreted, whenci) it is inferred that sotne of the leucin at ien»t is 
trauaformed Into tire.1 in the Imdy. In planta it ia known thatleuein 
combinea with hydrornrlions, producing alltunien ; nince the increased ex- 
^eretiOD of urea which follows the adininL<^tration of leucin by the mouth 
■^doeii not noeonnt for nil of thiti »ubKtAno«.< aitmiiiiHtored, it is <jul1« pjsHible 
tint a umilar conihination occurs in the animal. 

As yet leacin is Icnawii to occur in the ui-iue only iu two pathological 



143 DISEASES OF THE c'ltlXARY OKGAN8. ^^11 

ocnditioQB — iirute rcllrm- ntropliy nt ihf ljv<!r nnd ttcaln phoKj)1ionii«-j>oi> 
Koning ; its rcporteiE ofictirreiu-e in ca»e»of Binail-pox, tvplioid fever, nnd 
glAntlcrs U i-arft or altogether doubtful. Siuce ia lie two (liaises iituii«!il 
tbe livLT is tli&urgaiiiXDil, ami little or no luca (.■xcrelcd, it ihldih piniisible 
to infer that tlio mRtainorpljosis of Icucin iato iiron iukI albumeu occurs 
noiTLiallj- in lliis orj^i. 

Ill airute yellow atrophy of the liver leiidn and tyi-osiii npj)pnr in tlio 
luiuo in lur^n quantity ; in iu*ut« p)iDt<])liuni^poit«)[itn[;. on the other 
Itaiid, in muull quimtily. Tliit fiK^l li!i>i iMH-ti i-mjiloycd for difforontial 
diagnosU iH-twoen the tvfo ftni-«tioiis (Sc-liiillzen iiud Jtictis). It must be 
renie!td>ereJ, liowevpr, tliflt cohcb of uiidoubtcd acutt livirr ntropliy havo 
hwu «bi»en-cd in vblcb neither leuciu nor tyrosia could be found Id the 
uriuei. 

Tyro*dn acems to l)<i formed in the liiimKii Hiilijed iiiidffr preciBcIr tlie 
Bane comlitionA ivhifih ^ve rise to tlie productioo of leueiii ; at any nite, 
tlicv ftppeitr tofiether in the urine. 

Tim tioniKtl acidity of tlic iirino is sometimes replitced by n neutral or 
acid reaction. Tliia oct-ura t-ljiefly after, 1, DigeMiou ; 2. Tlie iufreHliuii of 
alkalies or of vcfrctablfi acids (wliirh m-i> tiaiwformcii in 1h<i l)l(ioil iii)x> 
carbonatcis) ; 3. .iViamoniacal fermentation of uren ; 4. AOotixlure of 
blood or puH. Alknliiiity uf tlie urine hsf heen ubsi^rved. tliout;h not con- 
Stsutly, in viiriouif condiiioHH— nnn-min, disctuo of the central nci-vous By«- 
tem, aft«r inuHcular esi^ri-iee nml waiTii batLtt. 

The sedivif.nlK fieciiliar la alkaliti^ urine ni'p the snltH of ealrium, 
ma^etiium, aud amoionian], which are romtiarHtively insoluble in alknlino 
liqiiida. Litniua pni)er rcvviils not only tJie aUuiIuii' ri'iiclion, l)ut also 
di»ttti;;iu!<hes botvcen the ftalt« of calHiim nnd ma^eRiiim on the ono hand 
fuid of tiniinoniniu on tlie other ; for red litmus paper, tiimeil blue by am- 
nianini!al urine, noon rejpiinR its red color upon expuKure to the air in con- 
sequenee of the valaiihty of the Bminonia-; whih^ if the nUnlinity of tho 
urine bo due to other buses than aiuuoiuuiii, the htniua retains its blue 
color. 

These aaltn Rppoar to he retained in soliition Itirprly by the carbonic 
acid coittaincd in the urine; upon Iht- iippHcieliuu of ht-nl, whereby this 
aoid is «s|>«lled. th« eedimpnt i« much inereoited. Another phcnonienon 
oinnifeRtea by alhiLUne urine appears to be also due to the ew'ape of car- 
bonic acid, namely, tJie production of a variepated ut-uni upon the Kurface, 
This acum ia found to coneiet chielly of phosphntc uf cjilciutn, precipitated 
on the eurfncfi by the i-M'apc of uu-bouic acid. 

The appearance of the phosphates of maffnetiiiim and oalcium in the 
Bediment has no especial aignincance ia allfiUine urine; their persuttcat 
occiirrcDco in neutral or slightly wid urine is HuuKitiines obecrved in 
VArioHn nenroHPs. 

Till? appejirnnot! in fii-ah urine of the triple ]:>hoaphate (amntonio- 
mngTiesiuiii nhosiihate) and the urate of ammonium, on the otiier hantl. has 
fp-<^ai clinic«l Hipnificaiice, since these tftx> snlts occur almost exchiHiv<!ly 
in aist's where men ia triiu9furm«d into carbonate of miinionium in the 
blndiier, te., cases of cyetilis. Normal urine contains comparatixely little 
anuuonium, and it is only when an excess of this ba»e ie produced by the 
fermentation of ureu that the fonnntiun uf ita ntdta in couHiilerublr quantity 
is posMhlc. It mntit, however, be remembered tlmt the triple pho«i)hate is 
not found exclusively in cases of cystitis ; occasional crj'stals are observed 
in normal olkaUne urine. 




U BIN ART SEDUISSTS. 



1-13 



OsniinzicD SEnnrcsTa 

1. EpnuEiTAL Ceua — Tlio opithcUum Udidr the urinftry and (i^nital 
tnct pi-nH(>iitK I'lii^Hy thr»e vnri«ti«8 of (^Ils : I. FlAt«oll«; 2. ColumDar 
aud caiidiif'- (-ulln ; H. I{ouii<l celld. Coluiuii&r »n<l caudate cella are found 
in Tarioiii* sectinna of tlio urinarr muRoua mombrone — tlie aretlim, tlie 
bU(I<ler, the uretont, iiiii] tbi> jK'lviy of tL« kidney : lionce their Hjipouninoe 
iu the urine niLtiiiot Ih? tnttw-il Ut iu>y particTiilar jiortion uf tbn trwrt iitiloiw 
att«Qdittit (.'iiyuuistaTiceB fiinuHli a clew. In inoBt caaea forhinately such 
cipcumstnniifia iire preaent, either aa chimicteristio features of the urine or 
M symptoma pce»eoteJ by the paliciit It in rarely difficult to decide 
upon the origin of theso columnar oellit, exc(<pt uiicu tlie diuguuttifi reHUi 
betweeu prixttnlitiH nnd p^vflliii^ Kiiicf) in viioli njixliiiun tlit-su ix'IIk majr 
nppour uccumpaiiied by thremln c-omposeii of pas-corpum-leH. In pyelitis, 
the nvinc: i» found to ciJiiUin ulbumen. wore tlian the pus present Bboiild 
funiiidi. while in prontntitm nlhumiiiiinA ix not n symptum; in pyelitis, 
fuiibermoFe. tb« urine m usually quit« acid and ofiUu coutjiius poiutod 
roiifih cryntidn of uric aoid. 

Tiie Hat cells ni-e derived either from the bladder or from the va^ntuk 
These cells from tht> blulilor oi-nir Biti[,'ly ur in a hiiiRle layer, while tbime 
from the vaginii iirw hirgt^r, uKuiilly RTuupi'd, nii<l in nevcnil layer*. 

Xlin rcnitnl eclla are derived eitluT from the tiibulea of the ki<liiey or 
from thf! doeper biyera of thH peivia. Their oriRiniil form in the tubules 
in uot circuUr but polygonal ; HOUietiiDcs such cella are found iu the urine, 
but iu most cases the imgleii have been obUtorntt^d by t)ic ubttorption of 
water. Thene round oclfi are often eonfuncd with the young, half de- 
veloped flat celU from the bladder ; in (act, it is practically impossible even 
for an expert to diatint^uiah individual celln from these two Bourcas : it is 
only when tlte kidnt^y ci-W* occur in groupa, thus presentinur their ix>lyg» 
onnl furin, that the recognition con bi; luudo with perfort <;oufid(riicc. 

Vai'iatiouH from the typic:d form, of Mie «pithe1itd <'cll* iirr^ friHjoently 
seen ; thia is cspecialiy tnio of the columnnr t-ells, which often exhibit 
long caudutv i-itruiuitit.'* ou ouo or Irath sides. Hucti cells are often re- 
garded ax indications of raali:^nant now formation — " cancer willa." TJioso 
uiiipohu- an<l bipolar caudate cells arc, however, normally produced in the 
pelviH of the kiduey. iu the bkdder and urethra ; occurring indl%idual^ 
they do not nlunc indicate a morbid growth. 

'i. BuMV. — The admisttu'o of blood with the urine is a frequent and often 
a perplexinjt symptom ; for it may be derived from any portion of the 
urinary tract as well as fi^m the seminal veucles or even the epidid^'mis. 
In mosb coses liaiiuaturia is on crtdenec of a ruptured blood-TOBsel or of ao 
oloerated surface in Uio urinary tiwt ; though m eone few eases Uw blood- 
coq>ii»(dea seera to eaeape into the urinary ehaunela by diapedeeis, without 
any nipture of vascular walls. 

Clinically it ia extremely important, tLough sometimes difficult, to de- 
ternunc the eouiw imd thu caufc of biouutuiio. 

Blood may oaraixi into the uiiae— 

(I From the urethra; 

{2.) From the neck of the bladder (prostatic urethra) ; 

(3.) From the bladder : 

(1 From the aret«r ; 

[5.^ From the pelvis of the kidney; 

(6.) From the kidney ; 



4 



144 



DISEASES or TUB UBIKART ORGAKH. 



(7.) From ihe oniim iiriiiiii^- tmcl : ^ 

(R) FriiiTi thf ti;en!tal tract; 

(it.) From sour<!«B external to Uie urinaiT and genitAl mucO'DS meoi- 
braneai 

(1.) hliviiingfrum Ihe uivthni is n frequcut oociirroiico cliirinff tliR cmirae 
of gonorrlKrit, mtil is oiicaKiininIlv dIisitvciI in glert, iiml fiTiin stricture. 
■ Zlw diogiiofliti m to soui'cc auil cause is eaey, since tlie blood in muod 
with puR If tilt' bltioit escape from mime |H>rtioi] of the inn(^nii3 incrii- 
brane aiil*ri<»r to tliv nii-iiilmiiunw Hretiim. it oaciipis poLstaiitU' and can 
1)1! prcMud out ; if the BOtii\;e of t,lie bltioii l>e in or l^o^ttri(^^ to the mem- 
hnuifliiH portion, on tho other linntl. bliiod encapes oiilv diintifr tlie net o( 
micturitioD, since the circular inueculnr fibres of tbo iiieuliraunuu uretltra 
by their tonic ccmtmclion occlmle tJn! urinary chaiiupL 

Bleeding mny iJjw occur from iDJiiricB hy inMtrtiinenta, from foroed 
coitus, and from polyps in tbe urethra. These tiimora iu% ])robubly rc- 
Rpoiisililo for iirnthrai hemorrhage more fvptiiiently than is petiemlly sup- 
posed : for the esisteince is seldom aacertained or even euitjiected durtug; 
life, thnut^h poNt-mortem cxiuuiDutiun shows iliiit tlity are not extremely 
vniv. Tho writt-r obgnrved a cose of uivlhrnl liemorrhape which censieil 
eutirely afu-i* the remoral of four vaaoular polyps from the floor of the 
[kendiilous urethra. 

In a few c»e«s bleoding from the urothm has occurred frotn the lod^- 
ineut of urinary eultruli and of foreign bodies, euch aa boir'pinB. in tho 
rhnunel. 

(2.) Blet^ing frovi the rtenk of Ihe bladder and the proslntio urethra 
UBUklly occurs only at the «ud of miuttuitJou, aud in atihlum profuse. It 
oenire chiefly during catarrh of the proHtate, a conilition which is oft«n 
observed in the fifth or sixth week of gonorrhoea, and is iudicat«<l hy 
the ueceosity for frcqiieat lurination ; prustdtittK aud poBtutic heraorrhat;e 
may aUo occur in thow* eaaefi of paroiiiH or dilatation of tht bladder in 
which Ihi; (rouHlniit use of the catheter is necessary. In caeea ol chronic 
prostatittH folU)win;r poiiorrhita, blood Bomelimea escajws spontnneouAly at 
the end of urination, but is espcclidly n|[)t to follow the iuti-uduction of any 
iiuttrumeiit into tbu bliuldcr. 

Another oauxo of hemorrhage from the bladder-neek is the eKistence 
of varicosities or ''bUdder-pilea" in this locahty. This condition is some- 
nhat iDfi'C(|uent, and in uaujtlly foimd in itidividuids wbu suffer nltio fruui 
rectal hn-morihoid«. in a few cnaen it has been noti<^ed tliat hemorrhage 
occurred alternately from the i-eclal and vesiciil vftricositieB (I'ltzmann). 

Auotlier unusual source of bleeding from the blnddcr-neclc is tho exiitt- 
enco of fissures at the vesical orifice. In one such cwie observed by Ultz- 
luaOD, tho fiauuru muh pluinly viuiblc upon eudoacopio estuoinatioa 

Urinary cnncretionB in the prnatatic siniiB, new growtha and calculi 
at the ueck of the bUdder, mayaUo induce hemorrhage from the prostatic 
urethra. 

{3.1 ffemfirrhnqfl from the lil/idd'^ occm-s in casee of neophwma, vesical 
calculi, pajWtea (biifiarzia hsemotobia and lilariii eanguinia), cystitis, tuber- 
culouHand diphlheritic ulcerutiontt. 

(4) ftnd (6) Blecdi'iy from tli^ pelvU of the leitincj/ oocurB moBt fre- 
quently from the pi-eijcuco of kidney stouees tnbei-cuhu- iuHo-iumatiou, new 
growths, and parasites. 

(6.) lilecdintf from the Nilnei/ is doubtless the most frequent source of 
luematurifL Forcmont uuioug the caufiea oie the various forms of nephritis, 
and the reool corgestion nhich occurs in go many iufectiona nnd constitu- 



J 



UROARY SEDIMBKTS. 



145 



tionol diacofies — emall-pox, Rcurlet fever, mewlfls, intenaittent and neor- 
rtnt (cvers, erj-sipfilaa, acurvj', jmrpurft. «tc, ; iu fiict. liwmat tti-iu eeetua ■ 
pOMuljlu i-esult ofn febrile comliticui fnjm whatever cauM. 

(Jlistruutioci to tlio reutil circiilatioii, Yeuoiui congesrtion of the kidney, 
thi-ombosis of tlio jeuol vein, emboLuB of the ren&l arter7 sre all knovn 
causes. 

XuberculoaiH, cancer. abacesK, (uut ecliinococciis of the kiduej hare 
Iteeu obaerved to produeo IiemorrliAge from tbia organ. 

Itenal lucmnturiu liiu beea obaerred after the ingeatioQ of irritant sub- 
fitances, such nn oanthnndea, turiieutiiie. niuBtJU'Ll, and even quuiiua Iu 
otli^r cidiiea it occurs in, diseaaea of orgaim wliicli are not intimntcl; cwsoci- 
nted mth the kidney ; thua it liaa been obsen-ed in drrliomM of the liver. 
Fiuaily & iGW ca«tee occur in which blood appears in the uhno oa the result 
of cx]Hjauru to cold ; this is a not iiifrequeut cause of luumoglobinuno, 
tboutjli the Cftsea in whioli blood-coqDUscIes fsntpe from llie kidney as 
a rt'sult of taking cold iu"e ab yet few. Greeuliow observed four casos of 
pamsyHinal hivmaturia with niinultaucoux rhcuuiatit; paiiiH and a Iiirge 
anu>iint of oxnlAte of calcium in the urine. .SocolofT rcporttt the cose of 
n Riiiwiiiu ulVi(;«-r who during eight years had oct^aaioiial lut-iiiitturia, which 
almost invariably followed exposure to cold ; Uie case was eHiiecially in* 
terestiug because the pntient exhibited duiing the hiematuria paresis and 
diminiuLcd tieustbility of the left side, and comptained of paiu over the left 
kidney ; the Beditnent contained blood-eoninHdes, blooil-c«8t»t, and renal 
^ithelial cells. Hi^matuna, ]>erlinps ivith paiu iu the bladder iLiid tP^>i>i 
is oocBsionally obsenred in hot weather, cajiecially in pereona not yet uc- 
eUmated in a givun locality. Pounibly thin ia cautted by the concetitmtion 
of urine from cxceeHivt! penpiration, and couseijuent fomuitiou of small 
CODCretiona. It 1.1 usunlly relieved by olkahea. 

In a few cases renal hemon-liage is reported occuning Apparently m 
ricariouH ui<.iu>ttrunti(iii ; iti one eiwi" a «-»iiiian 8t;vi;iity-tiv<; yt^unt of age ia 
said to have had irre)^ilar hieniaturia eiibsetjuent to the menopaunn^ twen^> 
six years previously. 

(7.) Uemurrha-je from the entire urinary trad occurs usually iu coses cx- 
hibitiufr ftuomalios uf the blood or blood-vesntels. In most of the«) cases 
lueiuo^lubiu only eecapes iuU> the urine, while tu sotue tlie aecUuent is 
found to contain not only tho amorphous mosses of biemoglobin but also 
diBtiuct oorpuscles. 

A more important class of cases is that in which hemorrhage foUo^'S 
tlie complete ersicuBtion of a dilat«d bladder; cases in which hyi>ertrophy 
of the prostate, stricture, or paresis of the bladder has rL-Kulteil in periua- 
nent (UsteutioQ of tlu» on^m with iucomplete evacuation of urine. 8ucL 
a couditiou i* soonor or later followed by dilatation of the ureteru. pelves, 
nnd tubules of the kidney ; tliLH couditioii uHunlly exicftit for yt^nra before 
it becoDicH necesBory to employ the catheter; if catheterization be in- 
cautiously performed, if the oladder be completely evacuatwl at oua sit- 
ting, there oocut* a oongestion of tl^o bloi>d-vc»s«U iu tho urinary mucous 
membraoe in coQMquenoe of the removal of the Hccuatomed pressure. 
This congestion often i-esults in oysto-pyelitiii and even iic-phrittM ; iu otlier 
ca se s SOTsre capillary humorrUiigo occurs in the difereut portions of the 
urinary tract 

(K.) lilting /r&ni the fjmilal traxi In the mnle is umiidly discovered by 
the admixture of bh>oil willi aemeu ; in Home cones tiibercnious or eolcu- 
loua inflammation of the seuiual vesicles causes on escape of blood which 
may appear in tW uruie. 
10 



146 



DISEASES Of TUU UIUNAKT ORGANS. 



The urine of femftlea cffcen ooniiuns blood iltriveil from Qm uterus or 
TOgiiiu, uot oaly durini^ thu nienHtruiU period, hut also in tlio iiiUTrtils. 

(1(.) Biooil id freipicntlr jnlsod witli the urine from si'tircea exfeDuii to the 
genHo-uritianj arganji. Li wu-li cases tliere is (isunlly iufliuuuiation or nli- 
BC«BS in the vicinity of the urinai^ ii-Act, such as i>eriucplmtiB or paoM 

To dstermiae the murce of the blood wliich may 1x3 mixod vnth tlio 
uritiv, rdliiuieo niutit bo placod cbi<>tly it])ot) th<- Hyiuptoms. and upon Uie 
microscopic examinntioD of ibi! oedimenC ; tlie reAcliuii, color, uiiil specifio 
gruvity of the urine furuiBh premuuptite tlioiif;b not coneltiaive fvidenw. 

The rrxtction of the iiriuc i« iwiuUly arid in hemorriiage fi"onj (lie kid- 
ney an^l pclvut. Olid alkaline in vesical bemorrkige, provided the latter 
proccii from sa irtflniiicl hlddder. 

Tfic color of the uriiie in cases of bitMDAturifi is lUfutdlr either bripbt 
red, dark re<i, or nearlT block. This <liflerence in color iuilianteR merely 
the lon^i^h of time (luriorr vrhicli the blood h&s been in iotiniAie coittAot 
ttitb the uritiu iii tlto body. For at tb<! tcmpeiitturu of the body the hri^bt 
rftd hicinoglobiD bccom*e oxidi7.(>iI by contact with tho urino into tho 
brown methfBmofi^lobiu, cauidii^ a correttponding cbajige in Uhi color of 
the urine, 'I'liis brown tint indicates, therefore, that the blood has been 
uised with the urine quite iutiuiately for notn« time ; f^ince thig mixture 
Dccun iu Uiv kidney, mid iu pru'cucbyoiotoui^ heiiiorrliiitces, the brotro 
color is usually found in cases of renal bleeding. Blood which escapes 
from the bltulder-wall ia retained such a sliort lime that tbia change of 
color does not occur. In coacB of parcncbymalous hemorrhage from the 
bhidder, such &n rcHult^ HometiincH from Cftiicdr and bI«iip, the blood may 
l>e HO iutiuuitely misuj witli the urine na to exhibit the change of color to 
brown. 

The S})^\liiy ^rraia'/i/ may also have Bome diftgnostlfl vn!iie< in determin- 
iag thu Hourco of ii bciiK>rrlia);(> ; for in iiillamutatiun of tJie ktiliit'V luid 
of tlie ptdvia there w often pnlyiirin irith a correspondingly low Hpecifio 
gravity. 

JJhvd-<-lols arc Bumctimes prownt and oftcu indicate the source of tho 
hemorrhnge ; fresh clots are usiiully fonned in the blndder or urothm, 
while clots of u brown or yellowish *oIor ai-e of lean recent origin and may 
have been formed in the pelvis or ureter. Ijong, rod-elioped clot« of small 
ralibrc arc formed in the uret«r8, indicating that tlio hemorrhage bos oc- 
curred itbovo thu»e cluumelfl. 

TtiK mirroscr^iic if Tomi nation ot the nediment euabletins to distinguish 
pmmwliynjatouB (capilliu-y) beniorrliage from that following rupture of 
urgsr Teoiteh) with conipai-ativc certainty, and since hemorrbnKe from the 
Iddoey is tisuiilly ciipillary. we con usually distinguish renal hemorrhage 
from that from otluT .scinriM-st. 

<!npillarj" or pjirpncbyniatnns hemorrhage is detected microscopically 
ehitlly by one charju-'teristic fentm-e — the varj'ing sizo and color of tln' red 
cor|iiiacles. Li benjorrbii^'c froiu il l.irper vessel, the blood -wn-jmst^lt-s ap- 
pear in tlie urine without, yreat^r vnriittions in diameter than we are ac- 
customed to observe in frenbly drawn blood : after capillary hemorrfaoge. 
on the other baud, tJie greatest diversity in size of the red (wq>u»«.'loa i« 
observed, varyiitj; from the ordinary diameter down to more gmnulpR. 
These smaller fonns appear to he fnigmeuta of corpuaolea diMirganized by 
the loiix-contitmcd contntit of tho urine Many of the coninsclea have lost 
their iwlor and are xisiblo only by rdfmction «t the jwriphery : indee>d by 
applying a weak solution of todme we can iu such cases oflvn bring into 



J 



LRUTABY SBDIUKKl'S. 



147 



TOW red corpusdea which had previoiialj- esnaped notioe. I'Viedrrich firal 
pointed out the* fnct that in canes of oapillni^ h^morrlmge, tlie r«d cot-- 
pUielw iu Uki HD<1im<!nt frequeiiUy exhibit amivboi'l JnoTciiionts swob as nro 
often laiui if eRtof] hv tho \\]nU'- ]}\no(\-cor\t\iiic](\ii. It lias herii foiuid ihnt 
tliese movements are excited by eoiiUcl wiUi ui-ca ; lisnce they are more 
froquently obsurvcd in conccDtmtac) than in dilutu urines, k>iace capillATT 
bemorrhiig« occtmi ninro fr«Liu«iitly from tlio kidii«y than cleowh«re in Uio 
urinATj tmci, thcne auwboiit uiov-<;iii«ntt< of Lhfi rcil coqiu»ctl«N iu« iiioitt 
{requently if not eidumrely nbserrfid in co-seH of renal hemorrhage. 

The moat important chwicteristics for d«terminiiif; the soorce and ^usc 
of hlood in the iirin^^ nre, however, as alromly irtatuil, not bused upon (he 
^Dpeunnces of ttie blooil itself, but upou the ftymptoins pn^senteil hv tlio 
pftUani and ii[>oii the elenieuta other iimti blood contained in the M^liment. 

Thus in i'asch of hemorrhage fi'om the kidney there iiro usually found 
Uood-ciuttu from the tubul^B im W9ll ob r*-u<il cpitlii'liinn. In boic-li cunea it 
can somotimAH be dfftlirmiitcd U»i the urine i-uutuinx u greiiter mnoiiiii of 
albumoi than diotild he furnished by the blooil present. 

If the hemorrhage be caused by parasites — iShu-ia fifLn^inia. cchino- 
coccus, or biUtnma— evidvnco of Uieir oxistecce nil] t>e found upon c»r«ful 
seikrvh in the sediment. 

Hcniorrlingo from tlie pelvis, if due to renal atones, will usually be ac- 
companied by rough, pointed crystals of uric acid, and sooner or later by 
pus ; if due to tuberculosia, the oharftctoristic bacilli may potuably he 
found. 

Hemorrhnge from thn bladder is often aocompamed by crystala of 
triple phosphate and urate of ammonia ; if from the bladder neck, there 
may be found mucous casts from the prostatic glands containing putt-oor- 
ptiMlea. 

Li liiftiiy cases asMistance in dia^oaia can bo dorivetl from the preaenc* 
of peculiar epithehal cells. In cases of midiguaut fomtutioii, iiurticl«s of 
the growth urc often discoverable in the uriuu. 

3, I'uii. — Tile urine may contain pus lit-rivcd from any poi-t of the genito- 
urinary tract na well aa front nl^HcoHHes external to this tract ; tliiis ab- 
Roenaa around the hiatlder, the womb, the rectum, the kidney, in tlie 
psoas muscle, in the abdoniinfil wnll, in tlm liver and in the Ridfcn, liftTft 
UMU known to break into llie i^elvis of ilie kidofy, the ui-eter, or the bind, 
dor, and dischar^ Uieir contents into the urine. The s^-niptoma of the 
patient and the other elomonts present in the sediment must be relied 
upon to determiae the Beat of iiiip]iuratiou. Tlio pus itself niVonIs but 
litilo informatJOD in thla regard ; if the piia-cor|)a«ole« ore imbedded iu 
muous BO as bo make plugs or strings, it may be infeiTed that the pua is 
derived from the urethra or from the ptutitate as a sequel of (tooorrhiEia, 
though such ihroods nro occaBionally obwrrved in cnscn of pyelitis, Tlio 
form of tlit; epithelial (rella aocompauyini^ the juia may distiugiush between 
the two sources. In animoniaGA] vu-ine pus is converted into a alimj, jelly- 
like mass, usually miecalled mucus. 



Tddb-casts. 

' thn diarovery by Henle (1842) that casta of the iirmarj- tubules 
n>pear in the urine in various renal diMuses, ihew cylindora bavo bean 
the object of much study and attention. It vas atfirab auppoaed thnt they 
oonaiMad altfayv of fibrin which bad eecaped from the blooii-TeRscla durini^ 
ttte iaOuoxaaixaj procei^s and coagnlated in tho tubules ; the different ob- 



148 



DISEASES OF TttE VRINAKY ORaAIfS. 




Fto. 0.— tlj-tUoDOM*, from ItcB»ICoi)i:Mtlon(FttrbTta|ai). 




jfiote oit«n obsen-eKl upon casts — UocMl-corp'uscIes, epithelial cells, wid 
granules — were Buppoaed to be merely cutauglcd in tli« coafrulutinp fibrijt. 

The cMta wei* ret;ian]> 
ed as jjositii-e proof of 
ren&l wtlamiuatioD. 

liccent iuveati)^. 
tioiis have, however, 
nhown t.lint castn ari>ie 
in different waj-s, mid 
tliat Home varieties are 
fonncd And expelled 
witk the uriuv vvva 
wben the kidneja are 
enlirely free from iu- 
fliuQiuaton' action. 
Etiologicdiiy coQBid- 
ered, tlic-re are tliree 
varieties of cylindern : 
1, blood-etieta ; '2, bja- 
line oasU ; 3, cjiitli^iiat 
casts. 

1. Blood-cists con- 
aist simply of blood 
nbich lias escnpod in- 
to tlte tubules and 
there coagulated ; they 
aire ioamX only iu cases where free blooil-corpnscleB are prtaeut in the 
uriiio ; hii<Tnnturin of ronul origiu uiid acute nephritis usually funiisli these 
cofits (Fiq:. 6). 

2. HvAUsE Oabts. — 
Ot thoHQ tlioie nrv two 
mrietieft, Uio very deli- 
cate and lraii»j:arent eyl- 
iuduns (Fi^. 5) utid Uie 
thiekcr mid more oftague 
cflsta (Fij,-. 7). The lut- 
t4:r oiit^iuatc in the epi- 
thelial c(<lls. 

Thi! dflicat« trans- 

Enrent hyahne casts are 
oniogeaeous and gUa- 
(ty, DoiuctixDca couUkia- 
iii£ A few OT»iuilc8 or 
emthdial cells, aiid iisu- 
oUy Terj- narrow (.01 to 
1 tntn. in breadth). 
^VhliIl btudded n-ith 
granules tli«y may be 
■nistalieu by a careless 
observer for " grunu- 
lar " easts — au error to 
beavoided,iuiM!cthv lat- 
ter arc found only during renal iuflanunatioii. ^e true hii'aline are 
reiulily difttinguiehed from Uie granular casts by tlieir estteue dtdicacy and 
tjrausporeucy. 




Fitt. ei— RvltliaM, lUood, and Onnulu Cute, troa Aoit* fiouhtlnil 

Vtvtti\Hi. 





3. Bfitheual casts appear imd«r three difEbMnt and distioot fonuB, 
vhich have received diffoicat names, but vfaoM HigoifieanCQ depends upon 
the fact tlmt tliey orig- 
iiiste ill the epitbelial 
coiljt. Tbceie are : aim- 
pla t'pithdlial casts (Fi;;* 
C) ; gruDular cii»t» (Fij^ 
6 (md W); opiujuu hj'»- 
line aud wasy C(^ 
(Fig. 7). 

^^lliIe UioBo ropni- 
aeot tbe three types of 
epithelial cyUndera, 
tuere ar« fomiii numer- 
ous brauaitiouiU and 
mix&d forms (Fig. 7). 

Thfl simple rpithelial 
etui'tj* Aro composed of 
epithelial cells which 
have bcon detached 
from the bnsoment 
lucmbraiie of the tu- 
bule and expelled itn- 
changod, so that the 
outliiiua of tho Indtvid- 

I >t 1 *>„» il..^- Pm. T.-XplUwUikl. AntrloU. and Pall* CuU Mil BnllMi Ipta» 

ual coIIr aucl often their lui cwi*. baDOtuDnic i-anMiiy ' ~ 

nuclei are distingniabable. 

The 'jranidar Oftsts ore formed by a ineUuDOiphoaits of the epitlielium, 

whereby the outline!) of 
the tsSlB and tbcu- nu- 
clei are but iudistiuctlj 
if at all vUiblo, tin? cam 
bdsK zeplaoed by uam- 
BB of giBnuleo. Tbeiie 
casts are often of umg- 
ular Dutliuo. fissured, of 
a dark bro^ra color, and 
thickly studded with 
dark gran ales. 

A etill further nwta- 
morphonis uf thu upitbe- 
lium results in the pro- 
duolioQ of lite t>pa^ue 
ht/aiine casts. Theae Rre 
r e ad i 1 y distinguiahcd 
from the tnuiKpareut 
hyaline casta (wfaicb tirv 
of different origin) by 
their ihickuoM, oiHtcity, 
Strong refractive power, 
and frequently by a yel- 
luvnsti i-olor. lu a few 

eoMB thc^ pKMhusB the amyloid reaction with iodiue. Thv^e thick cai^s 

of waxy ftppwuaaeo am often fissured uud frequently accompanied by 

joamm of swc^n epithelial cells. 



FlO. a— Plndy Onualx C*i4> ud ■ "CtltainM," trua JUvU 
Kcfihtltk. 



mgSASSg OP TUK CniXABT 0SGAV8. 



CMta of ftU nuicfice niAr coDtain, «nt<uigle<d in thdr i bafa ao . Tuioua 
toreiga cleoienU, ftucli u Uood-cor^ujtctuM, iadindiul epitLelial cells, hA- 
srailulaB ud djo|«, bacteria, and vnnoii* urinary aaltB, ktooiphou* or exyt- 
ullinu (umtM^ line nctel. c&ktium oxalaU, etc^. 

Tbe teno evlifulroid hw beeo wplk-d (Tucmuus) to yerj Ion;; and niir- 
raw euUta, v^iifih on, howerer, mSiy meta tuotliliuatioiiti of the dtHcata 
liynllna OMtii (Pl^;. S). 

Owun ur TtuK-cAifTX. — Tlit^ imnejMmil kifldine casta are compoiied ainw 
|)ly of coagulated AlbuiiMD wLivh tuiK uiidt-Tgoiio somo na y«t uuknomi 
BKxMcntioii, ainc« tbejr exhibit r«aotioiia diOereiit fruiu tliosv showD bj 
Krum nlbumen, globulin, and libriiL Tbey arc tonninl I'litiroly from the 
Benim of the blood, ami mny thvroforo appear in tho mine iii any com in 
wbLcb ■oruoi olbuxuvii ii founil, orua Uiuut-ii Llicro be no dieeaae o( tlie 
kidnf? wluitKibT(:<r. Woingarbar and Kibbtrt Iiutc produced hyaline easts 
ex|>eniiHm tally by aiitiplo preoBiira upou Uii- mud viriii or ocvJuHiun of tbo 
mini arU-ry : Ihay ore aim prothiced by HUch ai-titioial elevation of tttaper' 
nluftt AA MiiflicdH to cause albuminoriB. L'iid«r thtae circiuualancea ll>e 
•pitfavHiim of tlio ttibulcH cxliibite qq ubiiuruml oppcar&noe, bat their 
lamina iMKuitigc tlllod willi Bucly grumiliu- albumen, xvliit-h ufler a time i» 
tntiiHfoniiiHl iiitji j>orf»c;tly liyaUuu uisiHof tJie tubuleit. 

'HiOHo (aporiinnrital rcaciu^heH are in perfect nrcxird wiUi the clinical 
obMrrotiou ttiat liyuUuo uksta niny iippetir m llic urine during any of those 
COUtllliona ulrmtuly uiiiunoraUHl which iuiluro iilbiuuinurin independent of 
rrtiinl dlHoae ; henoo olono they do not constitute the dightesfc ertdenoe of 
iJrit,'ld'» diiMML«& 

T\n rpil/ftial, granular, ud opoyw hyalinr caets are coiupoBed of the 
opitliiflial r-clU of UiA tubules, eiUier im<Jiiu]|,'ed ur (in the two latter vu- 
rrutieii) iDotniiior]>ho«KKl. Li tbo Grst-notncd variety thv outlines of tLo 
ouIIh aud iiiii'lui ore diintinoUy viaible. la mrmy rnHta of c^pithclial origin, 
howarar, tlio ottllH oo&lHoe into n Imcly gronuinr matw in vliicb the con- 
tain of oelU and noolei ore nearly or 4|uiUi oblitcmtcd ^^^nuiulu' caets). 
Ato latar ata^e the maaB buuomus Lyuliue from the pt^ripbery and muy 
ttltittuloly Appear homoaenooua and iiliu»y throut;hi>ut ((>]>iupio lo-nliii«. 
VUiU). XulDOdi the truunrmatiOQ from distinct cpitbelial cells to a gU&sy,' 
homonooouamiLaHapiiearM tooitt-'urdiiectly in kuuio iniitaiicea Tbi.>imeta< 
otorpfloaiN of Uic epillifliid cvIIh in tlio urinar>' tubuU-^i during infliuunintion 
in niiiilot'(>ua to Dm Ij-niiiifoniiiitiou whioh occurs in the epithuUuni of mu- 
cuUM Murdiisi'M during croiipotM intltunitution. 

Epitliolinl eaata, properly s])uakiiig — tlio§e which ori^^nte in detnch- 
meut of tbo tubulnr opiuivlium during inOmuumtiou— -cuiuprise. thcrcforv, 
not only tho»a in whtoh t'pithoUal ccIIh ctiii bo dixtiiictly outlined, but id»o 
thoee vrhich ar« eommouly («riaed gnmuhu- and waxy cylindei-s. 

Since difTerent ooala vw at tfa« afuno vnriety vary much in diameter and 
in Bhape, it luta been supposed that they could be traced to different por- 
tiuim of the tubulea by thonu fuatureb ; that tbo brood coitta vnn formed 
in the vidc^r portiouti of tlio tubuloitjind the apirnl caxtn in the cDnTolut«d 
tobulea. There is, however, no }{i\)uiid for such asaumptiou ; there is, in- 
deed, no means for identifying the puticuld portiou of the tnbule froa ' 
which a giTAu east has been dmved. onleM dittanet epithelial cella ore at 
taohed, Pi-obably most cmAa arv formed originally in the convoluted 
tubulea 

It haa been asserted thnt so-called " secretion cAsts " are produced in 
Donool Iddneya by the usudatiuu of plnauiu from tb« tubuhu' epitbelinm. 
This certainly occure iu vertaio uou-iudamDiatoiy oonditioua of the kidney. 



TKINABT SEOLMESTS. 



151 



^ 



irliora the uriue contains an excess of iimtea oi- Itiu a liigh spociiic gravity 
{1080 or more) but do albumea ; possibly thiH exuilatioii in caused hy iv 
nt&tion of tlie tubtilai* opitLoliuni. Tlie«e c^UudDrs are (;eiiemlly included 
under tb« tnuni: " umooita caatu," Utouf^'b tuusl of tbg ubjecto bo called an 
ciuitH of tb« 8i»rauitto tubulee. 

A mi/hid cwiifjt seem to arise eitlier from liyaliuo or from epitbeliAl cylin- 
ders; they are found iu casus of ]]c]>bnli8 aa well as til jfuitt amyloid dc- 
oetiemtioii of the iudut-y. TJiey do iiol. tbt-refore, iieceKHurily iiuUentoa 
aegeoeratioD of Uio ii[)ii.)icbutii, tlicmgli found abio, as abready stated, in 
00808 where aucb de(;L-iiei-atk)ii htm oticiiiT«d. 

yalltf auli tixe either hyaline or cpitbelinl caxta whi«h urs studdod vrith 
oil-globulaa produoed by fatty degeneration of the renal epithelium ; they 
■re QHually derived from the ctHH of th« tubules, and heuui are properly 
isduded in the group of vpitliolial ctuAtt. 

J/i<twiw casta i» a terra appbed to obiecta derived from eeveinl sourcc-H. 
Ooder thia bead hare been described : I, eybndroida, wliiclt are really ex* 
tremelv long nnd slendor hynlino casta; S, secretion casta, which are 
fonneii (probably from lui exudate of th« «pitli(]litLl fclln) in th« tubules of 
tiomifll kidney*, capocjally under the influence of irritAtion byiiriuarvBaIt«: 
8, mcMt of tlie so<oal]ed muuons casta are derived nut ffom the kidney at 
all, but from the flpennatiu tubule. All these varieties, generally tenned 
ntuoous caate. are retn&rkablo for thoir extreme length. tnmspareDcy, and 
alight relractivo power. 

Tbk CLIKIOAL iu<Ki>'iOA!ccB OF TUBX-cum Taiies ncenrding to tbo variety 
and number present, as baa been already iBdicated. Transparent hyalino 
oostn do not necomarily proro the uxiifteiteu of Bright 'h diteaiK), tdncu they 
may h» fouud iu auy ease of nlbuminuriti from whatever l'kuso, ludepen- 
deut of renal iliseatta They are found in the uiine iu febrile eo»ditioii% 
in oh«tnictJon to the ajratenuo ctrculiUiou such oa occum iu di-wasea of the 
heart and liiu;^ in cases of long-continued or intense excitement, etc 
Ttiey are alvo found in omm of actuul diHea-se of tliu Iddncy, eapeciiilly in 
eitriious of that organ and in the aeute neplintia vrliicU follows scarlatina 
and otlier iufecttoun diseases. 

Tbe preaencoof opitbeliul caitt«,ou the other band — the term including 
the f^nuhtr. fatty, oud brood opiuiiio hyaline lurioUefl — indicates a diiun- 
tegration <.>( llio renal epithelium, aud tliL'refure m-))lu-itiiL 

An opinion as to the dej^o nnd duration of renal intlanunation cna bd 
based upon the number and kindo of casts preoont, especially when tolcen 
in coDnoction with tku hiatory and HVinploiiui. Tbe niunb^r of ausUt <U)- 
penda bu^sly u|)ou t\m anionnt of urine excreted, fur oliguria i» froqueutly 
aeeoinjMuiieil, eitlier as oauao or leault, by a retention of the casta in th^ 
tubulea. It La quito probable that tbo rapid formation of numeroua cuta in 
tlulddtiBy mny matennlly diuiiuish tlie uxerution of uritKi. Freo diureus. on 
Um othor baud, i« usually uo»onipaDie<l by tlio expulsion of miuiin-ous outH. 

In acute nephritia ulood-cneta, epithelial casta uitli we IKle lined cells 
and nuclei, and broail opaque hyaline coats are especially niuiK-rous ; in 
tbe chronic foi-mi*, the granDliu-, hyaline, nnd fatty casts preilominate. 
Th« other moi-phuIu<;icRl oieinwitfl found with or uiJuu the custs are ab» 
■ugaiSaaat; tbrni iniTiierous leuoooyteit aiv- found during acut« inflamnni- 
tdoD, liiri^ ilrups and luaasea of fat ilurin}; chronic uepliritis, etc. In most 
Cflees in which epithelial, gmiubtr, or byaliuo casta ore found in the urine, 
nllMtmcQ is also prbHOiit Vot it ia a fact of the utnioat clinical imjrar- 
touoo that diaiutegroUou of the renal epitheliiun resulting iu thu tormu- 
tioD of ca.it4 may oocui' without albumiuuria ; tlie ed>^fenl.v ^ albuoien doe» 



4 



152 



DISEASES OV THE rRI»ABY ORGANS, 



twt, therefnre, prow the ahtvnce uf renal (titeiue. ThuR in CA»efi of ne- 
phritis fo'UnTt-iitg Bcorleb fever, it is not rare to lind hyalinf.- and epitlielinl 
casts wilLout a trace of albumen in the urine ; nucl m cirrLosis of the kid- 
ney gianular nod liyaUno costs iire sometitued seen eveu whcu tlio urine 
is entirely free from albuiuen. bi otber cases hyaline aista are olweiTed 
in non-alDumiiioua urine, apparently without vmaX diseaee, or at motd wiih 
bnwrnmia of the kidney. This is fretjuent iu coeea of icterus (Valliii) : 
inilec'd, KotJmugel diHc^oveired tbiit canXs appear in every case of intenEO 
ict*'niK ill ivliicli tlie mine contHiiis the biliurr acidis, tbough in many of 
tliene )iii^taiice» no albiutieti is pretteiil. Experimentally it lins been deiuou- 
struted that tlie iujeotion of tho biliary acidn into the circulation caunox 
thv formntion of iubo-casts, ^vith or without albuminuria. Fiscbl hiis often 
seen casta in tJie urine, usually of the hyaline though sometimes of tbe i-pi- 
thclial variety, during ordinary iut«stiiiid catArrb ; in nuuiy ce£«« do alba* 
men was discovered. 

This disintegration of Lbe renal epithelium without albuminuria haa 
been observeil expcrimGntnIly iw well as clinically ; it has been produced 
by the iiiJMtiuii of biliary arids and by the introduction into the circulation 
of renal irritantR such na canUiaridea and turpentine (Schachowa). Thene 
subslfinces ai'B kuonn to cnuKa necrosis of the epithelium in the convoluted 
tubules without at lirst ntYevluig the glouiuruli ; bc-rcin lies duubtlciM the 
explanation of tlio appearance of epithelial casts without albuminuria. 

Befddes the tube-casta proper, there are found iu lu'iiie masses of ma- 
terial resembliDK them in shape and size, lieeaiise moulded in the urinary 
tubules ; some of these may be produced independently of renal disease, 
thou|{h often combint-d witli genuine cast-s of renal origin. 

L'ric acid ami uraJa are often observed in the urine in the form of 
tube-casta. In moat of these casea this form is of artificiid origin, caused 
by the rolling of the corer gloaa orer the slide during the prepiiratioa of 
the sediment In nursing childi-eu, however, who ore known to miffor 
from uric acid infarct of tlie kidney, tbeso cyliinleiit ai* evidently produced 
in the tubules. Tliey are composed of redilisli-brow-n granules aud balls, 
sometimes as large as blood-corpuscles, imbedded in a moss resembling 

OlUCUtf. 

Caalg of hiiiary pigvimt are sometimEB seen iu coseB of icterus caused 
by occlusion of the biliary ducts. Mi'-bius found by the examinatiou 
of kidneys in such cases tlint tlie glomeruli were alu'ays free from bd- 
iary pigment, but that the tpithelium of the convoluted tubules and of 
Henle's loops was filled with granules of bile pigment ; he obaerved, fur- 
thermore, in the lumen of the tubules numeroua cylindetB of a roughly 
granular appearance, composed of hilinry pigment. This fsct escplaiuM tli« 
clinical ob&iJiTutiou that iu such cases oliguria and cvl'u aiiuria may occur 
—the result evidentlyof the plugging of the urinary tubules by the biliary 
pigment These caats of bile piyment often apiiear in the mine without 
albumeu ; aooner or biter, however, album i nm-ia usually ocoure in ihtae 
cases, accompanied by hyaline and even epithelial casts in the Bcdimeut 

Oiltt« ca-nip'iKfxi of baclrria, or thickly Ktiiddjiil with these organisms, ai* 
often found in caries of sitppurntive nephritis (sm-gical Iddaey) and of 
pyremia ; iu a few cimch of uryNipidiia aud diphtheria also they have been 
aMD. In these cases tlie ap']i^'^i^°<=^ "^ bacteria in the form of tube- 
CSSta ia quite cumpreheusible. since the organism), are found in th« blood 
and iu tliv kidneys during tli<-AO dix^'asea. Beeeutly Litteu has described 
tvD caaea in whioi the occurreoce of costs oomposed of bacteiia is not so 



CKINART 8EDISIEKT3. 



153 



Th« first ease was tlifttorn girl nineteen ycar.t of n^ wbobnil prorioiwly 
enjoyed (-ood liealtlL After *dight intiiBpnaition for BOTeml days she sud- 
denly exhibited severe abdominal BynipLomH — pain, vomitinff, and profuse 
diaxrhcea tKcorapamed by clulls aimI iov^-r {thfi ierojiernture ro acliioc 
4r'C.) ; tlj« urina became very scflnty, 100 to 200 e.c, daily, and coutained 
much albiimeti anil r«tiiarkabty broad caato flludiled witk micrococci. 
Peath occurred in tliree days irom uncmia. The sectiou revealed enlarge- 
mont, PODgegtioti. and cloudy Bwellinfi of tlie kitlneys ; microscnpiwSly 
there wei-e obaeiTod irreguW local dilatntiuns of the tiibulea in both 
cortical and mudulliiry substance. Tlierte dilated tubuk-a coulaiuud masses 
of mierocoori ; the cpiUieliuai wna in many places filled n'ith the snrae 
organiBmaL Similar ranasea of bact^rift wei-e found in tho capsules and 
captllariGR of the glomeruh and in tht> vaitii nffereDtia ; there vna. in ad- 
dition only a slight int«rBtitial aepIuitLM;. Littcn observed a s«cosd case 
with i-aaeutiolly nimiltir history. 

Cahtb fbom OROAJta othek thax tbzKuwet. — There ore frequently fatmtl 
in the uiino microscopic cylindorB rcsembhn^ in their general outline 
iboati formed in thci reiial tubules ; theae are derived either from the pro»- 
tet« or from the testia 

Proniatic casts ai-e found occasionally in cases of chronic catarrh of the 
proatato aubaetiueDt to guiiorrhora. Tbey aru moulds oi the pruMtatio 
I0Uiel«% QSUalljr much broader than the renal caat^ ADd oommonly studdccft 
wiUl pus-oonnuclea ; they occur in groups and are aocom})anied with epi- 
thidiiu cc<11h from the proatatic urethra Tbeir compusitton appears to H 
simply mucus. 

OattaoftA^ seminal tubules are occaaionaUy encountered in the omuury 
ftediment They can often be recoRuized at once by the fact that sper- 
matozoa, or fra^entfl of them, are found imbedded in the castii ; othcrwiM 
they may bo c^od mucous casta Irom Uie kidiiey. They are very long, 
txKDsparoQt, and delicate. 

SpEauATozoi. — Tbeae cells are found in the urine not only after eoition, 
poUutiuiiK. and iu Hpermutorrhwa, but abto afttr epilt^ptic Keizurefl. In 
iqwaTnatorrhana there aru occuitioiiidly found partly develnpftd m>crmat070i», 
Urine which ooataias eemeu eometimes exMbits also miuute bodies 
which resemble tfraina of oago ; these are masHeB of albumen derived from 
the seiaiDal veeicloa. 

FuauKNTn OF Miirbid Osowtrs. — New foruintione in ttiu bladder and 
nrsthra can occasionally be recopnize<l by the discovery of froginonts in 
the urine ; neoplasms of the hidney and pelvis, on the other hand, are 
ruely revealed m thin vi-ny. 

Extreme care muMt bo exercised in deciding upon the origin of indi- 
vidual ceUs found in the urine ; iu fact, it in pntcticallY iniposaible to 
reco^ize any aingle cell as a ao-called "cancer ceU." For the normal 
epitbehum of the urinary tinct fuminhGit cella of great dirersity in shape 
•ud ii«! 1 caudate and epiiiillu ceUn are preiicnt uoniiuUy in the ureter, 
nretlira, and bladder. U many of tlicne be prencmt, remarlcahh- for (heir 
lai^e size and atypical shapo as well as for the size and number of their 
nuclei, a suapicionof a morbid growth may bo entertained if the s^-mptoms 
corroborate such oMiimption. Yet 8\ich great diversity of size and shni^t^ of 
tlie eptthi'liol cc-lb i» witnessed during,' n oiuiple iiithuiimattou of the 
bladder, that great reserve must be exercinod in baaiii); an opinion upon 
■uclidnta. It is (J uilc otherwise, however, when fratrments of neoplasme are 
found in the urine. Thetie may be di-rivcd from a cancer or from a jnpillonia 
(villous cancer) of the bladder. In the case of cnrciuoma, fnigmentti of the 



194 



DISEASES OF THE trKINART 0B0AN8. 



tisRuo nppoor in fcbo ui'ino oaly ntior iilccmtioii liais bej^u. by whicli tiiue 
tbo ityiuiitiiiiia and the pei-aisteut lii(.-mutiti-m liavo iiKiiiiIly r«iii]4-n.-(] Ibo 
din^ofiia oimoHl certain ; it occaaonall; linppcnE, linweyer, Uiat the s)nii>- 
tunis ai-e so obecuro oii ia ptiszlo eveu tlie experieuced mirgeon antil n. 
pLoott uf the growth is olMMa^viL 

THgmeDta of jrapiUoma, on the otiier Iibiic), are oft«ji obtaiued varly 

io the course uf the liioeaae ; indeed, it lian i«]>eatedl;r bnii])ciicd tbnt hy 

the inti'oduction of u ejttliijtcr » pie^c of an unsuspected papilloma lias 

' Iweu witlidra«tL This tjiowtli {jresuutH under Ihd microscope a clinrHCtei'- 

^wttc npiw'iiriiuce, resetubl Lug n tree in iU <nitliiio ; rach brnccL consist h oE 

a broftd blood-vtfwel upon wliirh rests a Hiiighi Inver uf cuhiiiiiiiu- cpitbeliuiu. 

UsTozi**. — Four auimal puraaitea of Ibe body occa^ionnlly give ^^Tp-ideiico 

of their presciico by the (ipitearKUco of tbo »ediincnt. These ore : 

1. Eclunac(KVvs : thu liookfl &Dd evou D'ii^ueiit« of the eiiclosuig BBO 
nifty uppciir in the uriufi when a vyst located ill or noar tbo kidney hiut 
buTfit into llio pelvis. 

2. Strangytus ijigaa, a iieumtode worm, opcasionally makes itH home in 
tbo bumiui luilnoy, though it in iax uioro fru<ju«utly found in the kidney 
of the do^. lu n few rare instAuces the e^gs and even llie lulult woruia 
arc Raid to hare been found in human unne. It is probable, howfrer, 
that the diagnogiH was crroueious, tbo worm having been actually a.u ascniis 

L^m thf rvi'tum, which nuicL rf^ciiibb-i* Id tippeHtimce tlio sU'oii^hts, 
* The latter isdistinguisLeJ fi'otn tbe ancai'iH Ly thti poesessiou of six pupilliD 
around the month, nbile the nscarishas but tluee. 

H. IHsloma htvmtitubuim, or billiania hanualvbia. is a trematode which 
malies ite lumie iu the veiiia of the pelvii; organa. especinlly the bladder 
and tlie rectum. Th« ptuiiaito la^s iiuiu«t'ouj» eggs iu Ui&ae vessels 
whereby the vascular channels ai-e occluded, causiug hemorrhage and 
ulceration. It is found almost csclusivelv in jVfrica, especially in l^g>'[>t ; 
coseH iu which it bua been obacrv^l in AiiiericH uppetu to bt! escluaively 
isdiTiduali) nho haro resided in Africa. SucJi a cAse came under the 
writer's observation in February, 18ls3, in whicL tb© mine contained au- 
meruuH tgga and much bluod. 

4. Filana »aiiguiiii» hotniiii» appears in tlie urine Kooii itftiT entering tbe 
body. At first the only symptom to dii-ect atteuUon to the urine niay be 
hiematurin ; nfter a time chylmia occurs, tbe urino now containing masses 
of 6bi-in nhich may senously itujiede tbe evacuation of tho bladder. U 
thoso muBHcH of libriii pikiscd during the night b« tiepai-ated into frag- 
meutuaud osaniincd mifiroscopicalJy, one or more of the embryo worms can 
uHually he found ; sometimes specimens ace observed disentaxigled from 
tbefibiinand biood. This pwasile also appears to b(iindi<.'t?uou!i lotropical 
counti-ios ; it has Ijeeu found in Itidiii, Chioa, Egjpt, UriL/.it, luid .Viinti-ulia. 
But few iMwes have beeu ohiierved in £urope and America, and these exclu- 
sively in persona who have resided in one of the oountries named. 

ui additiou to these four worms wldch are piunsitic tu tbo urinary 
orgiWH or iu the blood, other iiuiuiabt ocuottioually fiud tlieir way luto tlie 
uruiary organx and are discharged with the urine. The most frequent 
of thcae is perhaps the thread, woiiu so common in tbe rectum during 
childhood ; these not only drop into the v(.-jkm:1, but may even crawl into 
tbo urethi-a id the femide. 

In othi-r cases uhuormal communication i» formed between the intes- 
tine and tlio blatldor, tJiniugh which worms inhabiting the former organ 
find tbeii' way into the urine. One such case is reported iu which an in- 
dividual hud DCvvral times obtsurved worutt ibimiug from hia uruthra. At 




URINARY SEDlUEjrrs. 



155 



the age of twenty-eiglit lie waa operated upon for Btone, uid died fiv« daj-s 
later. The hccUou Bbowed that the Terniiforiu apjieinlii had bwomc nd- 
hereut (o tliv bladder Aud tb&t a SatuU exintej betweuu tbu two oiiguis, 
glosed by a viUrular fold of luucouii meiiibrane. 

S'VKQL — After exposure to the iiir thore iirc ofteu found in uriae sawol 
viui«tivK of fiuigua, chielly the yoimi or Hugar pknt t\nd the p«iioiIllum 
(^Inucum. Tliey ara cspwiinlly prone to (lerelop in slightly «cid, concea- 
irntctd urine, 'fho 8ti{»iir fuiigua oc-ouni with caprcia! fronuoucy ia tuccha- 
rin» uriD«, merely bticnuse the piosonce of the sugar reuders Ibu uriuo a 
favuDkble noil for tb« growth of Iho phinU ^ f ar as ist at prcHeiit kiiowu, 
tliCMo fim;^ nro iioTor pri^iKut until nftcr tbo tirine has left the body ; tbey 
occur more frequeully ia albuiuiuouH tbuu iu uoQ-nlbumiuoius uriue. 

Quite otbenma, hotvaver, is the xignifirfttico of tho tarcirift uiitiiD. This 
fiiugUH, like th» wiTCina veutriculi, occura iij gruupn of two, four, ei^bt, «tc,, 
but iH HtDolIvr thuu ita uaiuvauku from tho sUitDacli. It ia men but rarely 
in tho urine, but when prencnt fvidcutly pn>ceeds from the bladder, where 
it often ocicatnoua a troublesome mid ubHtiualo aCGBcUon. TLo ptiuiti; j^ovr 
in the bladder fur weeks or even nionthit, in spito of nil tn'utuieul. but 
6unlly di]>i!ippoar from causes as yet unkziovvu. The ^latit^iit mtmitvbiU) 
BU&ra from a low f^mde of cyatitiit ; tho urine prcKenta a thidc Hocculeiit 
sediment, i^ontaining tho organisniii. Att«iiipt« to pluut eurcinii' in the 
bUddera of healthy do^ and rabbilH by iujuctioii into th<i bluddcr and 
into the jufjiUorToiu have alivajn failed (Welcker, Ijeube). Tiiere must 
«vi[li>nt]y ho some influence -which prediBposea the urine and the bladdi-r 
for the reception of tbeite organ ihui.-*. In noibo etuKS reported the cntbetor 
bad been previously employed, »o that tbdre wiw a iwiisibility that the 
plants hskd been introduced into the bladder iu thiH wuy ; iu other uasujt 
Qo instruuicat hud wvr been introduced into the blai.lder, eo that the 
mode of nccotw of the aartdna remaiued unttxplaiued. 

B.tcTEBi.i. — These organinu^ like tlie utiier fungi ali-eody cientioucd, 
are found in urine nfter it has beeo ezposetl to the air for a abort time. 
Kiiido thfsy aro present in the body dunng many pathological conditions, 
and siuce tltoy are UMUolly wo xundl iw to piiM readily tbrough capillary 
walbi. tliey ofieu enter the urine before it laarea tbe body. Tbt'y have 
been found in freshly voided uriiis iu the following condition:! : 

In vfthoufl infectious diseases accumpauied by tlie preaence of bnoteria 
in the blood and tissues ; tbua the cbaructerintic bacilli bare been found 
in the uiioe iu caaes of anthrax, tliu K]^rilla of Obcrtneivr in relapsing fever, 
micTDOooci iu tbe various forms of seirtio infection — pyieuiia. diphtheria, 
tdeoTOUs endocarditiB, eta In moat caaea thcao orgaiiisniB Bcem to have 
poaaed frotn tlio blood tlirough the glomeruli into the tubules, and appear 
acntterod in the uriue. In uuiiiy ciitM-ii of Heptio infection, hawever, the 
RUCi*ocDOci are found in inaxMCit, iiHunJIv in the shape of tube^uta, ahowing 
that ihvy were rax>wing rapidly iu the tubuk-a. Microscopio examinatton 
of tlie kidneys from hucU ostst-H proves that niicrococRi frequently invade 
the tubiUea iia wiJl n» tlio vcimcIh of tho kidney. 

In the majority of diituiuws alrciidy rvfciTod to, tho diaf^noHia is cosily 
outdo without an examination of tho urinary sediment ; but a few ciiaos ore 
on recoixl in which an invasion of the kidneys by micrococci has occumxl 
without induciug chtintcteriiitic symptoms, and in u-bieb tlie duiffno^a ba« 
rwtal upon tbe appearance of bacteria in the ahspe of tube-casts in the 
iirin<k Iteference baa been olreody made to tn-o rcccut auKa n-uortcd by 
Litten. 

In the pathological conditions already discussed, the bacteria are car- 



156 DISEA8E3 OP TBTR CRINABT OROAKS. " 

md to th& kidnoy in the blood ; tb«TO ir, Uowc^-<'I-, n clns« of cftue in 
wliich llie,v gain tvccesa to ihe kiduey by coutinuous growtb from the bind- 
der nloti^ the ureter. 8uch are eaues of Rur^tical kidiiey or (suppurative 
□fpliritis, foUon-in^ operationB upon the blndder and urethra, or conee- 

rmt vveu upou me tiiiuplo iutruduction of a catheter into u chronically 
tended blcuhler. In these casi6a,too, the invasioti of the kidney by bsc- 
teria is iudicated by the appear&iic« of caste composed of these organiKmt 
in the urine. 

Xhtire is. moreover, a clnss of cases in which bacteria ore constantly 
prvseut in the bhtdder, where they huve been introduced by uietuis ut cuthe- 
lers. So loni; as the vesical mucoiis membrane retainH its noiTiiaJ coo- 
iliticin and the hiadiler evacuates itneU completely, ordinary bacteria at 
least do not lind a fuvorable eoU for propagation in thin orginn. 9Iany 
obsMTcrs h&ve repeatedly iiijeete<l fluids containing onliDAiy t>act«ria, 
even putrid higuids, iuto the bladders of henlthv animals ; but in every 
case these liquids aud the contaiueil bftcteria have been promptly expelled 
nitliout eauaing inflammation. It is quite otherwise, however, if the blad- 
der £iil to evacuate itsolf completely, so that a certain muouot of uiino is 
idways present in tho organ ; (or tht' bacteria of putrefaction, introduced 
uuder such couditious, hud u favorable soil in the etagniuit urine tuid 
propagate within the bintlder. Tiius it happene Oiat in cases of elderly 
men who in consequcinoe of pi-ostatic hj-pertrophy, veEdcol paretiia, or other 
cikUMC, fail to F^vncunte the bladder completely, the urine soon bocomnx 
turbid after the iutroduclion of tlie cathelcr. Xliia turbidity is due to the 
presence of Impteria which are introduced with the unclean instninieut 
aud ostnbUsh themselves in the stagnant mine of the bludder- In thi« way 
a pronousty existing rjatitis is aggraviited, or an inflatuniution is induced 
where nono existed prior to the iutrodut^ition of the instrutueut. 

In a few case& Roberts and FUrbrtnger have seen an inexpUcable " boc- 
teruria." The urine contained great numbera of thes^ organisms, whose 
sourt-e coidd not be ascertidiietl ; it emitted an offensive odor, but retmued 
ita acid renctiou an unusually long time. The complaint, often accom- 
panied with temporary irritability of the bladder, lasted iotenuittently for 
yeiura. 

Bacillus of l^iberculosis. — This organism haa been repeatedly found in 
the sediment from caneit of tubiTculous disease of the kidney iui<l pelvin. 
If present the buciUi are found in the pun derived from these tuberculous 
leaiout) ; a drop of the setUment is prepared upou cover-glflSBeti in the same 
mnnoer as iiputuni.' 

The unanimous experience of oil investigators, clinical aad pathological, 
has shown that these bacilli are never found in Usiona other than tuber- 
culous ; hence th« presence of these organisms in the urine may b« re- 
garded an absolute proof of tuberculous disease in the urinary or genital 
trftct. The exact location of the lesion must, of coiuse, be determined by 
the other charaotera of the uriue nswell as by the symptoms of the patient. 

^\Tiite the presence of tlie bacilli proves tuberculosiB, it is not true 
that their absence excludes tuberculosis. It has been ah'eady diMcovcrcd 
that in nirtuy mihary tubercles no bacilli can be detected : indeed, caaea 
of tubercuiosia ore on record in which competent obeei-vers haT(^ failed to 
find the bociUi anywhere in the tiasuea. Hence it may be inferred that 
tuberculosis of the genito-urinary tract nxg^ exist without the occurrence 



CKUTABT BEDIHENTS. 



187 



ti bacflli. at least in rliecoverable mimbere, in the urin«. My own experi- 
flOC* suiipoiia tUis infei-^ncc : for in tno cades jii whicli the tiyniptomfi nnd 
the urine indiciit^id tul>erculoaia ol the blad(l<?rneck, I was unable to de- 
tect tbe orgauiHiuH in tiio tu3<)imi3iit, lUlhougli 1 liiul cuusiJerable experienoB 
in the requisite niiiiupulalioD, and hod oftcii dxHcovered Uieiii in sputum, 
tissues, and pua from other Bources. 

Lpptathrix. o. fungus which seems to belong to the family of baptfria, 
boe beeu in tvro wisea fouiid in fre«lily voidi-d urine. In one iii»tnnco, ob- 
aerT(>(] by Kussner, the jiutient naa n diabetic whose uriae coutaiiied 
brownixh maaaea compoaed of leplothm threads encloBtng epithelial wlU 
Irom the bladder. This pliciioiueiKin penristo<I tiome weeks, until death ; 
the tiectaou showed a normal bladder oontaiuiog similar masses of lepto- 
thrix thrviulK. No information aa to their mode of iii^'rexs wiut uhtntn«d. 
Id tbe aeoond case the funt^s van dorirod from the piiEputiol aac, where 
a mass of the threads was ilisoovorcd. 

Accidental ingrr.dif.nts of variouH kiudfi are oft«n observed in tbe urine.- 
Bomt* of these are intentionally intmduoed by liyHtencal patients; indeed. 
Nuoh individuals sometimes deoeire tbe physician by introdueiiig Uood M 
well as forei;i;n bixKes ink) tiia iinii«. In cxamininc the nrtne from a 
female the puHxibility should alwnvH l)e borne in mind uutt blood, pus. and 
opitholiiiin o1)>u:i-v<.'<l way Im derived from the vagtun. 

Abnormal communication between the uriuoiy tract and vm-ious orornns 
sometimes permits tbu eutruaeo of foreign bodiea into the urine. Gall- 
Hton€>s liitvQ bvoii found in tbe bladder and voided with IJio urine, hn\-ing 
entered the urinary tract through a fistnla from tbe intestine or from the 
biliary duet Gaterback recently performed lithotripsy and found that 
the nuclei of the stonos w<'ro biliary cnlculi. 

Hain hare bet^u occasionally voided with the urine. Theiie are derived 
from rnrioua sourcee, being sometiiueH inti^ntioually iiitj-oduCed into the 
bladder (by women) ; in other cases the hail's have been derived from 
dermoid or ovju-iiui cysts which bad opened into the bladder ; in these in- 
ntancoH oliirr uiiiiiiiil tiKsuea, such ns t«eth mid bouw, have also beea evao 
ualed with the urine. Uarliiii recently obftened a newborn child with 
atresia of the urethra and anua ; the posterior wall of tlie blfulder pre- 
Kentvd tile structuru of normal sldn and was provided with fine hairs ; 
Miutiui rejicsrded the case ta one of eu|ierfu*tatiou. There w as yet no 
ooae recorded in which on otherwise uoruml bkdder produced haim. 



SANpn,' 



CHAPTER XT3I. 



CUyiCAL, EXAMINATION OF THE UEINE. 



An nrdinnrili,' praotiited, cvea in thp Gxnmination of appiiciuitti for Viiv 
insiirnnce, the llmu^'ftis o! the urine includes htile moi'e tlinn t]ie tlet^riuuia' 
tiun cf reaction, KpccilicfpiLvity. and ilio prcaeQCOurnbeeuceuf lUbunitiiaiid 
sugnr SupIi iil oxtiminntion is nlwava ircoraplflto and often iuiel^»ditig ; 
for it fiequonUy (iul« to reveal abnormality of tlie kidiieva or other orjtnuH 
vbich are actually present, and. on the obbur hand, often leads to a diag- 
nosifl of )r«nal disease or din>>ct(>H nrhffro none actually exista 

\o\v A tliorouf^li fixaminntioit of the urine, quandtAtive as well as quail- 
lative, is, of coui-se, too comphcated and dulirnte a process for ordiDiuy 
oliuioal use ; yet by a judiciaus use of a few ordinary reagents o far more 
BOCurat« and ictiiuatu knowledge of a paticutH condition cau bo d«riTed 
from the ui'iu« thtm i« \isiially obtained. Kven without tli* inici'oseopo 
nUUT patbologii^nl couditioua, both of the Icidncya and of other orgonii, 
can be reco^iir^d or nt least strongly Huanect^d. 

The foUovraiff method of examinntioQ is used by the writer in ordinary 
clinicM] work. Whilu it mokes no pretentious to malhuniatical nnntriioy nor 
toquAutitativecouipIeteueRS, it nevertheleas fumishea all the infornintion r»- 
<^uir»d for iliagiioatic and prognostic purposes, and can at the same time be 
flxecuted HO easily aud speedily that it is perfectly practicable for chnical use. 

■When posBiblc. tht? (ipociinvii for cxatiiinntion should bo mixed urine — 
ihatid, slioiild be taken from tlie entire quantity jiaMfid during twenty-four 
hours. Since thia is oft^eii impracticable, at least two Kpecimens Bhoidd be 
obtained on each day, one jjaaaed \ipon rising in the morning and the 
other TOided during digestion ut noon or uighl Tlie latter s]i«-c-iinpii, ib 
diould be remembered, may contain ulbumeii. though none is fonml in the 
lu'ine at other tiiuea. The urine seert-teil during digefitiou uhouM l>e neutral 
or ulkftline ; decided acidity of such urine indicates an abnormally acid excre- 
tion- Bi'fore coueluBiouB are drawn, how&vtT, tbo phy^ueiau should aiuiiu'e 
himtiolf Dint th(^ bladder has been eui|)tiud ahortly before digestion begaii. 
He should also innuire whetber the pntJent is taking medicine or drinkiug 
mineral watera which may materially influence the character of the urine. 

In many cases it is desirable to have the urine passed ut one urination 
Into two diSereut veaaeU ; an ounce or two. first posited, should be rec*iwd 
into one vessel while the remainder in voideil into a kt^cOikL In tliis way 
we arc often enabled to locate on existuig suppuration, hemorrhage, or 
catarrh in the urethra or at the nei-k of the bladder. It it be desiretl to 
obtain the urine uuuiiscd with tlie secretions of tbv bladder and urethra, 
B Koft catheter may be inti'oduced and the hiatlder thorough]}' nud re- 
ppCtfitedly uu&bed out, after which the urine tliat escapes tlitough the 
leatlieter is crouiparatively free from the undcNircil admixture. 

If the urine be turbid, the turbidity should be removed (fift«r its cauao 



t 

^ 



M 



CLINICAL £XAM1NATI0N OF TH£ URUfE. 



159 



It iiwrtflmetl) before appWinp rheinic«l tests. A tui'bitUt v due to uriuaiy 
nlte, pus, iiml eiiitlielititii fiiii he rt-movwl Ijy simple fillintion. A rloudj- 
neas <lue to bacteria wluch cauDot be leiaoYed in tlua way cao ofttu 1k) 
cleared U]i by alioking the urine with mftpnosia ""'a. ••' ^tU u solution of 
lead acetate — one part to eight of wal«r — and mierin^ or pomiitting tlie 
prBcipitiit« to Ml. Tbc Icud also procipilutea the sodium cliloridc und 
«nuspa tlid tmn« to eimulnto tho sagtar ronction with caustic potA«li (H«U«r'a 
test). 

For mirroRfopit! eiaminntion th« urine Bhoiild be permitted to Btnnd 
twelve to twenty-four houi-a in an ordinary bottle ; the conical claaaes Bo 
much employoti are undtrsimble, Hinca much of the ncdiment oaherca to 
thn sloping ades. If iiiiinodint« <>.\]iminati'iii he necessary, tlje sedinirat 
may b« «ollecrt«i1 by filteduf^ (hrcmgli fitm papt-r. 

The esnmination of the urine iiirUidei* : 

A. The detenninalion. of the ■juaulili/ ercreled m Iteenttt-four tioun. 
TliiH atiKiiint shoidd bo iu»ccrtaiiiecl not for ono day only but for ctuii o( 
several days lit iiitcrmls. 

B. The ri^icli/ni and nhr. 

C The (Muae oflhe turbidity, if any exist, 

D. The upeeifio 'jmiyity. THs hau often "bvi littj* nltW VBlflW On 
quautity of uriiiu uxcrtitcd in tn'Oiity-foiir Iiniira in known. 

E. '£\if! aiTfiomauxt produced hyciwltui. of nitric acvi. This acid i-e- 
Tcok ; 1, ftlbumen ; 2, escese of urates ; 3, excese of uroa ; 4. «xce6« oj 
Indican ; 6, biliary pigment ; 6, blood-pigmont ; 7, vegetable coloring mat- 
ters ; 8, iodine ; 9, (ixc««8 of carbomttiis ; 10, propeptoDfl. 

F. Electa of heal. This alone reveals : 1, alDumui ; 2, eartliy plios- 
pbatcfl. 

O. EfKdn of catalic potsufi and htal. Tliia combiiiaticni reveals: 1, 
KQgar; 2, biUan>- pigiueiit; S, blood-pigment; 4, vegetable coloring mat- 
tors ; 5, uroert'tlu-ine. 

By the»e ximple nipaiia — litmua paper, a uriuoinotor, nitric Mid, henti 
and r-niixtic potanh — we ejiii K|K:irililv rttid coiivt-uteutly detect any ab- 
nonaality of tlie urine of clinical iniporlancr', 80 far as this can be done 
witliout the mici-oseope. It is of course ueceoeary. in c*ae oertAin abnormal 
features are digcoTcred— oacli im tho prwenco of mu|:^ or blood — to eiu|>loy 
coafirmatory t«»ts. 

A {»-uper iril<-rprotation of ihe reHuIfn obtaiued by the reageuts above 
mentioned depends upon the following foctfl : 

A. The fpi'inlHy of uria» oicreted iu twenty-fout- hours tnkon in oon- 
ni^nfion tvitfa ihiB mviftc 'jnivitij fitruishun ndiinblo iiiformAtion. Polyuria, 
nilh a low speciflc gravity (1010, for examiile), tuny rcsott from transient 
csnaes such aa the iu;::eMion of lai't^e quAntities of water ; it ia also ob- 
•or^'ed in case« of hysloria, of diabetee insipidus, of pyelitis and cirrhotic 
kiduoy. F«r«iiil«ut polyuria with Li^li specilic pravity ia rari'ly found ex- 
cept in tlialMttcti. Oli^iria with hj^h epecilic grarity iu the ntltt in febrile 
COiulitioiia in caMo of dianiuxaor profuse pcntpiratioo. Oli^ninn vrith low- 
specific gravity ia ufiunlly, wbm persistent, indii^fttiTo of chronic nepliritia 

By nitiaus of the specific gravity and the quantity of urine we can esti- 
mnte with cou«id«nible accuracy flie total solida and the urea excreted. 
The last twf> figure« of tho Bpwilic gravity are multiplied by two (if below 
1.018) ; if 1.018 or above, by 2^. The product ri-proHenta the total soljda 
ill (Tramniea contained in l.OOO ae. (82 oimct-s) of lurine. 

ThuD if n patient paMS -10 oiuicfH (l.*2flO c.c. ) of urine in a day, specifio 
gnvity 1,020, tbe estluiatioii of the 8olid« is made as follows ; 20 x 2^ — 4T 



160 



ZnSEASES OF TH£ UBIKABY 0BGAN8. 



tlie number of gmmines iu 1,000 cc of urine; in Uie total (jtiaDtitr, 
1.200 c,c, there are of couiw containetl % of 47. or 56 grammeH. 

Since tlie urea usually coastitutea by weifilit about one-balf of the 
tntirv eoliiLa ot thu uritK.-, tkis colculatiou furuialiea on approximate e»- 
lunnto of tLo amoiml of urea i>xcr6tci3, whidi would be iu tlie above case 
2^ gram III I'M. 

II Tlie color and reiKtion of the nriue are noteil together, suice tbe 
aiguiiiciLDce of the color is often explained by the reaetion. 

I'cUc, almost coforleM uriuo of neutral reaetion is often excreted duhiig 
TariouM ueuroses. eapeciAlly L^-ateria. 

IMii: yilo^o Of reihiUh-yclluio urine, of acid lOftctioii, is unuilljr ob- 
serred dwisg febrile coadiUons. 

Vark brown or Tetltiish^rown urine, of acid reaction and tramfparenl, 
contnica hictnoglobiii ; if of 7>eulraJ or altalitie reactioti tuid lurbidy it oon- 
\ taina blood or biliarjr pigmeut. A siuiikr appeartuiL-e may be caused by 
tbe excretion of earbolic acid by tlie kidneys. 

Briyht red urine of ali^aline reaction usually contains not blood but 
*etjetal)le coloring matter, especially L-brjHopbanic acid derived from 
rliul>ai'b or senua ; the adibtion of tin acid changca the color to yellow -, an 
excess of au aUuili ree<torL-a tiie rti<l color. A similar reaction itt producid 
by santonin, gamboge, madiler, nn<l Ingwood. 

A dark brovn or aimost black color is aometinies observed in cases of 
melanotic canoer, 

ifvrty ffrwrn urine is excreted during jaimdioe from obstruction ; tJio 
reaction varies. 

Dirty bhte urine, of acid reaction, iwually contains an excess of indican. 

Many urines, especially those of ehUdMn, exhibit a gmdual dnrkcning 
in color upon standing for a few hours ; the cause ot this pheuomeuon is 
unknown. 

C. TvrhuHty of the urine is caused by urates, phosphatoB, Wood, put^ 
mucus, or bacteria. 

Heat dissolves the umtca. 

Tho nddition of n few drops of acetic acid ditwolvea iliS pliORpbates. 

Turbidity caused by Mood or pua is luiebauged or inotMaed (through 
coapiilation of albumen) by heat or an acid. 

A cloudiness due to bacteria is pei'sisteut. 

E. The ai»pHcation of nitric acid is a most important item iu the ex- 
amination, ami no less imporl^utt is tbe uiBnuer iu which the acid is intro- 
duced. A test-tube containing uriue to the depth of t^vo inches is held 
obliquely, and pure nib-ic acid is permitted to Bow down the side until it 
forms a layer half an inch in deptli at tba bottom of tbo tubo. Tbe zone 
ofcoufacl of uriue and acid presenta different appeonmcws occonliug to the 
compotiition of the urine : 

A tight bjvwn color is seen m nomial urine. 

A inure inCenK broicn color in obsefved iu concentrated and iu febrile 



unno. 



P 



A irhiic cloud indicates either albumen, propeptone, lu-atoa iu excess or 
resiiifi (copaiba, etc.). The diatiiictiau betw<*en the«o is simple ; the cloud 
of nlbumeu apjwurH juh*. at tlic line "f contact bctwetu acid and urino, mid 
is of uniform depth thi'oughout. The doud of urates is formttl a little 
above the aui-fnce of the acid ; it appears only after the lapse of some 
Bcconds, and fomm not n ring of uniform thicliucss but a cloud whick 
curls upward at the centre soinenbat like ascending smoke ; it diiuipppirs 
upon warming. The i-eaina disappear at ouce upou the addition of a littl« 




RLINIOAL KXAMINATIOS OP THE DttlNB. 



161 



nloohol. Propoptonn forms a cloud resembling nlhumaD, which (liHripposr^ 
npon lieatiD); to 170^ F,, with the prodtiction of an inUnw yellow color; 
I upon cooliug tiie predpitaU; reappeara It is diaaolved in ah cxceaa of 
laaA. 

' A. reddiah'broBm ring st the line of contact indicates blood-coloring' 
matter ; in nioHt cimes albuinfo ix uf courw iiIhu praieut, so tiinl there is 
formed a, I'eildiHli-bi'owu cIduiI. 

A hri'jlit gif<:n ria^ is produced by blliaij pigniciit beforo it becomes 
ovidixpr). 

A hnlliant hln^ or violet reBults fi-om an exceM of indican. 

A brown ioae. la prodiic«d if the urine contiiin iodine, 

An «TJ-/'.'j<n */ ui%« {(cHir or livt* prr eouL or man) i» indiojito'l by th« 
gmiUuil foiiimlion, in the oouraa of tliree to live niiiititea, of orvslals wbicb 
projeot into the layer of add, und are tlnw distiORUislied from the cloud of 
ur&tea, formed under similiir circumstances, which lire viHible nbovo Iho 
■citL 

An ejiccM of rnrbonntes, Rich nt< mnyocour fmin tfaa uiw of mineral 
watera, is indicated by aparklius; or even efferveBcence, 

If ujmn the nddilion of tbo ucid a bright-red alkaUoe urino bDcomoi 
eolorltes or yoUow, the presenile of i-e/jrlnhle colorinrj matter* i» itidicat«d. 
Aft«r iifutnUizing wilb uii ulkuli tbc red color n^tuniii. 

IJy tiieaUH of nitri<; acid we can not only detect the presence of al- 
bumen, but also (istinint^ witli coiisidorable nccnrncy ilie (jnitnliiy present. 
This cioantitutivc cKtimation is buifcd upon tbo appciu'aiic« of Uie cloud At 
till) line of ftontAct : ' 

A f'liul whilf ring, diBtinclly viailile only opfiinat a blnck bticlkground 
(such i\& tbo coat-sleove), iodicates from ono-tcutb tu onc-fuiirlh per vent. 
of albiimon. 

A iliMiwt whilst rlny, easily seen without a bWlt liockgrotiiul, exbibil- 
injt numerouH grenulea nod amiiU liunpH, indicateH from one-fotirtli to one- 
half per cent, of albumen. 

Thu pri'Mcucc of tariji lumps and^^tkrt, some of vrliich foil to the button 
of the tube tlirotiRh the ncid, indicates from onf^half to t«o per cent of 
ftlbumeu. Tbo quantity raraly cxceeda two per coot, except in esses of 
iinyloifl kidney or acute oephrititi. 

Thii) mnthod of Ofitimnting the quantity nf albnmnn prewnt in tho 
urine ia extremely simple and oonreuient tor clinical purposes, and fairly 
accunitc. 

I'\ Efr<'l* of hetd. Crino in jwurod into a tcst-tuho tn thft dr^ptb of two 
in(ihe.i 1 if iieutrul or alkaline, tno or throe drops of acetic aeid mo added. 
r7he renctioii ahould be /uinJ/i/ acid. 

* A wlitVe dinni obBeiTed upon boiling mny be albumen or earthy phoo- 
pbotw anil carbonntcs ; tho latter ure redii»H>Ivcd upon th« addition of a 
fa«r dropfi of acetic acid. 

A pTKvioMB furhidili/ may diaappear upon warming, in which case it waa 
due to tho iinitcif ; if it increase it is due to Ihe phosphates or to blood. 
puB, or tnncux ; if it rcinnin unchanged it is due probably to bactenn. 

G, A i»iUil\'in ••( i-uKjilic ptitoKh (one )>art to three of water) is addeil. In 
qiuintity BiilHcicnt to equal one-half the bulk of the urine in the teal-tube. 
Upon t>oiIing. a heavy sediment falls, oonnstiii^ of the enrthy pboAphatee : 
In Donanl urine this twdimont in about one ccnUuiutre thick, if tho uiiiu 
have been pourorl in to Uw dsuth of two iuches. 

A while af>f>eantne0 of the phoflphatea occurs tu normal urine. 

A nx^ or violet color of tbo Beduneut iudkates vegetable coloring mat- 



162 



DMKAHES or THE UIUNAIIY OKUANS. 



ten, iiimallv rhryanphuiio acid. If hrotiti, tlie tuiae ma; cnatnin bile-pig- 
tneoL A ffra>i color iixlicntos uroM7tUj"ine, 

A rtut fn\or !« prodin-^d by bliiod. 

Til" rolor of llie fliipernatJiiiL urine afU-r foiling with llio CAUittic pol- 
nah Hulutioii nia/ he nx fii^lflnaui aa the color of the a«i:lii]it'nt A yallouK 
j/eUowiMh-bruum, or liiavii;fJt-liroKn bIiucIc indicates »U|;ur. IL is fouud thnl 
mgur t<> tli» iinioiint of oiio [ht (.'eiit. cnuuea thu uriuo tu aiwaiDc- uii<lf?r 
tliese cintii til titan ecu u cininrj' color ; itvo per (wiit., it dork nmber rnlor ; 
flv« por cdiil., n Jtiiutucn-rutii idlur ; ami fire to ten per cent,, adfu-k.nlmoiit 
blnrk rotor, ho iutwiiM' Hint t)i<i urinn nu Ioit|:fpr nppcnrs trnnttpnrout. 'Dio 
nJtliUon of n few dn^ps of nitric Kciil blenches tliin dnrk urine nod cauftcs 
it to Miiil iiu udur of luuUuuiua. Tliin culur-tvsl for tljv prt^teuce uf sitKsr 
ja HBiinUy i^}pliuil>lo, unn tiiv original ix>lor uf tlie freitti urine in ctutat <il 
Uial)(rt4H b fttoerally veiy liRht. 

lly uiMUiH <)f hoiiL, nitric iu.n<l. and ("aualic ])otiisli. tlioreforo. any ordinorr 
ubnoniiiil iii);i'<'di<iiit diiuH>lvi'd in tin- urine mid pomK-wiinK olinicnl si^ili- 
itanoD mn Imi dr<t4K*tiid. ' A ]K>tuliv[' n-m\l by t-hen reageiittt Hliould be 
i'oiil\ri]ir-<l by Hjict'iid (cmIh : if no indication of aboonnHJity is furnished, 
tliD phyniciiui niuy coiilldi'iitty <U«i)oiino wiUi further leata nud pae» on to 
LliA niimMi'opiiml iuvc>HliKi>li()ii of the s^diuent. 

'Vtmm run Hrcuit. — Tlw onliuary testa for 8u;;ar ni-« w ciiinluirKoiiio 
illAt illpy tunt nuruly employed in pmoticc unless n EU&picion of dinbetCB is 
MtlirtiUlMd I vid Utny are so linblfl to ii))jd<fti(l. in t>oiieequeni^e nf the diH- 
ttirltliiK bifliiouco of niriouH uriiiiiry constitu^nUi nod Ot« iiiKtubility of tlie 
ti'ulH, iliiit (lin roitiilta nlitjuiiind nr€ often incorrcrt. Tli« pnpnltir ro]>|)(^ 
lt'*l in niiioiii,' tho lenst ri'Unblp, Hiii<-o II10 solution d^conipotws and cives 
II ivni'tioTi nitli Hn vx<;«^!ui of uric ncid : iiiiin»>vi>r. it fiiilH tu dcl^'ct p;lncoHo 
^vlicii till' iiiuuunt is lens limn njio ^'mi!i to IJic ounce. Tliert) i* tliereforu 
H Im-yi' Ill-Ill lor a flupar teet wliich is nt once delicate, reliable, aiwl Btublo. 
Nucli n reagent eeciux from picMcnt inilicitioiiK to bikvc been found in the 

/ViTit' Acid Test. — "When picric iicid i« bt-ntcd tn «ii alkalino solution of 
l<lu4-rHM\ piicraniic ncid ia fomietl. pviiig Lo Die liijuid a dei-p reddiHli-bmam 
or flvrnct color. I'liis rcttK<^nt pQescseeci the great adTBUta)re that it. ift a 
titiit for albumen as well as sii}^- ; beiiee both of thcise Kubetances can bn 
<lul«ct4id •ttniiiltun<^>uHly by n niu^dn miuiipuluiioD. Now gliicowii i« fiv- 
qiiently found, not only in mines of high spedlic graTJty (with which we 
nfft ftccuatomed to aaaociate it in onr minds), but also in comparatively 
li;{ht nnd i.ivv.n vi^rv dilnln iirini'it; (tK-c-ohuHii i* imWd bv no niciinf rare. 
Henoe it i8 rfieoniniended tliiit tin- picric m-iiJ test be employed in examin- 
ing er^rj' urine aa a test for butii nu);ur and albumen. 

Tins double tost ia madn ns follows : to ubnnt two inches of urine in n 
teet-tiibo Iberc in added an e(|iiiil volume uf n Haturateil solitlion uf pitrric 
uciil. If si'itiin iilbuiiK^n tin prcBeiit a tiirl>itiity iippcum wliicli ik incrciiwc^d 
by boiling. About one inch of Jiipior jwIasNi- in then added to Ihe boilioi: 
tnixtore. whereby the albutnen if present in redieHolved. The boilioff is 
contunied for a niinuU- ; a prono<ini?ed dark-red tir bi-ciwn color iudiuite* 
the prenoiice uf tm^r. If tlie urine contain two gnuiw or more to the 
oaaoo, tli« miitiiro bt'c^miex quite black (.lolintmn ). 

It is to be noted tJiat u alif;ht darkening o( color is produced during 
this test in perfectly uomuU lu-ine, but the preBence of Uid minut«8t twee 
oCn)gnr(iiH ro^-cnlnd by oilier rcnfront*!) pividucomidocided rbniipe of color 
mich as if* never observed with uonnal urine. The idiysician hhooUl there- 
fore taniiliariite Uiniaelf nitb tlie effect of this test upon noi-uial iiriDC* be- 
fore employing it for tbv detection of sugar. 



CLINICAL BXAMIKATIOK OF THB UBINK. 



163 



A deepening of color, simulating tbe Bitgor rMcHon, ts produced by 
tannin, /errouB salts, and ureiitiiiiae in oxce-iit. U^uce it is desirable to 
contiiin th« remilt by tlio uott of a neconcl reagent 

FfJth'i(j» tea. tufydified by I^rot'eanor W. S. /Jaines. oi RuBh Medifio] 
Collcgo, Ctiica^, is the bvst vf fill tbc copper tests for HUf;^, tuiviug tbc 
UDiiMiml (ulviuitngn of Rl.tbilily. The follotving furuiula and liirnetions for 
use arc kiadl;^ fumUhed l>^- frofesaor Uuiucs: 

Puresulphat* of copper 90cniiiu. 

Pure gl}'c«ririe 3 aracbms. 

Pure caustic potiwh — in stidis 1} " 

Pure water C ouneea 

Dissolve tho siilphnto of ropper and glyoerino in n pnrtion of tho wntor. 
and tliu caiiMtii; potash in the remaiuder ; mix the two solutions, wheu a 
perriM^tlj clear, transiiarsnt, dark-bluv liquid Mhould rcnult, whicfi mav be 
bottU-d itnd Hot auido for tue. An usiinlly nuulo it Kraernlly tbrona down 
a dligbt rodiliHh d»[iO)iit U]h>u Ktiindiiig a week or two. Tliis, however, 
dOM not alfec't Jti) vuhip aa it Uial ; in iitdug, aimply decant tliu dear liquid 
from the aediment 

IHTWtwns for Use. — ^Toke a drachm or two of tbo lent «ulutioii and 
ffently boil it, wbeu no chntige slioiild take place ; now add ftix oi* eight 
arapA of tlie miHjxietftd urine and again boil. If sugar liu ]>reiif)it an abun- 
dant yellow or yellowiflh-red precipitate is thrown down ; if eiignr i« not 
preeent, uo tsudi preoipitAte appears, but tbci color of tbd teBl uolution will 
DA rcadi'n'il Koiurwlmt H^ht^^r nnd Dflnn <if ii (^rM-nixli or even of a gn.'«iiiah- 
yelbiw shaile, by the dilution of the blue test-liriuid with tlie y^ow urine. 
A white Hocculi^Qt depoatof phoapbatea, comint* from tlie urine employed, 
in often sovn llontiug alxjtit ia thu fluid, ftod itliouUl uot be taiulakuu ok a 
reaetion for ^agiir. 

Care ahould Im> taken not to uae more than nix or eight droue of the 
suapeeted uriue ; this quantity will be amply sufficient to show the pres- 
Miee of 8u<pir, if it exist in Buoh an amount as to be of any ulinicnl HJgnili- 
'^eaiwe ; while the iiddittoii of a larger qunntity of urine, wl»olli<-r it bit nor- 
mal or aaccharine, will amif^tiiueii lead to reitults extrctnely perplexing to 
UiOHe inexperienoed in the nm of the tesL 

A few dropM of boney, disBolvod in an oiiuce of urine, pn>diifH-» an nr- 
Ijfirially »u!charine urins, which may advaiila^eouHly be employed by Uie 
beginner to Wm Llie exact reaotion produeod by diabetic urine in the 
abov« tc«t. 

Trsts for Pkpio.s-b — ^The moHt aatiafsotoiy methad for the eliuical de- 
tection of pcjitone in tbo iirinp ih innjlv with Pcbliiig** nubitioii or Hniuea' 
modification. Thix is poured into a teftt-tutie to the depth of an inefa, and 
ao »quaJ bulk of urine is Boat4>d upon the top. In normal urine a zoo^ of 
p1t<>!tphittr>) 14 fnrmod at tlie jiincliou of the two Ii<iiiid8 ; if p-ptonc bo 
presteat tbia 70nn Rci]uireH a reddish or pink tint. If there be hIso a con- 
siderable t|uantitv of alhunittn in tlio lu'iiie, the nil ncquirex a rioliit hue. 
.\dditioiuil proof of the presence of peptone con be obtained by now drop- 
ping into the liquid a drop or two of concentrated pieno actd snlution ; 
theoriginal rvi tint becomes deeper, then reddiah-yellow, and finally yellow. 

TcHTs rou IliuuiY PioHBrT. — So Itmg as the biliary coloring matter iu 
thn urine ntmainii unoxidixed. it onn bn detectpd with gitot certainty ; 
after oxidntion, howeTer, its detection is less positive. 

(7niicfiji'« Tetl. — Strong nitric ucid, which should contain abo aorue 



104 



DISBAHKS OP TUB TRINARY OROANS. 



nitru'jH arid (indicated bj red fii iuca) id pniirod ilnwn tito mdc of an indiDed 
fcKt-ttitio oontaining thu suspected urine. At tho leoue of contact Lliem 
oocuTB from below upward u Berica of eolorw — grcon. blue, violet, red, and 
LjwUow — >r bilirubin in praiivnt. In many coses the blue and \-iok<t are not 
robmrveiS; in fact, tbe green in tli« moMt jiromineut and iDdiiipciiwiblo in 
tliB r«DO|;:niUou of biUiin' pi^ciit 

Nitric iioid witlioiit tlio Admixture of nitroaa acid sotnetimes fails to 
Irevc&l btiiur^- pi^niont ; if |iiir(' nitric ncid bo pcniiitt«d to istand in tbe 
I pUDliglil for Momc tinvM, Uio nil color iDdieAtira of nitrous ncid becunies 
f'lppanint in Uio bottJn. 

I/rller'f Tme—Vrntr into a teat-tube nbout> two drncbma of pure hydro- 

<>hl(>rii; arid and ilmti into it j\ihL Dtifticicut iiriiiEi to iiupiirt a diulinct color 

to tbu lund. Aflur Htiiriii^f, tliu initliiriN i.i iinderlitid ivith pun- nitrio nind ; 

■t tiM xont* of rnntjict tliorr nrcui-n n jday of rnlont. If tlie roiiteulH of tliQ 

llMt-tub« bfi now thamagbljr mixed viilh a t^taea rod. the same play of 

rooloTH )K oinwrvod tliroudUout tlw rntire iiiixturo. Tlni! is tbe moat f^n- 

omlly npniicablfl tost for rlinicnl iwc TJi« presence of albumen does not 

, impair tlie ruluo of tlio tonl ; iiidcod, almoat tha ojxly posaibility of n)i»- 

I telto Riiniltii from tliu prcwmco of indican in oxcgbb, wbercby a blue, riolet, 

find rod rolttr may bo prrtdiieifd ; Lbc ;n'0<!)i- liouover, iK lavkirj^r. tbouf^li 

tbo a<ltuistur[i of iIki follow ui-itio witli tb» btu« color of tlie iudicau nirir 

lagR^t n ip-wu tint. 

i'Utmanu't Trtt. — To threo drAcliinH of urine add one dmehm ot pure 
ciuiHlif! iiolniib Koliitioii foiiti jxirt nf potiuib to tbrcT of n*iit<-r) ; kIiuIco ivt^ll, 
nii<l lubl un iDot'oH of niiro b.vdrurbliiric lU'id. Tbe uiixtiire aiwiime&a brill- 
iiitd otiicrftld-trricii I'ldor. 

AftT tlic ilecomponition of tho biliary pipfmont, tbcrc w no cortain 
titninN for itadotouUou. I'robnbly t)ie best nietbod onnsiitlx in tbr nddition 
(ifniia vidmnn of oaiiBtio potaali Holution to two volumes ot urine; a dork 
t'olnr iudiriilen llin prosonpo of biliary coJoring mutter. If upon the addi- 
tion of a fi)w ilrope of Kulplinrie acid thie dark color is much deepened, tbo 
|iniMiiniptiuii ia uti-engtaened. 

Tmrx ?nn Ihdicas. — Tlio Bimplest ia Hellcr'H, which snmvers for most 
fllniflal piirposJM*. A draeliin of pure hydrocliloric arid ia poiired into a 
tcwttitbo, nnd a f«w (five to tweuly) dropn of urine are ftdde<l wiUi conrtaot 
pitirrint,'. In normal urine the mixture aasunitH a yellowish-red color ; if 
nil rxccsM of indican be pi-osent. a blue tiiit becomr« nppnn-nt, iln inteiisi^ 
iiicretiHin^ with tbu quantity of indicuxi. Tbiu tvuetivii sauieliaies reqiiinm 
from livn to liftpcn luiiuitcR. By adding a drop or two of nitric acid, tho 
test is made more delicate. 

The i^rcscnco of albiirncn may mislead. Hinco thin Hiilifilaiire produces 
with liViIriK-bloric acid a fnint-blne color. It is, thirefore. neccK-sarj- to re- 
move albumen by boiling and iilleniig tbo uruie. 

If biliary- coloring matters are present, they should be rcmOTed by 
preoipitMtion with acetnte of lead solution (one part to ten of wiit«r). 

Jall'c'it test, mocMod by SalkowHki, is somewhat more compli<:atcd, but 
lem liidfle to niLitcnd. Etjiinl pnrtit of urine nn<] stmiiiJ: Iiydroeiilorin ncid 
are tborou;5bly mixed in a tcat-tiibe ; a Haturated solution of chloride of 
limo is then added dmp by drop until an intense blue color ifl developed. 
A few drops of eblnrofonn nrc !id<)ed tiTid the teHt-tiibc is Hhakon ; tho bhis 
[lignient |iiidi;:o) is disiwlvrd by tliu cblorofunn, whii^h seitli's to the bot- 
tom, luitving the urine colorless, In perfomiinp this test, albumen should 
b:; tin*t roinoved, and highly colored urine dei-oloi-ized. 

Tbst for CtiLOuuiifs. — It ia sometiraes cliuiiudly impoi'tiuit to kaow 



I 



CLINICAL EXAMINATION OF THE URINE. 



165 



whether or not tlift cliloridcii are eseretad in increased (niniitity ; not that 
Kuch eiceaa has in itaeU esjiecial iliaBnoatio \'alue, but bt-fause surd luiowl- 
edgo CDHbles iib to infer whetL«r or not iinia is pr«aeiit lu normnl nmoimt. 
Fur hiuci> tlio urine is pmetiojilly a solution ot urtia ttnd tJid clilorideH, a 
niinim.1 ([iiiiiility of Ihfl Intter wiUi u low speci&o gravity Ludiout«s a de- 
li cienry of urea, 

Tu two iiK-hes of urine in a t«8t4ube add thi-e(< or four drops of nitric 
ftcid (to jircrpnt pi'vopltutionof tliu ]>liaMjibiit«») luul t}itiii one or two drops 
of a nitrate nf silver aoliition, one part to «igbt of water. Ju normal iidne 
ft wi>it« curdy preoipitatd ia formed and falls readily to the bottom ; if the 
cbloridos are aeeroosed in qutuitity, no curdy masHCH arc produced, but 
only a gpoeriil turbidity. 

Qii*.\TrrATivK Kt'riauTiiiN or Ukka. — A Icn-owtedgo of tlw quiuitity of untn 
excreted in the urine liiks eeldoin any especial ebtiical value. For, ns haa 
been already HtaltMl. the mcrotiou uf ureii is so lai'({Blyde]HfiidGnt upuu the 
qiiiirility nf niU'Of^'onouH food iiii^o.ttml, tliiit tlio umotiut of t)to IntU'r niuxt 
be cftrefiilly ilelennined befure inforennes its to the cslent of tinsiie ineta- 
morphoHis are warranted. It ia uhiefly in ca^ea nf clironif- uephritia ilint 
the clinical Pstimntion of iiroa has dinj^ostic or prognostic valuo ; if tho 
excretion of urea U pon(i8t«iitly much \eff>t than tliv nvi^rac^ amouiit (thirty 
to forty grammes) an impiuriucat of Uio runal activity may be inferred 
with much coutidence. 

The simplest way for ostimftlitii:; the quantity of urea esereted coiisiata 
in MtUmntint^ tliv totjil HolidH in tlio xirinc from tbo upeciRc gmvity, by 
the method nireiidy mentioned, an<l in determlnin}^ tlie ciunntity of clilo- 
■ rides with tiitrate of silver solution. A persistently low escretion of solids 
without ftiiy dnlicicnry io tho cliloridpi* imlicatefi a dimiiiiithpd excretion of 
urea. Ypt tliia i» a decidedly crude au<l unreliable method of arriving at 
the amount of urea ex<'reted, ami u»itil recently tlicre was no aceutal« 
motliod of eufticicnt simplicity for clinical uee. 

In 1877 Dr. Oeorve B. Fowler, of New York, nobraittod a method to 
whieli wait awarded tna prize of tlxi Altiniui .^awocinliuu uf the College of 
Phmoiiuui and Surgcona, New York. This method lins Ireen extenstvely 
tMted oinoe tliat tiini>, and has been found to be accunite and trustworthy. 
Um prooaw ut ImMcd tipon two (ti*:U> : first, tliFtt the dcyKtinposLlion of unia 
ktwers the specific gravity of the urine ; and weond. that tliere is a definite 
relation between the decrease of urea ami (lie decrease in ^ecific f>r«vity. 
It wiw found that a decrease of one degree iu the ^ocdSc jjravity n» indi- 
cated by tbo uriuouietor mm ))rodti(«d by a luwi of 3^ gnini* of urea per 
ounoe^ that m .77 per cent, of tlio iiriuc. Tlio ttietliod, therefoi-e, conaiats 
nmply ttt notiuK the opccilic gravity before and after the addition of aa 
afieut which dti(;umpi]t»>s the urea: the difTureace hetweon tbo two niulti- 
]Mted by 3A f^iviM tin? number of Riaius of urea in t-ach ounce of the urine, 
or mnltiphed by .77 indictilvs the perceutiigo of urea oontained io the 
apMiineu. 

To decomftotie the urea, l>r. Fowler employs eillior I^barraqufl'n (tola- 
tion or SijiiibbM obluriuiLt«d soda : si^ven piiriA of citlier of IheMi liquids ia 
MifEcieut U* (hicoaipuMi tlin urea in ont^ part of urine, unletu» an esoesaive 
qnitntity bo preseut, iu which caae the ui'ine should bo Uilutud with au 
etjual bulk i}f water. 

VrncRXK. — 'LVi ono volume of the urine add seTRn volnmea of LaImiv 
raque's nolutiOD : decoiii position nf tiren lalcea place at nuee, indicated by 
fiffervescenee from the liberation of nitrufiun. The vessel contaiiiinf! tlio 
litUturo ts-ahakon a few timcx at interval^ and allowed to stand for two 



i 



106 



DISIEASSS OF THE tlKINARY OBOAKS. 



hours, at tlie end of which time the decompoiiition of urea is accomptifibed. 
Tbe specific Rmnty of the mixture in now uotej. 

It is (ilso uopeHsary to detormiiio tlio »i»(KaIir! grarit.y of llie uiixtui-e be- 
fore JecoiiipOMitifJii ; this m HCCumplUliod by imilriplving the specific gnx- 
itj of tlie pure Ijukirnuitio's ttolution b/ 7, adding the specific gravity of 
tlie uiiue, snd dividinj; by S. 

Subtract the Kpecific- Rrimty of Uio mixture iittor depompwBition fiom 
that before decomposition ; multiply tlio iliftcronco bjr 3j to liml the num- 
ber of (ptiins of urea per ouuce of urine, or b; .77 to* find the pert^entoge 
of ure.1. 

Itluntralion. — If the spetdfie gmnhf of the urine is 1015 for example, 
and tiiat of the Liibarrutiuu' Bolutiou 1040. that of the mixed fluid before 
decompoiiiliou will be 

1 » * a. T - m 1 a _ 1037 

If tlie Hpccific gravity of tlio misturo oftttr detronipontioii w fount! to be 
1034, then thedifferenre, 3, inultinlie<l by .77, or !i.21, shows llie pcrt-ent- 
age of urea. Or we may multiply 3 by 3^, mniiiiiK lUJ. tlio uuiubnr of 
gnitiE of urea in cucb ouiic« of ucino ; tluii multiplied by the number of 
ounc&a excret«il iu twenty-four hours allows the total escretiou of urea fur 
tbe dny. 

In perfonainfr thiH tcat^ only two precautions need be taken : firat, the 
specitio rrraWliea of tlio different licpiids should be talcen at the aanie t«iii- 
pnriituni nticl ut the HiiiiLS tiunu ; beui^e it is lulvinidilc to set nsidt! 11 bottle 
of the Ijaharrai.|iie «nlntion and of the urine in the same plica an llie mix- 
ture, and to make the Bpeeilic pavity of enob afler decouiiwBiiiou hits 
taken place ia tbe mixture. Second, if tlio epocilic gravity of llie uriue bo 
very bif-b. ehowiuy lui iinii»iiHl uinutmt of urvn, it la adviaible to dilute tlio 
urine with it« own bulk of wider befi>rG adiHuj* the l.abiuTmjue aolution ; 
for otherwise some of the urea may escape tlccom position from lack of 
the reagent. In case the urine biu) beeu diluted in this wuy, it ifi of court^e 
noceKMiry to iiailtlply tlio result Iudi(-utiii(^ Uie peruentage by 2. 

'riiis test in not iiiipnired by the proaence of albumen or tmgar. 



UEDfODB Tmre roa CaraR. 

Thirintr Iho Inst few years certain rea{;enta which had been employed 
almost excluaivoly by cbemista have been pxtensivply iiwed as clinical testa ; 
and through llio hiippy doiico of Dr. Oliver, of IIuiTowgnte, they have 
been rendered available tn the general practitioner in the form of bibulous 
papers impregnated with tbe varions substances required. ITie reagenla 
thus utdixed arc five : tor drtectinK albumen, picric acid, potasaio-mercurio 
ioilide, sodium t«ng«(nto, potiiiwium fcrrooynnide ; for detecting sugar, 
picric acid and iudigo-ranuine. 

The ailvautjigpa claimed are : (1), greater delicacy, and (5) greater COD- 
vauience (when used aa test-pnpere). That eaveral of these >«ngeuta are 
more delicate than the beat and nitric acid tests, revealing a smaller pcr- 
ventnge of albumen, isi undoubtedly trun ; liut that llitg niirftaswl deticney 
confers* any diagiioslio ltd vantage, is doubifid. For tmceit of albumen in 
the urine, such as can be detected by the potassionicrcuric todiile only, 
have no pathological significance unless accomppnied by other indications 
of n^uiil or gl-n<^rld diMiiKO. Indeed, it is tbe ex|>ei-icn(!e uf those who luire 
rarefiilly employed theae delicate reaftenta, that tmcea nf albimieti are re- 
vealed by them iu most urine* even from apparently healthy pei'sona. Yet 



OLINIOAL ESAUnrATTOH OF TH£ U&IXB. 



167 



tlie increased delicooy of tliese tests will dotil)tl6M confer ono clinical nd- 
vanta^ ; the more frequeiii detectioD of traoei of albumen in the aniM 
nill i>rubiibljr toad to the mure frequent tDicroscopic «xnTu iuatioii of tbio 
sodiiuviiU vribhoufc vrlucli no pouliw diuguutiii of chruuic n-uiil disouoti 
slloiild over lie made. 

Tlie oouvenience of tbeee testa, in that tliey can be apjilte*! iit tbe hnA- 
side, ix also uu iipparcnt rather tiiati a real adnrntoge. For tlio detection 
of albiitninunA nt the licbdiULla him no oUi^r vnlue than oa itii iudicaliou for 
ihe ueov)(ttity of tlioi-ough exiuuiuatioii of the apediacu at tUc 'office ; luid 
thin nJiouhl 1h^ made in every case, whether albumen be deteutcit or not ; 
for a negative result nitb these test-jinpt^ra at the bedside does oot insure 
tlib integrity of the kidnc^vs, nor ruUcro tho pli^'aiciau from tJia obli^tioo 
to mako a (iirUior iMitminalion of Iho uiiiie. 

The a<Ulitlotial deUcacy of these teala confers a value, thei-efore, iu 
}>hj8iolojricnl nithcr than in clinical npp)iciition!i. Yot tho vse of these 
tent-papei-s cannot bA too «inphati«iJt^' iirffTid upon nil plirsiciana vha, 
from laelc of limo or other onuHe, ai-e in the habit of iie^let-tin^ tli^ (■xam- 
ination of the urine except in in^nounced caseiiof renal diRease or tlinbeten. 
As already stated, such examination should )>e just as essential iu evei^' 
ciuH) of diHciuio us tlio iuspcctiun of Iho loti;^iic or fcoliiit^ of tUc pulw ; tad 
the general ubh of theae convoniont lc8t-i«ipor8 will neHninly further diag- 
nosis ami treatment without conauiuing much time. 

All of those rtn;;entH used in testing for albumen precipitate alito other 
itnbstiinces occnsionjilly present in tho \trino — prtptoiien, unten, toucus, al- 
k^ida, and oleoreKJus ; these are, however, readily distinguished from al* 
bnmen liy the employment of heat, icAieh cleant up aJt prcdyHales other Hum 
94rum otbiiinfu,' 

The ranuita reaj^ntH exhibit lUfTereat relations toward Yarious sub- 
Htances Qihc.r thi>n nlbnmen which may be found in the urine. Thm tlie 
picric and polassio-iuercuric solMtious precipitMto alitilfiui'. whiio the tuc(^- 
Htuto and ferrocyanic tests do not. Tliono U»l» may, perliupit, eiilarga Uio 
field of olinit'dl iirin.'ilytin by their power of pvopipilaliiiR jirfipeptanff, 
whiuli forms a cloud resemblini' seriiiii nlbumeu, utit luiliko tho latter huIv 
litanoc Rindually dissolves aa tho liipiid is wariuwl. and linuUy dianppejirs 
at a tompor.ituro of about 70° C. Siiico propeptoD« is not coagulated by 
hcnl, n i-oinpnritton of tests may eHtabli^h its preeeoee. Vtt t^ oliuical 
Ki^niificnncR of tliin Kiibstnni-e in the urine remains to be determined. 

Picric acid isi, for certain reasons, an especially valuable test; it pre- 
cipitates albumen in nctd and lUkulino as well au in neutral urine. In uian;; 
the b<mt tent, on the oUier Imnd, eore nuiet bo tnlK<n to soearo a faintJy aetd 
reacUoa of tlie urine, since an exot-fs of and or filkiili ko tnuisfunua serum 
albumen that it is not (-onK^Utcd by hnnt and is doubtless sometimes over- 
looked. Picrid ftcid can, moreover, be Ufled as a te^t for sugar ; for thin 
purpose it is most couvenicat nnd ilelicat* ; both album'^n and Kuprir can 
ba tauH detected by a «irit(Ie mjiiiipdlatiou, pit-viouvly dcsi-rilwd (p. lUti). 

A aouparinon of them i-nnnuH* U'mI» ban pvi'n in i1iftt:reiit hands van** 
itig cle^trecii of delicacy. Dr. Oliver reitorts as the result of his own ob- 
servntinnn that thcHO different reatrenta detoet albumen as foUoira : Heat 
and nitric acid — one pari in C.tlOO or 7,000 (.02 per ncni.) ; potaasium 

'Such l*tliuiirDi'rrtlH>)lof and tvuliinff; yet Dr. Roluirt Kirit tiate» ihalapradpl- 
tato of Mrvi-liiiinn )i,v Die i>ottMio-Di«rrnri« lo^tilo Ti^niilivl in iijiita of hva( (r.«ne«4, 
Kovvulwr 17, ItiKI). At muj rat*. <«ultaa uid cotifirpialucy t<nU vliotild bv enp)o*«tl 
iM^oni drawlDK final eonvluiioiu uatU all p««ullariUu» ui Uimm nogoaa hav* b««ii u- 
c«rtalntd. 




168 DISEABGS or THE USINABT OBOAITS. ^^" 

f a iTOt y aniilo — ono in 10,000 or 12,000 (,01 j)CTC«nt); potnssio-Tncimirie 
iodide, picrip add, and sodium tungstatp — one in 20,000 (.005 per tient). 

In a recent paper l>efore the New York Aondeiny of IlrltHlieitiv!,4)r. il. B. 
Fowler Htnlcil as llio result of bis obscn'utit>us Uuit the smalkHt nniouot of 
ulbunieu <leti<ct(H] hy tbo various tosU (tiio uruio hnviui; a epocUic (^vitjr 
of 1022) wits IL8 fultowa : 

Heat 2 

Nitric acid 1 

Picric ucid 1 

Fcrrocyanide of putuxsiuni 1 

Sodium tungfltnt« 1 

Potaawio-ioQTCuric iodide 01 

Dr. 0. W- Pwrdy uddd a series of obsenrations as to the oompnntliTQ 
delicacy of these testa in detocUiij; nenim iilLuincn and egg nlbiuueu. For 
llie former he Hilda tliat tlie potaasio-mercuric ioflide and sodium tuiiRStata 
ar« "th<- inost. delicate mid rt-liabk, and poasesaimf the ft: mi ^Ht ubjcctions ;" 
for recopti'mng effg alhuiuen, ou Uiv other Laud^ be considers Leut iiud 
nitric aejd preffraule to tdl othei-s. 

Dr. Vinpetit HarnM ciud«! tu tb« eoudiuttoti, after cionijMirutive tests, that 
'■ tlie tlin* tests — picric acid, BOiliun] timgBtate, and potattaiuui ft-rrocy*- 
nide — are about tlie moat delicate albumen precipilaiits, luid idiould bo 
reckoned as being about on « par, witli preference in favor of picric acid." 
His I'xperieiice with pota^sio-iiierpiiric iodide haa been uiiMiti«fuuU>i7. 

Allhoiigb Uia retiuUs ([iiot«d show much Jivemily ax to the »bfK>Iut« 
and reialivt* delicacy of the difl'crcnt reii};cnt3 in dttectiun albuiiito (the 
iltvcfBily due doubtlcas 1itr<^f>lj- to tbo viu'vintr eouipouitiou uf Lha urine and 
of the icstn eniplo^'od) jet nonrly all agife in ileiiititidtrntiiig Ihc relntivB 
delicftcy of the potaaaiivraercurio iodide. The wiilcr also can, as tlie resull 
of penioual experience, reeommeud thix ti'st at) debcate and reliable. 

Uee of thc»e Rvagt'iila. — These various ttsta iiiaj he craployod as sohi- 
tioQS. or nioro conveniently by iiieansof Oliver's tc8t-pni>ei'H. lii uwng Lb* 
Rolutiotis, core must be taken to add a littlo acetic or citric acid before in< 
troduciug the re&j^ent. "When thia hitter in luhJcd, a. cloud is formed at 
the £oiie of vonlact between the tna flitids if nlbunifn or certain other snb- 
stjiticea nn- con tiuiti^d in the iiritic. The tf-'at-tube is Uit^u haat^-il ahnoai to 
the boilint^' poitit ; a dond which peraiata upon beating is serum albumen.' 

In using the test-pnpera, the acidulution of the urine is first effected by 
iatrodiiuing a paper eatoralcd with cilric acid. About Uiirtj minims of 
the uriue are lutroduced into the tesUtube ; then oae or more (if the 

'Oa ftccouat of Uieir conrtaience Ihc lett papprs nrp prcrprrcl for Hh-ri; ri-a^iiutisi 
and I woulil corrllully roGqmnKfnd Hie porhet-rnse rouifliiiiiii,- ihi-w^ pniitrs umi other 
conTwni<>Tifi(ii, which U prirpnrKd anJ »oTd «t n low pripe bv M<f!tsrK P.-irke. I'ftvin A Co,, 
cif Uutroit- I'TOviUd'i with tills oaae even the btiKiesi prnrt1liQr)i<r oan mako it fair 
phyiioiil anil cluinicnt i<iuuiiiiMii>ti of the urine in orery OMu which he atUudi. 

T)ii' v>luliuii|i mre iiigulu iM taWov* : 

IStliitrio-iiifrfurie ioJi-U. 3.*J2 gr«aiino« of polwiiinm todlda and \.3t grikiniiie« aT 
tOBtBarie bichloridu aru i]isBolvt?ci in 101) c.c. ot diiitillcd nalor lutd Dlter^il, 

fimliii'n 1 11 i\fi»ti I ttr. A sntuTMuil icitiitiuri c>r tills Milt UlKillt on* port lo (our of walnrl 
anil anolli'^r of I'ilrlc m^Ic] ilivc ]m■^^ in Ihrca of nateri am inixM In eigunl roliimee. 
ttlnc«i IhlH itM solution contaim tri>t> arid, it in not nacwBurj to acidiiloto t)ii> unne bo- 
furn InntliiK, 

T'lf jKjiiiiM'im fevrooff/in^t rdattcnl con«ii,ts<if « saturated Rolotion of lhI«Mlt. 

IMrrtr .fiit \a iriinAoyi-d tar ti.')il(ii>i aM a Kit'i r*l«(l solution madtt willi bolUtis wBl«r, 
and ountiuiLing nbuut iiirun griLius to tlio ouuoc. 



CLrNlOAL EXAMINATION OP THE URINE. 



160 



vrins I30 nlkolinn) citrift-ncKl papers uro puslipil into tho tiihr*, on ns to 
prn<]uo« ftu acid reaction. Soiiieliiii^s a tui'Lidity m observed nrouiid Uie 
paper ; Uifci m i»ro(Iiic<;d by tliu urates and uric adtl. mucin, or oIcareaitiB. 
tpon he«tinf» thn tiirliiility rli«ap|>C']krH unless it ia eauucd liy mucin, whieh 
in Uiorcf'ir*- detected by e'ltriv airiJ and beat. 

After thn effect of ttie citn>c-iicid pnp^r bM been noted, one of tJie 
imuers oontaiiiing tli<* pMcipitant of nlbiim<'n (any one of the four named) 
u tatroduccd. A cloudiueBS pruihiced may \k duo to pcptouoe, olkiiloidii. 
«to.; sucli turbidity diRappeani iipoa baatiDg; if it pomist, tlio cloud w 
oon]pom><l of nlbutiibu. 

The papRrs ni/iyuisn ha ui»ed na follows {(Hiwr) : "ThnHewho prefer 
to develop II zotio of prof^ipitation aloiif^ the plime of contiict of n t«Ht so- 
lution Mill till- iii'itK- mil ill) Ml witli t.licor! pnporit ak fnllown : put tho ro- 
agent paper with fifteen ndiiiiiis of wiit«r in one lesUtulic nud a siiuilar 
qoanttty of tbe urine with a citric-ai-id pap*r luta another, "^^'hen the 
roagoTit is dissolvi-d, n, portiou of the Bolulion is token up with a pipotte 
and nllow^d to trickle duwu the »ide uf tlie tube, in wliiuh it will either 
glido i)v«r dm iiriiie, or collect below it." 

SiDRe Lb(! pntasBio-tncrcurin iodide is the moRt nenrative ren^ent, it may 
b% used lir^t : for a iiei^Uvs reoult by thiB tctit indicates certainly tho ali- 
MDc« of idbutnvi). Tho ruat^tioti in oft«n tnuiBii'tit, diiioo tho it>ilid« Hoan 
decompoKit in the arid urine, libomting free iodine, wliich colors the «)• 
latiOQ and obscui-ea traces of albumen. 

The eodiuiu tuii^tiito tost is noariv as delicate as the former, and does 
not cau8t> tho precipiUttiou of alknloitls, tliou(;li it jimduced a eloiidiitMW 
vith pepUiiic-K. Uctice a uritie wliii^b becomcti turbid with the iodide 
niper, but reinaius claar with sodium tungHtate, probdhli/ conttuns alka- 

TIki potjuisium forrtwyanidft t* fonsidftrficl Ickh dtU(ait« lliikn tiUior of 
the former ; but ii-i it iloes not prepipil&te either alkaloids or peptones, it 
u leiis linble ii> mi'^lead durin;; a linsty or cnreh^iM i-xuminaliun. Dr. 
Olivftr nHroitiiin'tuis it to tiiosu who have biwl but littlu ex^jurivucu iu th<t 
use of iiritiary tests. 

TAy ii3itii{ tlie^e tliree testa in fliicoesMon. j)eplon^« Rud aiiMlmda nan lii< 
iwjognizcd ivith considerable probubility ; for the iodiJf. pr'-ripilaien, bath 
the iHnijttoU: pf-pimi'-x only, luid tlio ftvrocj/ttnidd 7mrhf>: Heucs a uriuu 
whioh becomex i-luiidy uik)u tixn odditiou of each of tlie two formci' testa, 
but remains clooi* when Ibc fermcyaDido paper is introduced, probabty con- 
lains p'tplunc». 

Pifriii iicid liUH, iM idrnady ittiibod, thu advunUtgo tlint il prtNluccix a rt>- 
aoUon with both su^ar and albumen. 

Id using these reaRenta it must nerer be forgotten that the teat ia not 
completo until tlie li<|iii<l has been faeoted almost to the boiliii}^ jHiint ; 
nnca the peraistenct; uf the eloud wLcu bukted is the decisive proof Uiat it 
ifl oompoaed of albutn<>ii. 

tMt /or Sugar. — Tho two rengenle — picric a<.-id and indij;i><.'ai«iiuo — 
itud for this purpose muul be employed in eunneetiou with an alkali, 
preferably xodintu mrlKinatit. Tboy lu-c nut iiiturfvred with by the prea- 
enee of nlbiiinon niul of unttea in ezcesa, 

To make tlie picric acid teat, twenty-five minima of water nod thro* 
l^rauiH of eojiuui earbonn^lo niv put into a loKt-tubo witli one of the piivic 
iKUil poiiei-H-. llu'n ten mimmsur xha urine are added, and the liquid lioiled 
for fifty or aixty secoada. If nugar l»o preBent Ibe tui.iliire darkens 
lapidJy, often exliibiUug a dark-rod ookr. la thin ca&u tbo tvst obuuld bti 



170 



BISEJ18HB OF TUK ItKDfAitT UHOJUCH. 



repeated with Hmaller quATitiUe!* of arine — five, tbr<>4>, ntiil tuvfm onfl minini. 
If n tBOgle liiiniiu produces a decldad dfirkc-nin^ luid reddi&li lingo, the 
cjuontity of miRiir is prob»l>ly five <ir more ij-raina t<j th« oiiiico. • 

It i)) to be rcmciuborod that noinial uriim tiealnd iii tlii» vmy produces 
«p<T('i[itibli)diirkeuiug of ttie liquid ; heute the phveiiciftu tdiouid fntniliarize 
himself witii the miction of normal urine bcfoi-o drnwiiif; coiidusujiist from 
this te&t Siucc. icui't'OTor, an exccits of cieatmLne may liiiuulate exactly 
the BUgnr rcm^tiou, n coulirniBtoi^' U^t sboukl be euiploycil. 

A mors trustworthy reagent is tUnt with iudi^o^iinniuo. Oii« of these 
pajiers nm) a sodium fju-bon&td pftper are ploooa in « t«(tt-tulK! witli f»r^ 
miuUiis of wat«r ; th« liquid u then bout^-d iiutil it tii-quires a p^e-bluo 
(folor. A drop uf iho iiu«poctec) urine is Hum JntiwUiced uud the lifating 
iH)t)tinu(<i.I, uu'e heiii<r taken nut to ugitate the litjuid unr U* pcrtnit uctive 
ebullition. If Hii^'nr he. \irfit<tml the Utjuii) will iti the cnuivf: of « iiiluuUi 
present a Buccesfiion of colors — violet, inuiilc. rfd. onuiye. mid finally straw 
color. Alter coolin" and Khnkin^ tlieac vnritms ciiliirs iwc exhibited in 
rcvt^rsod order, dually termiiiatiii^ iti the oii^iual blue. Tbi- dcliau.7 of 
tho IckL in inurcoftcJ hy luting an additional jmper satuialcd wilii carbunat« 
of sodium. 

If no chiuif^a is produced bra iniiglEi drop of tbo iirin«, a secoud should 
be addrd nnd tbA procciu rcpvatvil. If o»ly u truoti of Kiigtu- be prttwnt, 
Ifae cbui^o of color will not proceed to jellov, but will stop ut one of tlie 
intermediate sliodca 

It is to be noted that normal ttnne produce* n similsir reaction whevi 
present in liiPger (luiindty (Gv« to t«n drupn). Wlien, however, only one 
or two droj)« of the iirino hare bf en added, th« aueeension of coloia ahore 
ineDtioue<l may be regJirded as positive proof of filyoosuria. Caro eboiild 
also lie taken not to a^'itnte the liuid duiiny the pructKa, since the coutoct 
of oxyguti rctard» or won prVTOutit the change of oulur. 



rt 



\K 



epr 




Ef.iolo(;t/. — Venniin confjeoUon of the kiilncy is a nymptom, reRuUing 
«itll«r from local obBtiuction to the cBciipo of blood, or from failure of tJw 
general aiteriiJ ciiciiltttioii. 3Io»t caaes ure iucluded iu the Iatl*r category, 
and Ate iacidcnl^il to <liii«A.HOci cuiitlitiuiia of the cirviilntorj)' ur of the rtitpi- 
rutory urgiiiiiik VfUvulai- heart discoEc, especially stonoeis of the laiti'ul or 
oortin orifice, iire, except duriutf Uio t>UH,'e of cotnpensutory hi-pertrophy, 
aooompamed by artennl naa'iniu uud vriiQiiH liypvni^niia ; cicgeiici'aliun of 
Uia heart miucl«. periconUtitt, itneuriflm of Ui« ourtiu nrcb tuid t^\t4-iit<iv« 
nthoromntous do^riAration of the lU-terieB, are atnonif tho roiiditioQa which 
uuy serioualv iiupedo the orteriul cirmilntioQ and therefore favor general 
veDoiui conaestioD. 

TLie vnrious HfTotrtionH of Utif ivt<i>iratory or^unti whidi iiit^u-fcrc directly 
or iudirecHy witli the action of the heart may, by their effects upon tlte 
rircnlfition, cauHc renoiis cungoitiuu : aiiiuug thcwB iu'b einphyseiuii. ohruuio 
broDo)iiti)i and iaterHtitinl piiouiuoiiiii. cbrunic plouriwy, uh woU iw nttitrly 
oU thf iitiule nffcclioutt (if tliu ree^piratory tnict. It is an uauaunl feature 
in phthiiiiit, pmbiibly beoaUBe of tlio coincident uuimuia. 

Local iiii]>edtmeiit^ to tbo return of bkwd fn.>m the kidn«y are raro, 
Iu a fow L-iucs venous renal cuii^^'Stiou tiaa been obacrred as a renult of 
Ihrniiibonifi of tho inffi-ior -vnna. cava abovA tbe eatranee of the retud vein ; 
from coinprexwion of this vein by tiimorB, ovarian c^'sts, ascites^ etc 
ITie reoiU eonKestiou wliicU Jiccompaniea pregnancy is doubtlctw io Mtnc, 

)gh uot in all. oaMCx the rttsiitt of tho promuro upon tho vc^on cava by 

I gravid ut«rua. Thromboaiti of the renal vein itself gccurs not infre- 
quently in nurslings and Butaetimea in adultii aa b result of general mans- 
laua 

Moi-bid Anatomy. —Thii nnafomiral appenranoca yary according U> Ibe 
duration of the renal coiigostiou. In the oarly period tha kJdnoya arc AQ- 
larved, ho that upon cutting open tho capKulc tlin organ protrudes. Tbe 
■teUate veiua of the surface are niiiHi ditttendod, and on Ihe cut Hurfaco 
thnra nro numerous dark epot^ produced by dilat«d blood- vcsmiU i tho 
Ualuigliiaii tufUt luro distinctly vifiible as dork rod spots. 

If the miiiU cnngentioii hnvo lnAt«d for some weoks, thfi kidn4)y \» found 

to be hard aa well as enlarged ; tlm condition hiw been termed tbo " cya- 

nolia iuduratiou." At a »till later Htoge, tbe organ shown mgns of atrophy ; 

■ ihe cortii?al portion hiw liMonu Tory narrow, and the opitMiiitn «■ mil 

'aa the glouiemU are de(:;enerat«d. Tho kidney ut auifiiiiL', {lale, and ex- 

tnuDuly hard. This luuxlncaa in Biploined upon microHCOpic examiiuitiou 



172 



PISEASKS or Tax VUEXABT 0KGAK8. 




bv a decidcrl increaso iu the intoretttial coDDecttve tinmie ; faero ntiJ tb«re 
tea reuttt strucLuiu huu btcii replsced by cosneoUTe tisttue. The coutruc- 
tton of this tifwuA result) in camttici^ iIfipi*8sion nf the (mrfaorr, foraiiiiff 
itcan to wLioli tLv <.-iipHulu is quite finuly wUitreot, so that ite reoiov^ 
often tofin tLo kidnoy tixxiio. 

Symplomti — The (iioj^uofiift r«Rtit partly upon the recognition of ditrturb- 
ouoos iti tJie curculatory or rexpiratoi'j Drg)Uit<, tai'X piirtly upuu nimoniud 

oonditinnti of tiie uriise. A 
feelioji,' of weij^ht nnd tciisioQ 
OTCr tbv luiliiL'3*s, iucrdtMcd 
utMin prcssiirci, is nti oocAWon- 
al Bj-mptoin. At a later stage 
Bome swelling of tlio feet, 
even pmuouiiocul drnpsy. oe- 
cuts wkI pereiBttt until com- 

Eeniiatnry liyiiprtronhy of iha 
eart is estaolinhcu (in car- 
diat" diHcikst). Tbc coiiilitioii 
of the iiriric variPB (urconiing 
to the caiiHe of the conges- 
tion : if tliJB be the rrsuU of 
floiDO locft] inip«dinieDt to th« 
return of blooil irliidi doo8 
not interfere nitb the artcriftl 
sxipply to the kithiey, the urine 
is UHUully iucreiioed in quon- 
tity, coataiOH r \ar((p pfirvoQt- 
age of albumen, ueuidly also 
floino blood au(i u tvve byalino 
tube-ojuitR (I''ijr. It). If tho (con- 
gestion be, m it commonly is, the res\iU of failure of the arleritJ circiJiitiori, 
HO tljitt the bluu(l-»tip|jly to the kidney in diminished. Uie mine is utucli 
d«or<:a.-«ril ill iiwiititilv, of dark color, acid reiuttion, high specific gravity, 
and precipitateti a heavy reddish 8edimout- (uratea). Alhuuit'u is prcBCut 
in small ([uantity ur may be uhnKut t^utirL'ly. 

VonoiiH cfijigcstiiiii of till! kidney, whi'ti it results from valrular heart 
diaease. is m^iiiflinuirt ntinpiimtpd by cmlioiiiB and iufarot ; KUch mmpliftt- 
tion may be itidicattid by nevei-e paiu iu tlie hiin, dfteii lu'coinpaniod by 
diill, fever, and vomituif' ; the urine itiay be suddeiily dctxeased iu amount 
and iilwnyH coutiuuH » cunaidLriiblo iiditiiMuru uf blood. 

lHaffwmis. — .K frequt^nt error iu «liii|>it(it?ia itt tu tucKumv tlio Pxist«<ncB of 
nephritis. Mwjyof the syiaptomaof roual iiitlauuimtioii art often pn-ucnt; 
lor tli« cardiac or pulmonary diflicidty iiiM»n wbirb the renid congCHtion 
depend^ ofteu prodncea cedenia of the feet iiiicl legs, catarrh of the stom- 
OCD and inlcHtine, palpitation of tlic heiirt. niid sliurtuvMt of bn-iLtli — fre- 
quent apuptouia of nephritis; and thn nii>itnk(>n diftpiiosi» is fm-tiliod in 
many iiiediijd initidn by the appeara-iice of idbumeu ami casU in tlie urine. 
Kciw iifiphriti»» may occur in the coui>te of venoiiK cnngeation : iiidci'd, tliis 
condition Meema to pr^^diapose to nvl.iifil inflnmmntion. Btit it will ^X1 ob> 
■erred that the advent of ocphlitis is ncoompauiid by the apiicaraiwe of 
epitholinl and {rmDuIor caabi in the urine, vrbile the iiercoutago of ulbu- 
men is inr!reased and. the specific gravity dimiuislied. So long na the albu- 
men is fonnd in small qimntity (ou«-tourtU pur emit, or Icbs), antl the aiH>- 
cilic gravity reuiiuiit) above the oonuol, while only hyaline oMa are prowat 



Via. ft.-t(aAlni<'nt trumaCnx ul Vunuai Caii|pa«l0Dc4 tbd 
Xidnu). fauxdliy MIImI Skgioda irjil IniniBalMiry^iMnUlDlBe 
k HjalUw Cut. tWiinl Oitl, anil Uluiid<«DipiuulM <lltehtiam). 



tVISJEASBS OF TltR KIDNET. 



ir» 



> 




in tlie Bediment, it is practically certain tliat no nephritis osiaU, imd that 
nono of ihoMcnuus complicalioUH of roiial iiillauimntion, tsHf;b lut urmmin, 
Deed be fofuwl. For it in not until ntmpliy of tlie kidnov lirw Ijctfun— in- 
dicated h^ the appearajice of grnuular and even epitheliiil casts in the 
urine — that an iiDpairtnc-ut of tlin rennl function occurs as the renutt of 
vi!iinu9 coDf^etioD ; nnd er^n then the solid constituents of the urine Are 
usually ciccroted in imrmdl qnantily, liotwithstiindiii;' tlid oUf^riii. Ttio 
dropsy of chronic iiPiilnititi is diffufte, while that of simple congestion ik 
loriJixi-d in tlift feot mni legs. 

The (liiij^osiH of UiiKilit'ailiHenHc ia often erroneously niude where there 
exiiitfl no iiiHurnnrntiun, but simply vi<uuuii ■■on^eatiou iif tho kidneys ; it 
hai» bc'fn my fortune to ttro mr^rnl c-OHes of Hucli firi^ht'o ditiuttKn cured 
by tbe timely admiiiittlfaiini) ut di[;itAliit. It should be rr^nioniberecl that 
dflt only in CAsea of prouounL-ed <'ariliao ilieeaHC, but even in leas serioua 
ftflcctiims of tbc lintrt nnd liinpti. dlbiimcn, h>-alinn (yisl-s, and lilood will 
prubahly he found in t}]« urine oa a dir«ct result of circulatory dia- 
turbniioe. 

If in the courao of ronous coDgevtioD of tbo kiduey. embolism occur, 
the dilficutty of dingnosts from oetuol nflrphritds l» in(>i^>iiKitd. For such 
rniltolisra tisually caufiea the eeoape of oounderahlc blood with Uiu m-inc, 
giving it tho dark smoky RppoRrance often obaerred in ncntn nppiiritiH. 
Moreover, the patient may oxperient'e audden pain ovt^r tho kidiipy ami 
imlTfr frrim chill, fovi^r, ami vomitin):;. Tho diitliiintioii nuiy bo poKKiljlc u])on 
tbe follow ingconsidfi-ations: embolism oncurs in thn oinntit of vnlvulnrdiit- 
t-nav of the heart ; the pain is sudden and aharii ; the amount of blood in 
tbo sediment is much iucrcnsod, whilo tho olbiiinan luul casts iximitin eeseo- 
liilly ttn Iwfoi-c. 

'JWalinfhl. — Hiticn i-onoun congestion of tho kidney ia niert-ly a aTni|>- 
lom, Uie treatment niUBt be directed primaiily to the relief of tbo orifanal 
affection. In nil or uoarly nil CAses two reniedjee are retjtiired, digilJilia 
and un itlkuUno diiinitii- ; th» acrclAti) or oitTKtit of jKtLiHMium, or lui alka- 
line minerrvl water eonibined iritb digitAliii, maleniilly improren tbe con- 
dition of Uie urine ajid the atate of tbe patient. To i-oduce a deoidetl 
dropsy, <li.'iphorc«i» niHv 1k> employed as dircct<«l iu the treatment of 
ftcutt^ iiepiiritis; it mny even Iw n«vej«nrv to employ iiicchiuiiciU meaiu; 
mich ua Soutlivy'ti tiilieit, for n-'iuuving tlio lluid fiuiu tiio HubouLoaoouM 
tisane. 

Thes« patients aro usunlly an«emic and may bo benefit«d by iron and 
'piioinc HIcdii'iniiM itboidd be HdiuintHtt-red iu smiill do!t(M<, nitice tbero 
fri^quently exisla cutaiTb of the stoinnch and intestine, as a result of wbioh 
digitalis in ordinarj- <loses produces vomiting an<l purging, and other 
remedies sr« not ivcll borni;. \'ct it in jiocofwir}' (o wrciiro llio inlroduc- 
lion nf a considerable quantity of digitalis into tlia circulation ; if tlie frs- 
([uent repetition of a Muall <]uanfity (five dro]M of the tiueture) occasion 
ditttress, the remedy aboukl bo aiibiiinisteretl as a poultice or fomectatioo 
over tho luins. 

In rt-(;ent ycnm, Kt^veml dnigit hnvo been recomiaDiiditd iw nimiu for 
rnducing the exi'relion of nihuinen in various renal difficulties ; promiaent 
amon^ thcfie are conrallaHa majalia. adonis vcnialis, and caffein. None of 
thdMt has, however, realized the hopvfl entortuinod for thom ; indeed, 
Uieir ntlue 8e«iu8 extremely doubtfuL 



174 



msKASES or thk urinary okoahs. 



^ iKmniu o? TBS Kmv^. 1 

'Ynan oongMtiou uf tlio kidney may perKixt for a long timo nilbout 
io^ji^emiitm of tho rrnnl >itnii<t»r«^is if Utt! nrterial ^up^l^v of blood ix imt 
materially imptiired in niinntity ur quality. An iuteWtTince with this aitr- 
rial Bttpply, hnwever, whetiier witii or witliout ti>iiuiih cougctitioii. onuses 
rapiil tlegenemtioD of the epitltelial rells, of Uie tiibulcH, luiil of tlx^ ^loni- 
eruU. SuL-h liut^^riorutiau ut the bluod exists iu various HtiitDiic aiu) 
cnchcfftit! c!onditioaii, RUfh iik rnnlnrio, Kj^iliilin, nud pbttiinia, but to » much 
(jTrnter extent in those titnlt^H ivLich ioelude a disiiitepratiou of blood-cor- 
pa8cl(>8— clilcirodis, Ipucirmin, pornieioim ansmin, mid above all Adatio 
cfaolvm. Tlie Bniuo ooiidilioii i-esulta from HUildtu profiirti! Iitmorrliiigo 
and from vhruiiiu inti-Htinid cnUrrh : it uiuy ofteu be obAerved in (lie ex- 
faaustin^ RiimmGr diArrhmn of childrcD. 

Wbile i£i(-bii>i)iia of tlni kidiu'V usHUiUy results from some disturbruice 
of tiic Kcnei-iil cinrtilfttion, it ia fciiomi to occur nljw in tcusfqiicnce of local 
interfewiice in tlie renal circulation. Tlus it fri'i^iioiitly obflcrved in ctacft 
of lead colic, durinjj which conlrnction of the rvaal arteiies occurs. 11 nlro 
takea ploco, a^'coixlinij; to Cohiilioim. in puerjieml echinipsia ; and Lcyd«n 
lias drmooslrat«<d that renal iseliiS'iiiia is an oi.-cii»i<>iinl conM^ijiiriicn of 
pregnancy. 

Morliid Anatomii. — R<^nnl ischremia iKmanifested by pallni- of the cortei ; 
after longer duratioii, wlien fatty degeneration litis occurred, by a yi>l]ow 
color. At tiiDiii this colur i» diffuse, involviut; the entire cuiU-i. while ut 
otbltrtiRios'tlio toUow color \n viAibl<> only in »\tot» nr f'tronka. indicAtiufi loml 
degeneration. The meduUiiry porlion tmitaUy pieaents a marked contrast 
in color, mncH it indark i-ed nr purple in consequeuce of venouH oon^^stiOD. 

Microscopically, theie is observed fatty degeneration of IliocpitliclioiD, 
eepeciully in tin; convuhitid tubules and tlic t^lonidruli. In iM-Ji^niia of 
bigb gnule, the intertttitiiil tixsn^ of the kidney usufdly contnitia a nutuber 
of wbito and red b!ood-coi-])uatlea, Ibougb no %-a»cidar niptare can be de- 
teoted. 

Hymj^omn anrl I'lMrm-. — liu-ltirniiii of the kidney i» in most eases nn m- 
ccmpiuiimeiit of general ischji'iiiia, whli^h is indicated bv cout.titutiansl 
syrnptoins. Tbo only fcnturcn directly coniieetcd with the ki<Uiey are 
oligurin, allniniinuriu, and thu prcBoncc of hyaline ciiiitn in the &ed)Dieu1. 
It ifi usual t'O tiiid in cu»es of cuoliexia from loataria or nypbilis, froui cblo- 
rosid, lifter prcifiiKo hemorriniHe. eta, tracea of albumen ond a few hyaline 
cnxt.-t. Tiicjip Inttcr arc soraetioies prorided vrith fatiy gTMinlee, oil->bopH, 
or even di.siutegrated epithcliiU ccUb. If the tonditioii be pcrsiirtcnl. tiiLTc 
may also bo found in the nedimr'ut niiinernns red mid white blond-eorputi- 
ct^s and epithelial cells fi-oin tin; renal l.iiliijles and pelvis of the kidney. 
The quantity uf blood Ih HometinieH so great aa to give tidoik red or brown 
color to the nrino. 

It lias bet'u repeatedly obscrv'cd that in iHclR-mia of the kidney, twbe- 
caitts ore the only sign of t}te condition found in the urine, and ihai thri/ 
art! jinv^nl when no alhtiittrn can be <iclfcleil. 

Another obsorvatiun m the frequent occurrence of iudicjin in cxcefla. 

/*rRi7iioini<.— Tlie course of the rennl aflfet'tion depends lnrg*ily upftn tho 
canee and the duration of the canstitntionol condition. If the cause be 
oidy tnin^icnt, such on profuse hemorrhnpe, the Hymptonia of renal diffi- 
inilty may siibHide, thoitgh nnemia is possible ; if tho renal distiirbajice r^ 
eult« from u jK.'T«i8tent cause, actuid uephritiH often uccun, owu tliougl) 




III8EA8KS OV THE KIUNKV. 



ITo 



til* (Mi((iniil (lifHculty Iio ultinuiUlj remorecL Tbiu lead imuonuifir nnd 
pVMmanc^ are HometrmeH the stnrliiig-point for chronic and mtul iicphritiK 
Tbo inaimvnC is of courw to be directed entirely to the uauso ot the 
etreclBtoTy disturbtmee. 



Athopitt op Tire KmsEr. 

^Atrophy of the kidtipy — (hat k. degftipnition of (ho Ppith^linm and ob- 
litsnttor) nf t)in ^lonicnili — run ofc^ur, n^ i<Jn!(ii1y ttUili'O, lu th<i ru^iH of 
ppniwI/Tit vf nmt!i rmijjprtion. which caiiaes increase of cnuitectiv^ tift»ai(! 
and tb© »t>-c(\lleil cyiujotie in<lui-ution. In fliis condition Ibft kidney often 
prQBent8 ita iKirrnM tixa or cvrn ii cauxiilcmbli- onlitii^ntiiont. 

Atroplij" "if tlie RecToting ftleinfliits, npconipftiiieil l\v de^rcftwi in tlio siw 
of tli« orgtin, is moat frequently met iw the result of an inflammatory flon- 
ditinn iiaimily teraicd cliroaii: ititonftitint ncpUritis. But ou almost pre- 
ciflely ainiilrtr iipiwtiruiieo, inifrowoiiii! ns wfll na iiincro8oi>i)ie, is cueomi- 
l«rc!,] without tlm i-Huicnl hi^t^iry and the moihiJ chiuinea in otlicr orgnnti 
iisii.tl in fsises of oin-hotic kidney ; tliia siini)l(;, nou^nflamtnatory atrophv 
LOccuFfl in oKl affp, apparGntly ae n pftrt of th« gpneml nlropliv to whtcn 
lilo tiwfuos nri? pronv. Tiio mittuwv i>f nj^ed pcT^tmii, <'Vfo thosr who 
liiiTe never esliihiMd ^rnptom!! of I'Piinl atfertinn, iisnally revpaU sioall, 
hard kidneys, whoM «apmlea adhere with more thftn the usual tenacitT, 
nod whoHe surfnccs are marked ivitb dcpri''Jwcd Bcon, to which the ctqwule 
in firmly adhf i-ent. MieroBcoplc cxniuiuation Bhowit a slightly increawd 
nriK>iuit of coriiiputivo ilaiue, a ^'Miiulur degeneration of epithelial cell-t, nn 
inrrconeil thickneaa of the Malpij^fliian caipsules, aiul a Imn&formation of 
niimflroiitt f:;lomeriiIi into liornopieneociu Imi11*i, iropcniieiible to blood. 

Thix Hcnilit iitrophy of llut liidney uHimlly attmotH no nttontion during 
lif«* sifif* it dnpR not ocra»ion nny of the ByiJiptoms whicli dtrnct suspicion 
to the renid function. Au exanunntion of Uie iii-iue ttometiuies reveida 
tnwtta u( ulbuiuen with occasional liynliue or granular casta. The quantity 
of iirini> is apt to ho diuiiiiiHhod, hy wliteh («uhire tbo siiBpioiaii of renil 
cirrhosis, aroiwej hy t.tiL- jirc^enfic uf ulhiinirn, CJui \m'. alliiyftd. If tlmni 
tnppdn to be carrlinc liypeitmpliy from wiJiie nUier aiiiai\ polyuria may 
OKiat, in wliich ciwe tha dixtinHiou of ttimple senile atrophy from renal 
ejrrlioitist l>«>r(nnPn ihtlirTiilt 

Sinro tliis condition at tlic kidney appears to be a natund. or at lensl. 
inovit.thle. re§utt of oUl age, no treatrueut dircvictl to the kidti«y in required 
or prolttublu. 



AhTLOID DBaKSEEATION OP THE KlDMBf. 

Althoiijrb thi> amyloid def:;enemtion of the kidney ifi freqnemtly found 
u ft complication of renal iu&toimatiou, and in usumlly described as onu of 
the fornix of Jin(;;ht'H ilisnaAO, yet it iK «tiolo^cally quitn distiaot from ae- 
phritit, aitd iM merely a loeal niaaifeatAlion of a general diaeaM. Since H 
u deainble to (.-liininiite ho far na possible all the nnn-intlammaiory sf!eo- 
I lions of the kidtiey from lh» (>oii(.-f'ptiou of Bright^ dis«<afl«, I coDnder it 
wdTisHblo lo diwuBM tbiu di-^'onemlioii with Uiu other Hoii-uitfantrantory 
ebangiid ; even thouf;h iincomplicaled amyloid crliani::^ in the kidney is 
eomp«ratively rare, the dega&eratiou keiu^ generally aocotupanied by 
ohrooio Bvpbriti*. 



I re 



XnSB&SZS OP TUB UKINART OItOAN& 




Btiolojj'j- — Amyloid dcffcnerAlton ix nloiost tnvnrinbly n sequel to eitiier 
ehroDic suppuralion, cbrouic tnberculuKis, Hyphilis, or xcmtula. As tu 
tho ooDD«ctiou belwefiD tbme pntl]olo;pcal couditioim aiiJ tlit^ foimntioti of 
nniTlcnd matter, wc biwc no definite iiiforniation, but oulr theoiics mor« 
or leas unsatiefuclorv, lu })orl]aps tLe mujorily itf ciisimi chronic suppura- 
tion, rnp4^uinll,y ilh it ni:com]>uiii<'tt [lulmonnrv rciiiNiiuipl loii orenricsof oodc, 
prc-exintA Yet Kiippiiration in auy tissue, even ns in ulcers of tLc leg or 
of the intestine, in cancer of the womb, etc, seems Ruflirient to induo« tijc 
fonnDtioit bu<1 deposit of nm^loiil matprinl in the kiilsev. While tbe evi- 
ilence of such jini^-Ioiil c1iaiJg« is uMuallv iipparciit only iiftpr Kuppuration 
litu long existed, jctn few insttftiicc* aro ix^fionleil in vhit-li it spems to 
have occurred mtluii tbr{M> luontbs (Coluiliciui) tui<l oven in ci^litecu da>'s 
(Bull) after pus formation had hcpun. It is KomftimrB obtwi-ved in adult 
life in individiinlswlio lia»I siiffcrpi] from scrofulous 8up|)iiratIon of glotida 
nml liuiK'H ill i'bildbood ; itiiit il is fuiind post-murtciu wboru no BUpporfi- 
tion ia or b:is Iiocn npiiaronl. The iirst nyniptoiiiB hnvc been ohnerved in 
oocasioiiiil c-nses aft«r tho priinarv affection bos been liealed anil suppura- 
tion htui C4;a^f;(l. 

Hiirti-U <!:iipha«ze8 Ibo itt/Ltcmcnt thiit tliu Oxisteuro of cbrooio sup- 
puration is not of it»eU sufficient to induce arajloid change imleSB the 
suppurating surfnco b*- in cou(ii(-'t with the air ; and iimuuiea thai the pe- 
nuLiiir iJTOiieness of BcntfnUiuit and ttj-pliiliti(! Hiippunitiuii to cause aniTloid 
defeneration is eiiiiaiiied h_v the fact that 8up(iuration due to thcBe taints 
80 frequently occui's as ulcemtion upon the skui and mucous tnembrante. 
Ue sfiys : " Caries €)r the vcrtobrw ntuy lead to extensive dcsli-uction of iis- 
8U0. resultiug in the fonnatiou of t-m irmous burrowiiife' iibticetMCK. aud yet 
amyloid depenerntion of tbe nscera doea not cnsuo so long an llin pus rc- 
maina pent np in n largo abscess caviiy, and has no access lo the aii-." Tlinl 
sach cuaes of cbrouic supxiuriition, cicluded from, »a well as eijiosed to the 
nir, do occur without amyloid de^^t-uemtion, is unqueKtioneil ; Init that 
access of the air ia not csaential to ihe occurrence of cuch dct^-ciicmliQQ is 
equally true. For example, I recently made nt the Cook County Hospital 
the autopsy in the case of a womnn, twcnty-cif,'lit yenrs ohi, who had pre- 
sented the t4,vn)]itoinB — ^eiienil diopBj-, ulliuiuinuriM, livnliiic ciLet«, eta' — 
which led to a dingnoniii of clironic pnrfTiciivrantous ncphntiH of "iditv 
pathie" oripin. Tliere was fonml no nephiilis, but esquisito amyloid dcgen- 
ortttion of Tlia kidneys and spleen, the result of caries of tbe doi-sid vert^ 
brm, from tho sccood to the ninth inclusive. The posts^rior njcdinhlinum 
was Oiled with cheesy pus ; no comuiimicaliou exiftted betwcfu tbe abscess 
and the siirfao' ; indeed no suspicion of the spinal caries had been entw- 
tained during life. 

SyphUis and tubercalosin appear to be direct and iuimcdiAte causraof 
thin degeneration, since Ibis is oft*n observed in such cases without the 
intervention of cLrunic »u]ipvii-iiticiii. It iipp^am probable that even con- 
genital syphilis may produce tbe sane result. 

The cause of tbe amyloid degeneration ia evidently not n local COndi- 
tfoD of the kidney, but u gcuorat morbid stnto ninuifeiDted in the blood ; 
lifir it ftflecta different organs — tlio liver, Rplcpn. Ivniphafic glands, iiitcsti- 
nal canal, suprarenal capsules, and thvi-oiii glaiid^us well as tJic kidncya. 
Tho spleen seems especially miscoptibie, fiometimcs showing Ibo dcgeaera- 
tion whero none exists in other organ*. It is doubtfnl whether the kid- 
neys alone are ever the subject of this dcgeueration, notwithstanding 
Itoscnatein'tt oascrtion that such was tbe case in about seven per cent of 
hU cftMfl. 



OISBASXS OF THP. KIDKKV. 



177 







NumeroiiH instances of amyloid (legenerstion are recordo*! in which 
none of the iiaiml (^uiises wi-re fouud to exjtit, and wbose orit^u in Ktill un- 
explained. If nil kidncj's rontoved po&t-iDort«m he subjected to the iodine 
test, a suipriangljr Urge perc«utugi' ia found to cxliibil Uie Amyloid r«eio- 
tion. 

Tlxiti iJegeneration ia observed more frequently in male§ than in females, 
fuid may op;cur at any period of life, 

Murbul ylno/omy.—Sinco t)i6 ftiuyloid ciliiuigo iii umiftlly a com]>licaUon 
of cbtviiic uvpbritis, tlio appeanuiceti ob»erv«d in mo^t cases in ^^bicli 
Kitclt cliiiiigfl i8 npimrent nre those of renal inflamniution. When tincom- 
plicale J iiuiyli)i<l degeneration ia ntet with the kidneys are found to be iior- 
luol oir t^nlurged, the sze (teiionding lew upon thu dcgcntTutiuu tlino apon 
tbe othm* changes presi-nt. Tb« capsule i8 ea»i)y Kb^nitcd, leaving the 
Hiii-fniio remnrkably smootb, pitlc, luid waxy looliing. U[>i>ti cutting open 
the oi<,'au, tltp sruno waiv npjM'arftnoft is mnnifefltv espociaHy in tho cortical 
substaoica; the pyramids are frequently deeply injected, presenting a 
striking contrtust in color tn tho pidUir of thv cnrtcx. The Dlalpigliian 
liifta (iro oft-en proininoiit nx grny trauiducsnt poiiita, which ha™ be«D 
likeut'il to dn>|« of dow. 

Altliough Iho ffcnf* appomancc of lUo ur^n is vhoracterifllic in im ad- 
vancer) stage of th') lU-gciiurfttioii, yet the criiicjil lest contiists in thti npjili- 
catiou of iuiHiio or «f aniline |T:iethyl or ^utiaua) violet, ti> uicroacoptcal 
aectiona. The inclino iu>hilIon shoiiid contain three crrahis of iixline and 
sis of (be ioiUde of potassium in an ou&m> of distilled water. The aniline 
tv«t cotii»iBt« of i\ one per cent, nolutioii of methyl violet. Tho latter agcn( 
18 MuaciaUy witiHfactory iu htaiiitnf,' mioiottcopiv Kpctioni^ ; ch« amykrid ma- 
terial exliibits a bright red, which ooutrasts strongly witli IJie violet of the 
reuiainin}^ tissue. 

Wluni the iodine eolation im poured orer ilii> cut >iurface in pmuoimccd 
oemm, the Miilpigbinu tufts, wliit-h ore firat and cbietly ntVectfrl by (he dis 
generation, stand out pi-ominintly as dork-brown puints : the arterioles 
te&ding to the f^lomeriih may nl^o become visible as brown hues. Kiani- 
tnation of mi^rriMoupiu Mti-iions dlaiiiod with luiiline violet often hIiuwh tlie 
amyloid chaitgo where none itt visible to the naked ere. 

Upon iiiii^roacopical exaraiiinlion it is seen that tbe capillai-ies compo»- 
iug the glomeruli present the carUcat and most advanced cbongc. Ttieso 
loopK ]i>Hu their chHract«rislic8trtii'tn 1-0 and exhibit a poeuliorDliiMyboino- 
genMiuK Hpjveni-nnce ; tlii^ir diiuuet/r in iiicn^afwd. At an early ktage it ii 
often olMprved that Imta small portion of a lungk-loon preeente tlie brown 
color after treatment with iodine, the remainder oi the ttift api>eiariDff 
at)oiit iinrniul. At n luli^r Htage th«t brown oolor in prmwoted not only by 
the captllnrien of tlie ^IninerubiH but also by the vasii alTereDtia, the degen- 
eration eridently proceeding from tbe glomenilus along tlie art«riu]& It 
tnay ultimntely involvo the rwa rectn as w^U ; occasiooally in adviuiced 
caaes tlui iut«rtnbu1ar capillaries exhibit the brown color ; these Tcaseb 
tbua degcncruti'd nre alwaya larger than normal, the incroaHo in diameter 
restdting from a thickening of the walls aiid not an eipautuon of tbe 
lumen, which may be indeed decidedly decresised. 

lu thffi majority of cnwes the amyloid dcgenerution ia eonfini-d to tho 
vcBselB; in some instauoee. ho>vover, it is fonud to affoct the miithelium 
and even tho interntitial conni«-tire liiMue. At> might be expected, tlie fir>t 
etntbelial cells toexbibittheamyloid change arethose covering theclomer- 
itli : next arc thoMi lining the straight tiibulee : the epithelium of the con- 
voluted LubiiiiiH randv uxhihitH Ui« amvloid rcnctton, but usually sliovrs 



1^ 



or TSS TBIMARY OnOAKS. 






jMOMt of amyloid mnttcr in the epitbelinl 
a dMrided increase iu size which innj much 
_ lliiT tubules ; tboy ohsu pivwnt a fi.\iis»y a\in&at- 

. ^g ^^ ut— mil to the TmlljH of tlio bJooil-veatK-lli. Bucji 
H* moMinnnllr found in the 6(:^iiii«ut> where they mny lit- 
t Um color leactioQ with iodine. 
!■ * |k« MMM tbm liAve been observed depouta of iuii;rloid eiibBtnnce 
hk tlM keiillHiT liHlM of BOeh 8Jxe && to be nrntniv Dt an cmy Hpci-kH to Uiv 
„t»J M«k SimiUr nWBsee liare been fouaa iu the wnlU of th^ rciiul nr- 
f«M ■ thiouboiiaof the renal vein, origitiuting in tko inliltmtioii ot its walls 
iriui'tai.vk4d matter, bas also 'been seen. The (I('|)uBit iu the vails of the 
MuJl^r rcwaclw may rc»ult in audi (;otitrai^tic>n of thiiir cnhbr<t tbnt inject- 
inH duida miiiiot be forced into tbe glouiei-uli ; on the other huiid, eucli 
{nMction oft«n micceeda iu r^uchia^ ui^ai'Iy ull of the tufte, even those 
which exhibit tbe amyloid ubriiigo (MudkcI). 

In iiiiomw'upiv sections of tbe kiilney. cnate are frequently obserrod in 
the tiibiilcH ; mnny of thcae exhibit tbe chatif^'e of color with iodine, indicat- 
in|{ their origin in the cpithelinl ccUk ; iudt'ed, the coaleiKeiice of the tubu- 
lar t<iiiUieUum into im nuiyloid cattt is Of catiioiiAllr wan. 

It boa boon nlroady Htnt*.'<l tlint fnlty d<f^oiit;ntti<>ii of Die reonl epi- 
Utelium. especially in the convoluted tubules, in usually seen iu amyloid 
IciilueyH ; this epithelial deKPneratiou may be so pruuoimcL'd aa to suggest 
tlie reaiilta of an inflainninturj' iirocuss — nephritis. Siiirc [iinyloid degeu- 
onitiou is moreovera frequent oiuplicatioii ol chronic iit-phritis, it is oftcu 
dilHciilt to decide even with the microacope. whether or not there is an in- 
|liiiii>u)Ltory elemeot in th-u clinnf^uH jircw'iited hy the Uidaoys. Vet uon- 
iiillnmniatory dtgeuoratioL alone can result in the appcftrouci: of fal in the 
opithvliuni and eveti disiorgantzatioa of these cells. 

SijnipfomH an4 Courte. — Tbe symploins of uncomplicated amyloid de- 
gonemtion of the kidney are found less in the urine Ibau iu tlie patient '« 
geuei^ condition. Since the arnjloid chungu la usurdly coneeqiivnt upon 
a prior abnormal conditioo, Hucb as suppuration oi* Bvpbilia, tlip attentiou 
in rnrely directed to the kiiUieys until au advanced stage baa been attained. 
It should, liowcrcr, bo a rule to esujnino nt short intervals the uriue of 
every pntient aOeded with »uy of tliose nbiionualiUca already euiimtralwl 
Ail originating nmrloid cbnn^ L'nlesa such special cxominatLon ia cnado 
the condition of tbe kidney is raroly discoveml until dropsy occutb, for 
there are uo aubjei'tive Hymptoms chHiiteteiistic uf the couiplaiut, nud the 
urine pruaeiits no ubjectiYu tip]ieariiti<;».s which attriKit the puticut's attcn- 
tioa. The dropsy alwava appeaia eoouer or later, taid ia at Ci-st confLue^l 
to the feet and iBga ; indeed, as Roberts pointed out, tbe dropsy of amyloid 
kidner sprends by extension from the fcetj nud does not aJTect tbe £ace 
and ihorivcio cavititd m often as in chrouio ueplmtiB. Before the btol 
termination the limbs may be swollen as high as tJic trunk, in which ease 
dropsy of tbe pei-itoueal cavity frequently eusues ; indeed, since the amy- 
loid cufiti^e may affect tbe hrer aa well us tbe kidneyn. ascites may be an 
early Bj-mptcun, The Bwelling of the feet and legs in coses of cpiinuniption 
often iudicatcH the development of tbe amyloid cbaaj^ iu ttii:' kidneys. 

The occurrence of dmpgy is usually preceded or accompanied by a de- 
cided ]niUor and waxy appearance of the akin. Theie aie, however, no 
characteristic cbuiges in other urpans aignificant of amyloid dctrcaeiatioD, 
anleaa ve oKcept the obxtiiinle vomiting and intestinal catarrh which bo tre- 
qnently occur ; tbenc seem to be generally due to the amyloid de)^iaera- 
tiou of vesaels in the intestinal wall. Otiierwiae tbe various organs need 




DISEASES OF TOE KIDNET. 



179 




prcMcnt no evidence of abnonncility — a fact which is of the utmost im- 
portHiioc iu {lilTtTi'iitiatiiifT tiw amvloid de^ent-riJitioii from the intliimtiia- 
Uiry a ftp f lilt III* iif the kiiinty. Tiiore in an u riilii no Iiyiicrtnutlij- nf Iho 
left licart, no iii(rr«iiHeil t«nHioii o{ l.he piilne nor hfl^ of tcitipinilnre, no 
cerebnil lit>tui>rrliii^'e nor cliangOH in the retiua. no urmmia uop serous in- 
flitmmntious '^rxl iiridoiii trRnstiilntinn into tlie plpuml or poricnrdial ana 

TJpoa exauiiiiin;,' llic uriur^ the atk'utioij is arreitted by the presence of 
Klhtim«n ill deciiiedqimntity— on(*-hnlfto out-, two, or oven more per oenL ; 
yet in uevei-ai carefully obtterveJ cases tho urine has been occasionally or 
pemmnenlly free (roni albumen, imd hua bi*en nonnril in lill otbt-r rfttpecta. 

The dnily qunntity tisunlly cscooila Boint-what the avcnuffi onioiuit of 
beolUi, though great vai-ijilious ia tbis xeBpect occur, dependent upon the 
condition of the heart, coincident nfipbrilis, diet, etc, ; the reaction is acid, 
the Kpecific f^aTily somewhat diminished (1.006 to 1.015). Tho iirino U 
rcuiurkttbly p.du and i-k-nr, rarely dcpositinj; a (1eci<led eoditueat. Tho 
lonnal ingrodii^ntH uro. exorftt«(l in Romfiivhat dimininhol (juiuitity; in ft 
CHSea an excess of iiidicjui liaa been detected. 

l;i>on microMfopic! examiuation of Um Bediment there are seen lympb- 
coipuscles. KonirtiruPs blooiI-corpwwloM, cpith^tlinl m41h from tlio kidney, 
uid iiorrow hyaline ciiBta ; Hoini-timeH aJi^o very broul, opanue, wa.\v-looiE- 
iiiR cnsts, wiiicli (rarely) exiiibit the brown color upon tne nddiiion of 
iodine. A pccidiiirity of these amyli>id casts, leas commooly obsrrvcd in 
olhor rnriutios. is Ihu frt^giiL'ncy und dtpth of tho iudentivtiuutf on thb nittcn. 
Tho opithclinl ooUa nccjLitonnlly tuni bromi whcu treittiHd with n diiiibn 
solution of ioiiiiie ; before pronouncing' these amyloid cells, howerer, care 
uiust be tukcQ to iliHtinguisli them fnnu tho cpitlicUal otiUo found in normal 
uriii<-, which exhibit a brown color upon contact vitli iodin« (Filrbringcr). 

I>iatfiiomi: — The exJMtence of amyloid degeneration of tlie kidney cau 
uavnlly Ik aSinned with confidencB if there be dropsy and a bit;))ly albu- 
ininous. dear urine r^ntbont the snuptoma in other organs charactenHtic 
of rvuol ill fliuuniu lion ; ihv jtrolnibdityiH tnuch iiicn^itaud if th«re huruhcen 
epn>4xi«ting <.'on<lttiou prone to ontiw tl]<>. lunyloid change. The dcgon- 
ei'Ation IB, however, often overloulitd, Mnce it may exist without giving riwj 
to tlie mrni|)touiH mentioned ; tliUH there may be no evidence of sniiiniin- 
tion, rnihilifl, tnboiviiloKiA, or malaria, the dropsy may ftp]>eAr only late in 
the disease, and in » fciw ctuK^ no ulbumcu is at any time diacovc-rablc, 
oltbouf^b the nosl-niortem examination revenlsan abundant amyloid deposit 

I'ure imiyloiil degeneration ia rendily distiuguiabed from renal citThoais 
bj Lbe abaeucf of cardiac hypcrLiophy, uioroaeod arterial tcmuou, untinic 
attnolu, etc., ami by tho cliarotrter of the urine. It is, hon'«vfir, often ia- 
dietingiiisluible from chronic parenchyniatoiia nephritis. In many cn«c§ 
the two morbid proccBscs coexist in the same kidney ; for both lire pro- 
duMMd by the xamo catuwi, A dficidod enlnrffomc<nt of the liver and spleen 
ConBtitutcB strong preaumptiwe (.■vidnncf of amyloid d(igc-[ieinli<iM ; while if 
there be no Hucb enlargement and the iirine ia leas profUBe. of darker 
color, of hir;licr 8|)ccilic gravity, cloudy, and deposits n macroscopic Bedi- 
tnent contiiiiiing grnniilur luid c]nthi-Uul custa, tho probability is that the 
kidney ia tho neat o( porencliynintoiia iiepliritin ; yet even then the exist* 
«nce of amyloid degeneration cannot be disiiroren. 

The dilScultics of tliiH difTfivntial diagnosiH are well illufltratcd in the 
obecrvatioQS of Fui'bi&ger upon four oases of co&sutnptiou.' In tlicse four 
there wae ohronte pulmouory tubercutoaia and tubeiGular ulceiution 



180 



DISEASES OF TH£ CRINAKT OROAVS. 



, ot the istMtiae — comliiionK wliich puppriidlj- tuvor (lit funiintinn and de- 
I poiit ot MiylMd mnterial. In each oi th« four Furbringer observed Uio 
^Trnptoms which nsuiUly cbaractema saeh depusit — eolorf^nieut of Ute 
q)leeQ anil liver, tbv n{)p(inmDcii of iilbtimcn una cuile in Uioitnoe, drop^i 
etc. Yet lit the autopsy ainylaid ilegcncnitiun was foiitid iu the kidneir in 
only one. of llie four cattca; in this one tb« ^lobti alao (.•tliiliitwl th« re> 
action. Iu the leuiiiiniu^ three cases no nmyloul returtion could be ol>> 
tAtoed iu atiy oF tlit* or^^uux : in tvfo of thvae three tliere waa deridptl 
[•nreiicliymfttiniH iicpiintU ; in tlic ri'-inniiiing tMm> no (-Tidonc* of renal 
liiseamt wiw re^oitled. In eyeiy <ra»e it is to be remeiubi-red thiil renal in- 
ftammntion oiid the Htnyloid chani^ luiiy ooexisL 

IVn^'win. — Aft(ir stMiiiitif^n higb dr-f^e, and involvinR the ft[>leen ftnd 
iutvotiuett us well us the kidiM>y. itiiiykiid dv<*ouvnilioii upiifArs to be inev- 
itably fntal, (-vi-ii though tlic priiiiitni' ItTxioii from wbitOi it n-siiUn Iw cared. 
At aji wu'Uct atA^e, however, recover)' may be expected if the un^iual mal- 
ady fluliHide Thus cams of relief from amyloid degeneration of the kid> 
ti«)-8 following sypliiliH iitid innlniinl infliiPitco Ii.ivp been repentedly !■&. 
jiorteil, after cure of tlie priiimry dittitmlty. Oirliiuxit couBidem ttiat 
i-ot'orery is hy no menns iiitreqiient in oliildrpii. It iniist bo ivliiiitted tliat 
tbe dntn tipon whii^b this possibility of a favorable pro;^Ho§i4 is lieuied aro 
not altogether ^tiH£u.-tury ; for. us ulruidy stittvd, the uiitc-mortcm diagnoids 
of aniTloid dogVincrstion m frequently erroncoiig. 

In many cases the priinary disorder is iucurttble; und*r lUeso circiam- 
Htztiines tlie amyloid deHeneration in necessai-iiy jjemistent. In otiier ciweB 
a kidney wliicb wiw originally merely thti neat of tbe amyloid clinnge may 
mibscqiKTiitly bccuiuo involved in purcncliymutous intlumiiiiilioti, siuou tho 
ciuinc^a whicth prodiico thn nno nro often anfBcient to iiidiit'o tho other. 
Tliift complication practically aboliabes all licpe of recoveiy, even if the 
, inim;u>' difficulty be relieved. The diiriiliun, dcpcndoiit largely upon the 
natiiv« of tho primary affeetion, vi\i-it* froiii a ftivf inoiittiit to many yonra. 

7 ff'jl intent. — No tneana are knonii whereby amyloid material once de- 
posited ran bo rpraoveci or its fmHier formation directly arrested, Tlie 
treatment in these casoh conxiMa in tlio nttrinpt tt> rcuio%'« the primnr}* 
niorbid ctpnditiuu and to Huittaiii the jmtieut'it stif ng-th. 

I'roleolioT), tbcifforp. consists chiefly in prevention; to this end tliv 
raost careful seai'ch should be instituted for tbe detection and removal of 
sypbiUtic, tuberculous, or malarinl tniiilK, soiirt-L-N uf nnppunilion. ebo. ; in- 
doed, tli<! bii*fory of prdvions itj-pliiiisi in tJm Biibject of prrsotit nmyloid dp- 
geueratioii abould induce the a^lmiuistrntion of tbe icxllide of {)ota8Bium 
and men-urialu The preilJE>poHinf; influence of prolonged suppuration 
abould also be tnken into connderation as nn nncriiinont in fnvor of onrly 
HU^ical luterftrencv iu ou»c» of caries, bip-joiut diaeaac, loigc nluers of tho 
leg, tia The trenlment of Ruch. cmtes should therefore include freijueut 
examination of the uricic. 

Anidr from propiiylniiifi. but little cnn be doii& A nutritioua djv^ in- 
Hiiditig tho free nen of epprs and milk, in^n, quinino, nnd ood-Hvpr oi! inay 
]iioloMg the |iiili(-nf« ul>ilily to resist the ditiease. A most aiinoyiuf{ and 
Qtliauiiting feature is fre(]uenth' au ubatiuate dianboaa; tliin can be miti- 
gitcd by laiK^num and (ftccor<]in<i; to llarlbolow) by Fowkr'A aobition, 
lUree drops uf which may b« tulmin loitered three or four times a day. 



: 




DISEASKS OF TUIC EIDNHY. 



181 



EuBOLiaai ani> Ihfabct or tse Ejokkt. 



The emboli found in tlie kiiiioy are uaimll^r derived from tli« cardiav 
valTeB, and are Uionsfuru (!s})c>riaUy fretiutut in canes o( (^iidooanlltift. In 
septic infection, howovnr, tlirHmboais of viutiJi in n fitH^ueDi occurrence, 
wuoBe seqiwl may Iw. embolism «( tbe kiiluey. 

Tb« ftlFuct of thfise emboli deiifiula upon tbeir composition nnd tlioir 
awe i septii; emboli aMHts HUppurittioQ rdJ nbHcossc« in tbo kidney, while 
siiuplv librinoim emboli produce only ubcmitis. Snpiniiutive nephritis is 
titv UHiiiiJ ri^Hult ill cuuH^M of M:pti<'- infvrlioii, Aiid htfumrrhu^ii; iufiirct lu 
CUMS of fibrinous euboliam. Tbe biter occuituuco ii> by uo lueuus mro ; 
Id threa hundred o&aea of fiiidocurditia Sperling found emboli of Uie kidney 
fifty-eevtrn times. The left kidney is found to contain (emboli tnoro fre- 
quently thnu tlic rigLt, prciiuuiiibly because tho ubrupt augk' formed by 
tJio ri)j;kt rnnnl arttaj witlt tlta tiorta prot«ctH tbo right kidnoy in grcjit 
measure from these floating maxeee. 

Morbid Jiiatomy. — Tbe clmuguH occasioned in the kidney by emboli of 
aseptic origin vary nith tlip nzo of the obstructed Te*<«el At lonxt two 
oases ftre recordixl, one by Cubiiheiiu uiid thv uther by Friudlouder, in 
whirli emboliiiTn of the renul nrtery itself rosulted in necroflis of the en- 
tire kiducty. Emboli of the iatrureual bi'iuicUea cause infai'ction, the tnzo 
of wliich varies with the mlibru and poBiliou of the urttry ()luy{jcd by tJi« 
embnluiL 

Ah is well known eiubolium in tlie kidney cauHes n wedg(>-e1iaped in- 
farct, tba npcx of wlucb lien in tlte BubstiiuL-c of tlio orgiin, ivliilu llic base 
in foniid lit th« HirrfiKip. Tho irfiirct in soniotjmp!* ixjiI, itn buno prujccling 
uom^what beyond tlie rent uf Uio tturfove ; it^ t)ub»tance coueUts of tho 
renal tiiutue in u state of fntty degenerntion and flooded with blood-c(in>'i*- 
ole«. At a Inter Htngc tbe entire tatusti is repkced by oouncctive tiimuc, 
(liully reitultitig in a cicatrix caueiiug a depresbJuu in tlie aurfnoe otf the 
kidney. Thin is the liemorrhafn<^ infarct. 

Tbe nhile infurct, originntiug in the same way, is not liemotrhngic but 
oniemic; th<i tiNSuo di^privcd of iltt blood Hupply by the einbolmi becomt-a 
Doorotit^ and undcrgooM fatty degsnorntion. 

Tbe occurrence of nuioeroua emboli resulta in tbe formation of irregular 
eloatri<:eK, wbicli may cautte liie kJduey to present a lobed iippearance. 

S>/iiiplwit-<. — 111 many coses cniboUstii and infarction of thi' ki'Im-y pnt- 
Fbent no chaiacterit^tic ayaptouin. Canes urv on recotd in wUicli sudden 

Edn and tenderness in the loin, vomiting, chill and fever have iiidioated the 
dtfment of an embolus in lbs kidney in cases of citrilinc \-BlvulHr disuiute. 
Tbeae Bymptouia idoue ore, howvvLT,*umuffic;i(ial to eatubliiih n diaguosis, 
unless Uie urine fumiiih coatirmatory Cridonco. Ha'maturifl, eoJncidADt 
with tbe symptoms already mentioned, affoi'da very strong presumption of 
^t«nnl infarction. Exaoerbntions of tba pain and liEt<iniLturia in casea of renal 
iiigOMtioH diinng valruW heart i1i»eaee are also frrquontly duu ta reuiJ 
embolism, which may bu mitttakeu for ncut« nvphvitlH. 

TVeatnieitt. — In tJio majority of cases treatment is useless ; it is only 
mrhoD tbo pain is severe or tho bivmaturla profuito that narcotics and bscmo- 
atioe ore rtixjuired. 



182 



DISEASES, 07 TOE URINART 0B0AN8. 



Dnrtno: NEpmuTRt (BRiaBT'n Dihkasb). 

The Ut«r&turo of Bright'a dlscaitu duriuR lliv Liat twcuty-five y«im lina 
beeu a mass of direrRetit tlicorieR nnd views ax to llie BiifiU)gy nnil morbid 
' Mwtomv of the uumeraus couJiiioiia diuicoily Jt-gcribeil aa Bni^lit a dift 
ease. Several ilisliuct tyjivsof rL-uul iliscufic huv*.- been clitticiLlly rcuo;:^izetl 
tiuder thU icrm, hut there hns Ixtpii tlio t'l-cntcst ilivci-si ly of opiuioii ns 
to the i 11 tei-iU-j>e rule lice of tliese vaiiiiua ty]io&, aa w«-l! hs (■outinniiig the 
Tobtious bttwLn-n Ui(; clininil Kvim>toms aiiil the niorbiil anatomy. Much 
reacai'ch liiw bt*ii iiiNlitiited ami eltbrt expended to ^stitbhiih a di&tiuct con- 
nectiou betnecu the utifttoiuiuLl tipixitu'iuicvif itiiil Uic cliuicul syin|iU)iiict ; a» 
a KSoIt DUTueroux typea of liright'H disease have been created, rJiieflv 
based upon the uiioroBco^tical researches of euthtiaiaalic invest I'tnttors. It 
ia uuw, Luw<:vi-r, (^ncmlly admitted thai it ia cliuicimy itupuHuiblo tomuko 
HUrli Ano distincliouH Iwtwttcu difl«ri>ut foriuu of Bri^bt'ii ilii!«iis(]i na would 
correejiond lo the dintix-'iit uiintouki(-aI pioturua, both ^fj-oss und inicroftcopi- 
c&l, presentoil by (tisenHod kiiJnftVfl ; and patholoKists its well ns clinicians 
ore now content with the recognition of a few tj*jw8 of ntpliritis with the 
tuuhrrMtjiiidiii^ tliiit a lar^' utitiibtrr uf ciist^n pMiperly sii-ciiUed jir(>M^t> 
boti: clinicaJlj aiid nnatonucnlly, fenlui-eR couiojoii to two or more of these 
Cy|>ea. 

As now Renoritlly imdci-Htood, the Icrm Briglit'ii (UaaaBO is limited to 
tho diffuKO iiitlamniittious of tliu ktd]]oy«, and excludes oth(<r coiiditinnii ac- 
companicKl by alhuiuiiiuria and drojmy ; rttial congestion and amyloid de- 
generation, CHHOtitially luul often eiitirclf noii-indamtnatory jn-ovctuics. ore 
uuroforo no longer iudiidiid under Uiv uoiue Bi'ii^t's diseoso, which ig 
qrnonyinoiiK with difTiiMi; ik.-])! iritis. 

Three diHtinrt dinicnl pictures nre i-erngnized, asBorJaled anatomically 
with difTuiie Dcplii-ilia ; each of these is reguLiily accompanied with oliarnc- 
terintii' iiuirbid mipciiniDcea. TLtTi; axe, th-ereforp, tlirei! tv|»o« of dilTVit>e 
renal inflamnintioti : (1) Atrute uf^jibiitis, (2) chronic nephritis, and (ti) 
ciirhosts of the kidney. 

1.1.) Acul<r iicj}hniis includes the Tarious more or Ichb b}-polheticiil 
suh-fomw u-hioli h«vo Iwea dosit'Lati'd the ftpst stftgc of lirig-ht's di». 
e.ise [Frerichs), desi]uaiuative iieiiliritis (Johiiiioii), hemorrhagic oephritig 
(Tmubc). catimhiil nepbritis fVircIiow), acute descpimuutivc uepliritiH 
(Biirtola), croupous and epithclifiJ nephritis* etc. In thiw iguoring the finor 
distinctiontt of iictitu iuflaniinatioii of tliv kidney wliic'h have been made by 
diJt'ereiit patbologistsaiulcliuiciana, it is not nsseiied thnt suchdistiuctioDS 
do not exist, but simply that they are cUnically impmcticahic Anntoroi- 
cuUy th« discnso is not olvruys a unit ; it in douhtlt-sn tnio that the epithe- 
lium uttually showa luidor Uio uiicroseopo a more decided departure from 
ih^ iioi-m than the iiit^^mtitiid tissue ; it ia nlso true thnt in luany eases a 
decided dcsquajnation or catarrh of the renal epitlieliuu i»nppart:u(, and 
that A croupous exudation occurs in tlie Cfipsules of tlio t>lonioruli and in 
tlie luiuliia of tht! tubules. But mtne of thi'sv chaii^^'es compi-iaea tlie en- 
tire morbid condition, and therefore none jnitUlies an esclusivt' iippeUation ; 
moreover, no one of these aniilomical cbaiacteriatics is fiO iutiuiiitvily n>t<w>. 
ctattd viith a purticalar ^oiip of clinical feiktureu or with au t-xpeciol etio- 
logipal intiuenoe ns to justify a subdirision of the general term acute ue- 
phritia. 

(2.) By chronic parenchymataiut ntfphrilis i» deaigiiated tluit form of 
chronic renal iultaiumation which is ordinarily accompanied with dropsy. 



DltiEASKa or THE KIDNST, 



183 



And irliiHi famiHlies upon pOBt-morbem examinAtion the largo wliita bid- 
ney. Tlioi'u liiis boon noino i.liHpule an to wliellmr ur not it is uhuaIIv roh- 
BecutiM! to iicuLo tK^phritia. That it is souictimeit ho iu iin*1ovibt«a ; but 
Uial it is frequently n primarr affection, becininiig ijisidioiLsl}- witbout Ibo 
prc^xutence of aant» ns^phritia, in now uuaciutnblo. 

(3.) By cirr'iyfrtK of ih--- kithu-'j ar vhromc iiitcntitia2 Ttepiiritis la de»- 
itrnnti^il Ibat fui'i]i of duoiitc tvtiHl uifluiuiuuliuu nbicb is t(>^uc>mUy arooin- 
pitiiiod liuriiiy lift! by dtHcjuiu of tbubciu:! nrnl iirti-mut, romplicntions in tba 
serous inembianea, the retina, eto., but without t1ro]i8y. Upon |)OBt-iaur- 
tem PxamiDatioii tbe kidney is fouml to ba Btuull, Uai-J, aad often (granular. 

Tlie grcntost diversity of npiaiou bns existed as to tbo ori^n of cirrbo- 
Ns of thu kidney. Tlic Ot-nuniis bnvc, Abuuttt witbout oxvuptiuu, imice the 
A]>[)oai*)i»co of FrencbH' work in 1851, initist«d tlmt rcnnl cirrboxis wim al- 
wnyaaiid iiet'esairily ft eequ^l offlirouic parench\inatoun nepltrilio; tlmt 
the Kiiiiill Rr:"i"'»r Iridiiey wim product-J by fontJactioii from tbt? lai-ge 
white Lidnoy, Kii^li^b mitboi-n imvc Ijcun jiint (W positivu ui mtiiiitaitiin^ 
Utu origin i.>f thici L-onditiou iudepeudeully of ac-uto aiid obri'iiic piu-uudiy- 
inntouii nephritia, UKHertinR that Ibe diHoa»o ia ottfin from the tir«l a prim- 
ary aft'eclioii. It is now cstnblisbod beyond all question thnt tbere ai'isett 
M s priiiuU7 oCfoctiou a obiiii-nl piutiiro pruM'iitin^ piT-n«.'Iy the some feat- 
UTM M taaj bA exhibited bv a caho of prolonged nhmuio ii(-pl)ritu ; nod 
that in botli conditiona tbo kidjiej'a are found jjoBt-morteni to be uiucli 
reduced iu size and to cuutaiit au exceHsive derelopment of connective tiiMue. 
In short, tlto two nfTvctionx nt'o botli clinically and aiintoinicHl'y one ; tbat 
tft, tli« ftyniptoma aud |>o«t-mort«m appearances may occur either with or 
witbout n i)re.eiiBtinK acute and cbi-ouin nephiitia. 

It t§ tbereforo (-Htabbslicd that tho tlir«e distinct clinical pictmwa, eucji 
lUtHodatcd with adi'tinito aud [locubar ftbiionn«lity of tlio kidney — acuta 
nephritiH, olironie nephritic, and renal cirrhosiii — are frequently jtncecfunvo 
Bla^r<^ of tite eanie affectiou. Tbe two later etaf^es are distiu^iHUed aa 
clinmic jMireuubymntotin and dironic iiik-nttitiid m-pbrilis ; IUlsic tenca 
imply, not that the nfli-titioTi ii« noiil^uod to tlie <'<iiiiicctiv<i tissue iu tb«oDu 
case nor to the ejiitbelium in the other, but eimply that tbv prc-)>uudt^raiico 
of abnormality i» found jxist-niurtdm in the epitbeliuin and in the oonneo- 
tive tissue n.'Bi>«ctiTeIy, 

Siiii'u both c)u*uuio parenohymatoua aud intcnttitial Dcpbritis may ooour 
an Inter fltnf]:e.<i of an at^ute uephritiH in one individual, it t8 dvidi^nt that 
there can l>e no aharp Una of deinarcafjon between them ; for a gradual 
tiausition from one to the othtir ocuum iu both clinical HyinptomH and uuo- 
lookicftl appoarano'^a In maay eaaoH. theivforo, thero ar« found tlio jiymp- 
, tonw belQu^J^ing to both typea, and a large Quiul>er of diseased kidneya 9X- 
J^jiit aiiataiuiual chantfea. grotu and microBCopical, charaeteriHtlc of Will ; 
• tt IS P are tltn Inuiiiitionii) forma bet\>k-een Iba recognized tyj>oM. 

1116 clinical ttymplunia vliantctttristii: of the rettjK^clive fonus of dironio 

nepbritifl are not <IiroctIy dopondcnt ufinn the condition of the kidney; 

rhetlM the i>ost- mortem apfK-nmunea of tiii! kidney tmnnot be predit-tud with 

I certainty from tiie symptoms ; a lat-k of correMpondence between the two 

[< ia WMcially froquont in thosecns^ain wbicb the lyjnnl cirrboHifl is a Koqueneo 

of cnrouic porcnohymatouit n«pbritin. (leuerul dropsy and prunoiinctid 

albuminuria are uaunlly, though not always, aaauciated wittt tJie large ubita 

kidney ; polyuria wilb a flinall percentage of nlbumon and freedom from 

drojmy, tbougU UMually aignificnut of tlio smiill giiviiuhLr kidni'V, am oliso 

foandm ohww vrlicre the autopsy diaelQaca the laf^o wLit« kidnoy. 



IS4 



DISBASEH OV TUK UOlNAKr OBOANS. 



AccTK Kepaitma. 

SUcloffif. — ^Thifl mnynriee bh tlie extenmon of nn inflnnnnaUon from 
lower [Kirtionit of tliu urinury Inu't or fnmi the timuf. Murrounding the hid- 
neir ; ,v<^t. titicli [irc>|»i^ntioii umirUly jiroducM a. BU|)i)araiiT« or ctuontc and 
not im aciitc Deplirilia. 

Nuirly uU ciums o( ucute renal inilniDmation are of liHmiittogmoiu origiu. 
Tbo liiilin-TB iirr piv-*niiiieiitly cx>irntory orgniiit, t-limiuulin^ tJia uatural 
prixUirIa *>f titwuc iiietniiiurpliui^ia tiM wtll iw (ixlmtiei>ua Ri>iit>tilueiitfi of the 
olooj. This ftliiniiiftfion is acpoiuplished liU-Relv tliroiifjli Ihu vital activity 
ot the c*ll8 liniug the coijvolut«a tubules, and jwrtly, [>orliiij>«, tliruugb 
ibe iiistniiiit'DlulLly of t\m cells cuvorint; tliu gloiuenili. S'ow it is wi'll M- 
tivbliKlicd cx])cntn0ntidly that nciit« D<-p)iriliH imatrH from tli4) eliiaiiiation 
of certAiu foreign Riil)nUiiic(.-H, tniob lis cAiitliaridef -, aud ihiit th« ibflMniUr- 
tion in Uiis case be^ns nnd iimy oven t>e confiuecl to the celU coDc«nioil in 
Utia work of etiminntioii. Moreover, it is a familiar cliaicalolmcri-ulioii that 
acute nephrilia ia a rt-^ulnr fmtitrv in tliotto iiircctiouH difle»A«H in yihieh a 
foreign element fif iiiffM'lion hiut Iwoii d^'iiianntrntod ; I refer parlicuUrly to 
tlip Heptic dist-aat'fl — sepli«t'iiiiii, pvn-'iiii;i, ervHipelaa aiiildiphiiKiriii — «iid to 
)tnthi'a\ ( m III i pliant puhtulc). In thcscr diiieiuw^s it is dc^monslnitud tbat the 
inorlkid ('ti'mftit of infootiou ii n iiii'TnucopicMirganijitn ; htu\ it ia equally 
well e8lal>lit(li«il tliitt tlibttv •Jivuii'^itii* nrv fixiiid in tlie iuHniued kidnef, 
wliere they oonHtilutn fooi nf iriflHinumtion. In other inferlious diseun 
in wijicli nciitc nophritia is a fretjiieiit otfurretioe, the intcrtions material 
liaa not yet boc-n lociiUzod ; beuci' tbu aisKuiiiptiuii thitl t\u> vbasil iadaiainn- 
tioniBori<rinat«tl by tho cfTort of tlii^i-UTt^ttury ccUatoGliminate iLeinurbiil 
materinl. is an inference aii|nx>i'ted l>y attiilof;y. 

A» already stated, it has beeu amply dt^ruonxtratod upon auimola Uut 
oeutA nfphntis in originated by tbc'^'^retioii of e^rtain mibatiince!! used m 
ramediea, eapecislly caiilhuridfM, Mnuy eliiiiial observations prov« tliai 
Uie BftliiB rewilt is produned by the elimination of the BBine drug* in tiu 
human mibjf'cl ; aiiionjj the most conclusive of thcso nrc tlw olmervationii 
of Loeanr.' Aflvr duniuuHtnitiD^ tlio ruiiul irribitioii induced by the inunc- 
tion of (jetrolemn, eroton oil, enntharides, ett!., in rabbits, Lai^sar KXperi- 
nxinti'd with nbnman subjeot. A healthy man, twenty-four ypnra of a^je, 
waa nibbe<) wilb Peiiiriiui baliintn for the reUef of Krjil>ii;«i. lu u few dayt 
he exhibited ^ctnrnd dropuy, which involved thofa'^onawnll.'U) the extreai* 
itiea, The urine waa red, awiiity, ti[>e('itic gravity 1,02G ; it eoutiiiued anjtt- 
nien. blood, and lymph-corimsclea, fatty epitlielial cells from th* kidoe;, 
hyalinv, gmnulnr, epithelial, iiml blood cn»ta ; in sliorti, thnrp wua an noul« 
uephrilis. The iuuudiona of bahsani wtro discuutinn«d, after whicli tb« 
HymptomH grmlnnlly mbHi<lnd and tlie uriuo bw-anie perfectly normaL To 
oetermiue whetlieror not tlia n(.>|ihritis wna a cousecjnence of the iiiuiiotioax 
or oniri'ly a coinddence, Ijissur i-enewed the former condition by Ttibl>iuf; 
20 gminrniCH of Perniinn balftnm into the skin on eneh of Uiroo I'oniircutiTe 
days. After the w^i-nnd imini-lion a sUgbt idbuuiiniiria ajipcared while the 
daUy urine fell from 3,«no to IJiHtr.c. After thp I.hiiil inunction thcro wait 
decidtd albniiiituiria, the quantity of urine 8intin<< to 1.051* o,c. ; tlvfi fK>(li- 
nieiit coiil;iiin.'d blootl-forpiiBcIts, epithelial and blood casts. Ou the fol- 
lott-ing day tlierc was tome iT-domn. The iiriur ninountod to TOOcc, Bpe- 
oifiu grnrity 1.U2&, very albuminous ; blood and epithelial mats in ^rreat 



DTSEASHfl OF THE RinNET. 



185 



profasion. On thfi next. <lay thcrn wnn a g^iiprnl pxn^opntjon of th<> xynip- 
tonijt Under trsfttnifiiit^uvauraiftiul warm batliH) ilia tiriue be«imo novntud 
in tliree days. Sevend (inys after tU« restoratian o( lieiiltb the cldn w** 
a^in rubbed wit.b IVriivinti bttlsiiiu ; on tho following' day llicre wiw do- 
ciJod olbumiaunti, but tliv experiineat wtut RbAiiilou.«d as witiMfnotorflv 
il6nioti8tnit4n(T the drpendonoe of ucuto uophhtiit in the human subject 
upoD inuuctioDa witti bolBam. 

The miuffx of ncuttf nopliiitis are chiefly as follows : 

1, Till' iit/V''(iV>»M ifiMCUM-y, foremoHt luiiong which. M to frequoDO^, in 
iMuirli^t {v\isr. Th(! sdjiti*; di.iea-Htts, itiL^itJiit^ uleercma enJooftntitia. eryai]^ 
elaa and diphtheria ; typhus, typhoid, yellow. iuhI miiloriai fevors, paen- 
nionio. BmH.U-prkX. and neute rheuiiiatiisin ht*^ some of the morbid conditions 
with w'hicli iicuU.' iicpiinCiii miiy be expected. 

HpftHitli lift! iicplirilis lioi/iiiB Hsiinlly (ilMiiit the end of tho third wenk, 
but may hr< delayed iiiiiil the fifth or even the eiKlIi week. In very many 
iDSlanotiH tlir little piLtioiit ia uppiirentjy cuui'uIfMM^ont hefar« the lirst Hvmp- 
toiimol Mil' iTiiiil iitfuction an- immifes'tol ; twti the serinus, often fatal ili- 
neaa which then eiiHUCn ia fnUely attriljiited by the Inity fuid by some 
phyHiciaiiH to neclent in pi-otflctin^a child from '" taking cold." Tho fiict 
tteeiDS to he th;it cspoauro to coKl hua hut little if any iul!ueni!o in orif^- 
uatiii[{ ncphritiHafU'r Kcarlot fvvnr ; th<' inllninmAtion is ^rideiilly produced 
by the spprtilie infcetious matnriai. Yet whili- no ofqiecial cara is nocesaary 
in preventing the cliUd froiu enjoyiiip fresJi air in a proper way. it ia nbso- 
lutcly imperatiro tlint the phyidcina Hhftll keep a ntJiL-t supurriHiou urcr thu 
gennml coniiitiim nnd OHpadnUy tto nnne of thn ^wilient iiniil tho sixtli 
week lias expinad. This la neoessaiy not only in the eevero nnd dangeroiw 
eases of m^irlot fever, liat aluo in the iniUi oiica : indeed, nephritjti in uut 
aneomtnun in thom inslaneci; in which senrlet ferer in iiuiniffatod qiiito in- 
disliiK^tly hy Mirt'tifH^ of thu throiit and perlinpH an iudeflnito raah with 
Hlipht feVer — the Mi-i;n!led abortive form — or even when, them symptoniK 
havo been mvircely noticed ; for in cert:tiu epidemics the nepliritia may hfi 
Iho only ubagr^od uianifustution of iwitrhitiiia. 

Them ts, unfortiinatc^lr, uotLinf; in the history nf neorlnt fnmr upon 
wUteb we may ])rediet tue probohility of renal eoniplieadoo ; it oc«um 
many mild cdwes taul fiiila to apptnu' in fertnin severe inHtonccs ; the 
ehnrnottfr of an Aptd«tuii) mny lurtuich n olno. for in som* rtoftl iu- 
lion is an uhiio^t {.-oiLatatii fciitiiit% while iu oLh«ra it Is ft milty. 
Tlw condition of the cervical plands Nhould he rarefuUy noted ; for tlie 
obsefvatiotis of Wnt^ner and Li'ichtensterti har« shown th^ nepliritia ui 
tui VMpL'cinlly frotptctit cuiuplication wlivn tliOKo inlands an» mudi bwoUoDi 
and that the tK-jjiiinin^ of nephritic during conTaleRcnnoe in often Mooin- 
panied with a aei^oud enhu^nieut of thfine glands. 

Iu moKt coses of Hoxrlct fever alhumea ran l>e discorvrtKl during the 
firMt or^nrly in tbo socoud woek ; thiti fKbrilo nlluiuiiniiria innnt bo (ii«- 
tinguished from tlie albiiminurift nf nAphritis, whii-h mrelv oi^curs before 
Uio third wi!ek. It may be, itidP«d, iinposHihlo to dmw a Hborp line of lie* 
miirmttoii l>otween the twoconditiona, unless a daily microsiNipical «uiin- 
inntion of ih*' tiedtinent Iw mruiv ; for the Oiiwt of n^niit iiidnniiiiation may 
be ven* itiaidiouH nnd imu?cnni[)anied with chiUg, dropHV, iocreaaed «xerA- 
ttoD 01 alhumeu. or other pmminent symptom, 

2. fiiffaiHriiation, uspvciiilly when of septic ori^n or nocompaitied with 
imppnmiion, is frp<iufintly fnlhtwvd t>y iwiuto nophritix. Vtu-timn uurt^ical 
aflertiiiiii* and operation^ irLroiiic and sii)>]»uraling diaeoaea of tLo tdcio, 

loorperui fever, and cxtouiuve bums, an eiuuplee. I>ui'iiig the eiisteDos 



in 




186 



DiSEASsa or tub urinary oroans. 



ot BOob eODditiOQs, A^ueut examm&tioiia of the uhae should be nutdc. 
loABlDtnntiDii of the heart and ito ralveH, of tlie lungs nml ploiin, are occa- 
aiotuiUj'. tlioiigL Ic^s fr(.)qiiOTitIj:, Poni[)1ii»tt«<l ivith acut« iM?pliritiB. 

3. The iiitrmtuclion xiito fht: tiyitan of t-iniaiH snlMancvx cxiTeied by the 
kidneijt. FVromoat ninonfT W\&ae at> to th« d<>Ki«e of iiritntiou U nntljAr- 
iili's, itia external npiflieatioii of ubioli ii) suflicieot to iiidiico tliia rtnitlt ; 
but copaibft, tliouRh K-im imtaliiig, in probably more frefiucnUy reaiionsi- 
hie for (Lfulo iK-iiliritis, bfi<^AUiu^ it in ^ven so extAnnv^lr m Ibe treatment 
of (c^uurrbu-x Tur|it.'iitiiie, eiibeba, sciuillo, aaliovliu aotd, losrcury, pbo»- 
pbortis, arscuit!, the cliloi-nte and even the nitrate of pottsnum nrc cimhI- 
ited with the same abilit_v, when Inlceu to excesH or Xt^ I>et.-uliat-lv BUBee|)- 
tiblc iudividuiilB ; ut ifauy rutv, tbo lulniuuHtnitiun of thi-HC tlrurrs HbotUd bo 
fiiiiitfiiUy Rroideil during' nny irritation or iiitliinmialiun of the kidney. 
The lint of iiic-di(diK-a tuigbt be iiidefluttely cxtouJed, Hince ituUndunl cobcm 
of ncute nephritis fi-oni immei-ous druRH have been reriort<d. PoHsibly 
alcohol hiL8 induet'd it, ah asserted byGoodfellow ; Penzoldt pro«luced fatal 
liephi'ltiH Ml (Ii>;^ liy nd in in isle ring ethyl und niiiyl ideohol. 

Varioiu poiHoiinug aubstRIKKB pmduoed within tlio bodv i\re sAnn rnpn- 
ble of est-itinp acute i-enal inflammatiou ; this has been aemoiiBtrat«d of 
the bilijiry iicids (Notbuof^ Leydon). 

^'orioiiiK subsbuiccs coniinouly employod mi topiciil npplimt.ion« may 
cause reual irritjitioii and iuHamraation ; among tlieae are ciu-ImiUc aciil, 
iodoform, petroleum, mustmil, p>TogaJlic and clu^soplinnie at-ids, napU> 
tliol : LftssAT obaerv^ a fntnl cnso uf nritte nvphritU follon-ing iuuuctions 
with jtetrolciiin in tho trnntDK'iit of ai^ubJ^-'S. 

It is Certain that the f ffe<-t nf thene druf^H upon the kidney dependi) 
largely upon individual t)i!fpo§itioii ; when eK)plo<rtu<^ tbein, the pliysiuau 
riiouli not fad to dctcet, by cxuiniuutiou uf Ibe uriiiv, Iho poaitihk cITfx-ts 
upoL tbo liiilncy, 

■1. The dirtlurbauce of the circulfttion rBsiillinp from " lal-tn^ rM " ia 
undoubtedly productive of ucutc; nephritis, though oft«n u)iliz«d n» an 
etiologiwd He«pogoftt •n-hcro other muses are m^ponsiblp. The rclntiou 
hctwi-'tn cnuae and effect biui not yet been HatisfaL-torily explained ; yet Uio 
fact has beeu demonstrated. Midler showed that cooling of the akin 
oausea arterial hyperieniin in the dog -, hoMnnr inditood genuine acute 
iiopluritit in rubbitu by nitddculy itumL-ntiii^ tbu auiuiidfi, after cuttiuK off 
tlio hair, in icc-wnter ; bn'inattiria can bo induceil in nonin individuals by 
umple immersion of the feet in coUl water. The reual irritation is pro- 
ducod by a Buddon cliaiige of tcniponituru of tlic akin rather titan by pro- 
longed exi^osiiro to uiiifonn cold. 

Binipli; iiie(:hiiuicrd irritiitioii of the Hlcin, fiiieh ait tbc scratching in 
cases ot wabies aii<l pniiign, Beeni suflident to indure at least renal irritA- 
tion ; Wolkenstein produced albimiimirin in nuiinolB ljy pencilling nrith 
tbo Fnradic bru«b. 

Prct!"!"^^ eoiistitubis eitbor a cnuite or at least n preditqiosing inBuence 
to acute utrphrilirt ; ilic arrest or termination of gestation ia usually fol> 
lowed by reatni-atiou of tbc normal renal function. 

The cii»teuce ot a chronic utipbriliH rondoii) tlio individual especially 
HiMtreptiblu to an attack of aiuite rtiial iiiditmination. In nume few cnsed 
arute nephritis nmst be referred io injury, such as a blow, in the region 
of the kidney ; in other instanees it ie due to tJie formation of eoncretiono 
of uric M'id and nrnteit in the ri^iiol tubules. Several coiiKtitntiouid diit- 
eawR, especially ttyphilis. oonstiinption, and malaria, neeTu to jtrediapose 
to renal infliuitmation ; it ia observed also i^uite frequently in varioua 




DISEASES OP THE KIBNET. 187 

obronic diRcasen of the nkin, eczema, [i^nriaitts*, and i>i?itiphigii» ; it U k fi'C'- 
qucnt complication of exteuBiTe buma, anl ia a i-ei^ular ftoture of thu rkcut4; 

lu sonio 4!n»PK no prolmblo cnttse uor pr&ilUpoidtit,' iiidu«u(« for au ex- 
tating aciit« nephritis li&s hiseu liiflooverotl. In mhih! of tht:«« iiii iiiviuuvu 
of the kidney l>y bacteria appears to \>e i^eaiKinttilile, na iti the two cases of 
acute nppliritis ami iinttniii observed and related by Litl«Q, to which reJ- 
eren«(! lius iiln-iuly boon made. 

Acute nephritis occui-s with fur greater freqiioocy iii c«rtimi cliujntes 
th&n in otliera ; it se«u)a ia be ^fipA^inlly Romnioii on Die H^a-<!Oiutt imil in 
i«^oti8 wbei'Q the cUuiate is rai'iable, eidiibitinfr sudden cUouges of teiii' 
paniture kdi) moiKturt.'. In very hot im well an m ver>' cold re^iotiH the 
ataaaS6 i» pnictienlly unktiowii except iiL coiuivclioii with infuctious aiicl 
toxic a^nts. 

Tiio ti-oqiieut Betiuenco of acute nepbritJH upou sMu-kt fever accoiintfl 
for tlio (iK-t thuL it 'i* ho often observed in oLililbood. 

Morlrul Jtiiatoinij. — The gi-oss and miiToscopical ftp)»tamiioeii of tlia 
kiduey vary acconlini? to tlio diirfttioii of the ditteane im wf^ll lut with Uio 
cniinc-. At an I'nrly hIh^o tlip ki<I]i(iy is viiormoiisly enlarged, evtii to Iwicu 
it« norii]id »ixe ; tho mpsule is nuooth luid tniiisp^ent and easily separated 
(roin the orifiiii. U|H)ti lutotion n avrouK lliiid inixi-d vitb blood excnpea, 
BfaowinR oKlciua as ircll as congestion of tlio kidn<^y ; tlif:! Mdj)it;1iiiii tuftK 
np]war as prouiiii£<ut dark red pointa, whilo the cortex of tlio kidney ox- 
liibitH till* puqtio color of inl«-iiHO congcittion. At dilfevettt poiulii, small 
heraorrliaccsare obsened, usmilly not, liirt-i-r tliau a pin's bead uiid Itwati-d 
chiefly in Ihe cort«s. At a later utoffo the pnlor of tho eut mirfaco i* nmch 
lii^htt'i', ujiproaiOiiii;^ ;i, ycllow or gray ; the size o( the organ, while ^'reater 
than nni'iiiul. in U^^ Uinu in the former caxe. Here mid them ui'e seeu 
diuk red spots, indicntin^ tlio wtiil (■<ingi.st*<l vcsMtls. 

Upon iiticroHcopic examination thero in at &rst eviddnt only inteuso ooi^ 
gestion and cloudy sweUiit^ of the renal epithelium. (Istpillary hdinor- 
rhagCH iu-« initneroiiM, cKpoeinily in tho c*p»u](?«of the glomeruli and iu 
tlte atrught tubulea 

At a Tator period the epithelial ceUa, especially of thn oonvolutrd tubulu. 
am found iti a stato of mpid nroliferation, tbe products of the ctttarrh 
■oinettine!« tilllni; the liiuieii nnd-diiit«udii)g the tubule beyoud its nnrmol 
oolifare. Many of thecipithclialoelbiAxhibitprononnoftd fat^ dogoncmtton. 

In <K»Cc iiephriti-'sj'vllowiivi an in/ectioua dieecue a similar catarrh is ol>- 
Wtred in tho «pithE<liuui uf the ciiptiules ; indocd, the ttlTecHton is so muoh 
mora pronom^cirJ here thiui in tint roKt of tho kidney, tlmt it has bo«a 
tenuetl ^iomcriUo-nitphrHin or rapKulilu ; tbe frequency of this occurreQVO 
after aau-let fever has also given rise to the dpsitniation scjirlatinal nfphri- 
tiii. Tbu ntjHub'it tionliiin masses of cells 'which ai-e tbenisolves fiulUcient 
to rnmpiTss tlie glomeruli luiil tlma interfere scriouHly with the circulation 
througli them ; tliere is fonnd in Addition, as Friedluuder has recentljr 
sliown, KW(01in<; and fnttydp[,'eiierYitioii of tbo capiUiuy waU«, which furtliw 
interftire with tho p;i8MHKe of tlie blooti. llieiie niulomieal facts exjilain the 
familiar clinical al>si;rrrit.ioQ that tbe diminished exoretioa of urine which 
conBlitul*« ft serious feature iu OTory miito miphritia is especially formi- 
dable in the <lise«He after soarlet fercr, and that tlicre ia under the»c oircuD]> 
stance!! an r«pcc.ial norcssity for securing the excretioD of waU-J- from the 
gkinieruli ; indeed, this lilfiii(,' up of the capsules with celln and nuclei 
oonstitutes almost the only abaormality ohsorvcd iu some fatal caaea of 
•carhitinal Dc]>hnti8. 



188 



DISEASES or TUB VHINABV OUGAHS. 



In nmny rtuten of aciit« n«pbritia the lcidi)e^i( alone proMct ■bDormal 
appeanuioeH, UiourIi the bodj: ufuemlly is no a niie ilmpnoal. The dro|)- 
MKn] fluid ix fotinJ in the stlbciitfLiiooiiit ci>niiective tiiviiiu (letieraliy tm wnll 
a> ill Die variouB Hcroiu sues mid freqiii.-iiUv iu tbv nlvcoli of tto lungx. In 
ncctutioiiEil nuicM tlifi iducoiir nifRitiiunp of tlio Liu'yiii: (•xhibiU & niDiilar 
ilropsiml nwolHn^. It has lately lieeu iloinotiHlj^ilcrl, niuifomically ok wp)I 
iiA cUiiiailly. tlint nciilf! dilaiuliou ami pvpii )iy)iprtropiiy of tbti lie«rb i» not 
iufrcM^ucnt in tin* c«iir«u ni la-iilu iiopliritiB, et^mlly during the iafo«tioaa 
disea8e& 

The iiriiiary (-Jmiinel, the kidney, uelviti, uruU-r, fuicl even Ul« bladder 
lU'D nccitxioiiidly fouud in a etftte of luHfuimintioii. 

Acuto infltunmation may, lut aii-vtwly stated, unae as n complioation ta 
tba couTHB of ubronic tifpliritix ; iii ilm enxe tbo anatomical nppearanceB 
in tlie kidticr lut well an elsewLere pr&aent Hw cliangiM) cLnmcloristis of 
both HtTe^cUotin. 

The acut<> nepbritis whieh ariBee in the course of R^ptiA diBUkaM ift 
often mnrketl hy llib np^xianuice of iniliiinF' uliBcesws, origiunting in emboli 
of l>ac't«riii. 

Si/m}'l<imii and Ctnirae. — The dUsnse way begin <juit« abruptly or very 
iuBidLoiuly 1 iu cliildrcti fixpficially suspicion is often tint ttrouB«d bv the 
occurrence of uileinii. iiianifosleil citliitr as drupMy of Uw feet or iih pufiineeB 
of iihtt eyelidH aoil broatleiiiug of the liiidge of thi; itoM^. Wlii'ti it ocr-tm; 
IU It (tc(|iiel to ecarlet fever, acute noithntJH is ttonietiinen unMin|Mrcte<l until 
the initial H\inptom8 of urtL-miii are lutmifeKted. I was i-prently aiimnionwl 
in Uasto to see ii child in cnnvijlxiinis. The Utllti {intipot had heen nppar- 
I'litly well in (be nioniin;^, Hnmcwhiit iliowsy in the idtcmooij. hud been 
put to ix-A nt ciffht oViock. and at miduigbt was found in con^iiUiooM. I 
asi-ertuicied that the child had about four neekH nrevioiialy eiifiered Irom a 
mild attiick of scurlet fever, which had coutiut^d liitu to thi> bed only u few 
dsyH ; the pliv^icinti in iitti-nibincc bail rliHroiitiiiund hix vimIii Nomv Ihiic 
previously. A little uriue which I was euikbled to obt^iin was very iilbu- 
minouR and cnnlaiued uumerous hlood-corjumclea and epithelial" costA 
Death oecurred before dayliplit fi-om urrcniiii. The child hiu\ Injen re- 
garded for n week its cou%-(de80«-nt, and uo stispit-toii of the «sisliij^ iKunl 
ioAammation had been entertained. 

In the greater number of cnsos, esjieciiJIy those occurring in adults aa 
tlie* reHult of expottiiru tu I'obl. acute nt^pbrttiii i» uxbered in with one or 
more B«v«tro chillK, followoil by dt^citlcil (ever ; the Intliir niny be truMtient, 
UiD disea.ti; ruDuing its course without any constant elevaljon of t«D)pem> 
turn. NfiUHea and vomitin.^, Ines of appetite, beadaohe, and oonstipaiUw 
indicate some constitutional disturbance ; ilio locality of this disturbance 
in often indicated by pain and teudemvHH in the ]oin^ thou{;)i this symptom 
is by no incnns eonotiuit or «ssi>i)tiaL An (^nrly tiyniptura in some cases in 
irritJibility at the bliuhler ; urination ia frequent and often painful, a small 
quantity of bloody urine being voided at euch act. Tliin Myuiptoui. takea 
iu coiinodion with the app(>anuice of the urine, may, if the oudenia b* 
B%lit luid undiucovert^l, niii>« a mistaken suepiciou of cvBtitis. 

Moanwhilit fi prominont sTiTnptom familiar to the laity usually bocomes 
ap|>areut — dnjjwy. The swelling is ottou first observed around thi' eyos, 
usually Hjireading awr the entire surface, but sonietitrtcs aflccliu^ only the 
face and th« g^nituIR. Tlio (listrihution of the n^lema depen<l» Hoinpiwhat 
upon tho patient's position, being nsuallymost pronounced in the depend- 
ent portions of the body. The dropay mity chiiuge entirely tlie facial ex- 
pression OS well as interfere with the movements of the limh») ; ti peculiarity 




DUiKASES OF T1IR KlTtSKT. 



180 



y 

¥ 



often obser\'G;I ia n broudeaing niu] fiattomng of tiio brid^ of ibe noee. 
aniMd by the swelling ou either aide. The cedeum is at first usuiill^ nub- 
entaneoufi, but Rooner or later the large oenius aacB are also iovolved, and 
oDdema of the gloltia, tbo lungis or tlie bnuti may close tlie scene. Drop^, 
tliough usuiU. is not a i-uoaUut eyiuptooi ; moreover, it may exist during 
scarlatiQa \ritlioiit nt-phritia iQuiiickoj. 

Tlie moHt chai'a>.'t«nBtic Hviuptoms are founil iu tlM) coiulition ot tb9 
urine. This in alwnya scimty, liirbiil. and rwi, browro, or t>raok,v in appear- 
ance from the ndiuixturo of blooil ; tbe siaoky tint is seeu in verv acid 
uriue. The quuiitity it ulwivjn* diuiisialied, eometiiocs to 2U0 or SUO cc. 
jwr (iny; pvpii I'omplfito finuria may occur. In nearly every uuso albii- 
itnn ifi premeiit in appreciable aiuount. often from oiie-bolf tu t«u jiur <«iit. ; 
wtiPd ronKuliitcd by heat iiad allowed to settle, the alliunien nijiy ocrupy 
from one-fourth to one-half of the test-tube SVhiie tins mellio'd by de- 
posit of th<! c^oii^tiluttrd albumeQ may be a convenient way for ibiily coxa- 
puiwuii it sliould be reuieiuhcred tlwt it doea not afTonl a meana for eirti* 
06lSBg even approximately the acttiul percentage of albuiiieu iii the urine ; 
thfa quantity is rarely uioro tliau two per cout. 

It ig clinically ii»ixii1ftnt to note that in aome cases of ncuto sepbritjs, 
eapuciiilly those following seai-let fever, the teniporaiy absence i>f olbututn 
ia not rare ; hencu a failure tu detect albuminuria does not ncccBsnrily 
prove tbo abuoiiiH- of u'-phriliiL Iu acut^ renal iTitkmtiiatioQ Irora oUiM 
oauam it hitH al^n been iK^i^^etioually ub.Hvrviul IhiiL thi* iiriiM!, oltbougli gcii' 
ernllv albuminous, may for days at a time be free from albtnnen. 

The KoJimeiit furnishes important informatioa, nod llie microscopic ex- 
amination of it tihoiild ucvur be omitted; for ciiitlivlinl ii\»U niul renal 
epitbeliuin an^ present even when no albumen can lie detected. Tbe sedi- 
uieiit in uMially copious, and consiittB largely of the acid ui-fttes ; the im- 
portant elontGnts preaonl are, however, blood-coq^uselci), Ivucouytea, raiol 
C[Hthcliuiu, and casts (Fig. 10). 

Itlnwl-cyr/iuncitfii ore rarely abaent, eren though the grom appeai^nce of 
the lirtue m.ay not indicate their pre-senco : they may conetitnte the bulk of 
the sediment In some cnaon they arc doubtleite overlooked evpu upon mi- 
croucopic oxiiniiiiiitioti, itiaco they aret often devoid of the iiRiinl coloring 
matter and ahow many vaiiationa in size and shape; thua they fivquently 
exhibit the <TGiinteil form and are foond in varioiiB sizes from the usual 
^motci to mere {>oiuts ; these are the iw-eaUod " luiorocytee." In aomu 
ftw casen tlie rud eorpusolea linv© beon seen to Picciite nmoplxiid move- 
mciilK ; tboy arti often Heeu adhering to hyidiue or epithelirU ctixia 

The lufif-'Tcidit observed vaiy niucb in quantity and variety. If the urine 
contain considerable blood, ai^ffreffationa of blood-corpuscles in the shape 
o( caslA are uKiiolly tuaou. In itome coses there ia an iibuiidauoe of epithelial 
casts, while in otlieni. especially tltou which follow Kcarlet fever, but few 
mioh cyliiident are aeuii, tha greater number being b,v>diiio auJ granular. 
The hyohiie casta are often pronded witli oil-drops and grauulea, urates, 
eryatala of calcium oxalate, and in a few eanea nrstala of hfemalotdio. 
SomotimcK they exhibit a tint derived evidently from the coloring matter 
of the blfH»). while at other tinies their appearance sujjguate that of tJie 
ruatfl found in amyloid degenemtion of the kidney. 

The prcpoDilenuicft of one or nuollier clvmeiit of renat orig'hi in the 
vedimeut in ttoinetimM dgnilinant aa to the ooiine of the diaeaae. 'Iliiia 
epilbeliul,cellH and castB in abundance indicate an especial implication of 
the renal opitltcUum, a condition which may bo overlooked, aiitcv the 
quantity of urioe excreted may be but little dioiiatshed; on the other 




1»0 



DISEASES OF THB UOUTART 0IHIAH9. 



baB'l, (nil titw rciittl onllM or opitlielial oasts mm- he obaervefl 'm those cases 
ID wlijrh the glnmenili xuflTer espedallj'. a1UK>u;;li the aniouiit of urino ex- 
enUd u nucli diminulieJ. In tlieae camm of glomoralo-iH^phntU tluTrc is 
flAm pnMwut Hit c'&pi-eiuU}' liu^e amount of blood Aa alreiulv stated, «pi- 
tbatial euU ore BOiaetimesfniimlirithniitalbiiiiiinum; tbeynro freriiu-iilly 
t^Mirmd tti ut earlier poriotl ilirtii Ukt nnmintDunB, tmd BometitiKM jM^mint 
for n eoDiidenl)l« tJme after the albumen has ilistt^ipoAred from the urinp. 
Tb4 Danib«r of ievcw^es obBerred rari^R muoh in different oaaea ; in 
■on* iDBtaoceH tboir nbundnnc« iDdicnt^'K n rAtarrhol condition of tlio T«nal 

epHheliiiiu. Thtiy iire dGuhU«a« oftea luiataken evuu bjr experienced ot^„ 
MDrmni fornniU dpitlicliiU celU. 




m. l(l.-a»lliMBl tVnn AcdM W w H ltiM K ip>rt»K miMtolw IbaHnt, Onaahr, add AsjIaU GHtK 

The sediment nlwajB contains » conKidcrshlc amount of f^nuiulax matter, 
which conAUtU hur{;«t,Y of unileiL Thcro is aim an Abundiui«e of taUj 
granules f urni»lied by the ik'bris of epithelial cella. 

lu some cancH casta composvc] entirelr of granules of iinifonn sia and 
fflistonintt upp«araooe are obaerx-ed : these granules exhibit with the an&- 
liiie oolorinK mnttcru the resction (?li»nu.-tfri»t:« of raimx-ncc-i 5iu<-h amimi 
are aeon tjuite often in casck of arut« nephritis from septic infection— pT»a-l 
roia, puerptral fi-Ti-r, clc. ; they twv n1w> steen in oases of ne]>hrit)s arising 
bjr estetuiOQ of the iutlammiLtion from the \*e\vis to the tubiilcs ; luul in a 
few oases such casts Itare been found in easea of nephritis of unknown 
origin. 

In some caws of ncute nephritis Um patient experieceea a constant de> 
sire to mioturate, though but s few dnma of uriuc rtv «>xp<dlod st tacb act 
Tliiti NMuiitom iit uot to be tnlc«n as eriuence of c>-Btitis, unless supported 
hy otJier imltcations. If the renitl iRfiamiuation hitve been cauiied oy caa* 
tnarides, copaiba, or turpentine, or if th£<»e remedies havo been vtuylojed 



DISEASES OP THE EIDNEy. 



191 



interoally oi" externnlly in tbe courae of tlie ofiVction, Btrangury mny oemir : 
ill onaeH of poisouiuf; b^ c)iiit}iurBc|pi4 extensive Iiliriiiuu8 cluta liii»e fonmil 
in tbfl urint:, rcudeiing the use of ttiecattieter aeceeeary for the evacuation 
of tit*? blmlcior. 

In till; liMt tew yeiu% it has been ^emonstraterl that nn spprciriublo rlila- 
tatioii of the lieitrt is a frequeut phenomeDOii ; it U lui altuotil coiistant ami 
Dft«u an early symptoiu of aciirliitinul nephritic iu uhildi-cn. If prououncutl 
it can be d«t«ct«ii by phjaical exaiuiiiation ; but even when um'eco^izable, 
it in»y L'lkuse severe lutliiim aud cyiitiusia Titia dtUitaliou iu uheen't^i) 
i-tpocLiilty iu tliP loft hfiirt, and no xudik'nly that it uiny be nii>itAk(>n for 
effusion into tl]« pericardiuu ; it'iiiiiy be ho severe 08 tu cuustlLule the im- 
mediate oaiwe of death. Dilatation of the lipart raay be Bii«pec-ted if blood 
inurmurH are distiuctly audible ; these disBppeiu' wbeo componsntoi'y b'k'per- 
Imphy i» UHtAbliabed, n proL'ea^ which may be acrotnptitilK^d in h surpris- 
iiigly Bbdrt titno. DilatAtiuu niid hypcrlrophy ore the roi'iill of nu in- 
creased blood-pressure, wlitcli is indicated by the untuuol tension of the 
pulse. This increawd tcntuon i» coimtant in nevere uncotnpUcated cases, 
and ia nccomptimei:! by n retardation of the heart-beats (Iticgo)). 

In favorable cotics no implii'iiUun ol other orgauu is obtH-rred. The 
RynipboniR already doHcribeil continue with inore or Icrr cnD«taury for one 
or two weeks. It is noliceable that the condition o( the urine mny vary 
extxemely durinj( thin time ; not infrequently the blood and even tlie iilbu- 
men disupponr, so tlint tlie urine shows no abnormnlity except upon niicn>- 
HOpio examiuntiou. This return of the uurintil appeomuce sometimes 
de(»ivflB the phytnoinn into the hopn tlitit the renal intJummalion luui sub- 
sided. Such hopes are, however, uauidly blighted in a dny or two Ijy a 
return of the bluud and ulbumcn in perhupa uveu Lir{.'er (juaiitity thaa be- 
fore. In nmny ctftMCH (hero i« no p(>nnnnfint imprnvfttnent in the condition 
of the uiiue for two. three, or even (ouc uiontha ; periods of improvement 
alternate with exacerhationfl. A diminution ia tno quiiutity of urine is 
ugu.illy ncuoiupanied with an iiicreaii6 iu the u}d<imA. 

Sgotier or lut«r there occiira n |>orniiuicDt improvemeot (In non-fatal 
cn-ses) which in mn,rked by n decided increase in the excretion of the urine ; 
the nmount eiercte<l mny indeed much exceed the normal quantity, even 
t^>ee- or fourfold. TliO excrctiun ia tispeciuUy copious when the uidcma 
has boeii ext4?niiive. The emaeiFition which has owuned (Ihough iKO-hivps 
concealed by the nnJtanrca) now disappears, someliiaea to bo succeeded by 
an uuuHiial deTtdopnicut of odiiioae tissue. The blood uHUully diaaj^Mnn 
from thii- uriii«, Ihough the albumen may be flet«cfe<I for inonilii aft«r the 
pa1i«)il ia apparently convnleaoent ; oasts too, ereu of the epithelial variety, 
may iwrsint even longer than the alhunjinurin. 

In a cei'tain number of cnsea, couatituting only n small percenta^, the 
kiiJnevs nvver rcsumu thoir normal condition. Tnu patient makes an np- 
mreut reeovcry and tjnjoys good health fur montbii ; i>erhap9 the albumen 
aiaappeara from the urine. But aft«r the lapse of some months the dimin- 
ished excretion of urine, its turbidity and hi^h specific gravity, the oiarktMl 
albiiminurin, cedomn, etc., show that the inflammation of thu kidney bos 
be>oorm! chronic. 

Oom/jfifMfioji*. — The oedema soraetimM ooouions Berioiis and eren fata] 
eomplic&tiuua by accumulnliou in tlie puhnonarr Teaidee, the peiicnrdial, 
pleural, meningeal, or peritoneal sacs. In occasional ca.-Ka tliu mucous 
mambranea become Godenintous. and a fatal tarmination may result from 
sudden a>dema of tlie gloitis. These serous transudations may occur in 
the course of a feiv liours, and can acarccly be distinguished from the prod- 



192 DISEASES or THE UHINABT ORGANS. ^ 

nets of i DflAmtnntion ; it muitt ba remembered thst sudden dilatatioa a( 
the heiUi is iift«m (Il-v^^IojimI, Kimnlnling effusioti into the pcncnrclud cav- 
ity. In some few cases tiieni) oiiroiui elhisioati bocuue punili-ut, uuially in 
cftwe of Dtphrilis foUoniuH infection ; Uiense of the tro(!ar or aspirator for 
removing the liquid is unsafe. (Edema of the Bubcutaneous tissue tuny 
cause localized slonghing of tlio skiii; the Bwelling of the Bcrotum ta 
Honietimeti so ^reat aa to impede tlie exit of uiiiie, uid requiro ths uw of 
the catheter. 

OiulriL' and inteBtinal irritation mid catArrh are frequent Kymptoms in 
th« coiirmi of nophritie, cspociidly irliea it follows scarlet ferei- ; these 
may d(TubU«es be produced bv sLiBplu uxk-ma of lb9 mucouit mvmbnuie, 
though it is poffidblo thnt nn inHtininintory nction also ooi^inti ; Xon^ of ap- 
petite, obstinate vomitinff. ami diairhtfin rt-sult from tluB irritAtion of the 
alimentary ciuinL Iiitlunimutiou of the semua membranes and of the lungs 
is an accaKionnl complicAtion. Loss of vision may result from mmplo «qid- 
iitia of the retiua, or may bo duo to aii lu-tiiAl inlliDiiNiiLtioii of tliiN structure. 

The most serimia &s well as tlie most in»ii<lioui4 danger to bo appte- 
liondcd in the course of aii ticute uepluitis is, however, ura-mia. The 
probabiUty of such BCriouii rol«ntioii of tbo uriuiur comitituciity iQcr«asea 
of ouurse nith tJie diminiilion in the quantity and HpeciHn gmvity of the 
urine ; yet luwmia may occur in cases where the cMoiparatively free excre- 
tion of uriiio Uua nUuvvd any fcnm of this complication, and where do 
dfopsj' oxiittit. 

A suspicion of ursBnito poisoning should be entertained if there be coo- 
tinuuuit or rioleut headache (ii frequent fiipu in the nephritis of prcgnuncy), 
Audden iuipairinont of night or lieniin^', repeated votuiti&g, eomnolenoc or 
dixjwsirteai, a^thmatit: altadts, watei-y cliairhoBO, intense itching of Ih© 
skin, Kpasms of tlie mut*ples ; pi-ofuse epistaxis and initabiUty (»f temper 
lire iileo frequent premonitory si^is of the relontion in the blood of n dmi- 
[^erouB ntiiount of uriiiiuy cont>liIitc;nt». Yet the attack may oc;;ur without 
the exhibilion of theinn prcliminoj'y i<ymptoma; obUdi'eii especiidly are 
known suddenly to fall iulo comn and coOTulsions even when appurontlj 
t'onvalcHceul from scurlol fever ; Biiice, niureuver, th« syujptoiim of ii«phrilj8 
after nearlfttina Ar« ofton obscure, it is incumbent upon the physieian to 
examine tlie urin« at iiitervaJs fur two or three weeks after such an attack, 
even though the child be apparently free from diseasL'. 

The duration of scarlatiitnl iifpliiitis itt viiriable; death may occur 
in a few d&va or after the litpse of uauuy weeks. ItecoTcry — ibe t«i'mina- 
tion in about two-tbircf» of the cases — is Heldum atUiiiiuil in l<^w thim a 
month, and may be postixjiied for scvernl months, jwiihups by r«Lij)si-» into 
the acut« Btage, lu eome iustjiucco the kidney never recovers its fuuctionn 
eotnplctely ; after an intf;n-id of apjim-ent heiillb. la»tiu(^ seronil muuDiii or 
ft year or two, the symptoms of chronic nephritis biK-oine appiirf lit. The 
peraiatcncc of albuminuria or cnats or both for some weeks after the di»- 
appMmnoo of other symptoms is not unusual in coses which ultimately 
recover eotirelv. 

The neplmtiB of diphtheria is developed dwrinR the intcniiity of the 
disease and is inoro frccjuent in aevere cases. Much albumen and blood 
lire contained in the oriue ; yet recovery from tlie renal compUcntion ia 
the rule if the patient eun-ive'tlio primary dinease ; Leyden has wen cases 
ultimately recover after lantiiijj mor* tlian a year. During the course of 
typhoid fever uL-pltritis is most frequent in the eecciiid week ; it« symp- 
toms may be so prominent sh to dislruet attention from the orit^iiial affec- 
tion, especially if the luaiory be incomplete ; for this reason French 



I 



OISKA3E3 OF THE RIONET. 



193 



» 



natbors dosciri'be it iia a "reniil fonn " of typhoid. Cra»nia ifl uot tiiiooui- 
mou. anil tlio iirof^osja ia iu general t^ravc. The renal inlliinatnntion in 
often aocouupiLniecl vi-itli cntm'i'h of tlio uritiurjr cbnniielH ; the nuiubor ot 
Iniieooytest iii»y tlK^rtiby Ix-coiiiu (to j^i'itt as to simuUtv pim. 

Acute uo2>Iiriti!i i]i-v6lo|ieJ (turiu),' tlio course of crou]ii>ui4 piicumoiua 
aplimum uii the fourtli or liftli day and subsides in cj^'bt or ton days ; it is 
uot a soriniia i-oiii{)licaLiuD. The ticulv rtniiil iulluuiiDiitioii which (.-oiiipli- 
catea inllniumittory rltcumaiiHin nct^tnx to upju'tir only in tiiom cns6» in 
which the vinlucurdiuiii in involved in Ui« iiilUuuiimtioii ; thta nephiitia 
frequently Imm^ohhis ciiroiiiic (Leyden). 

Sypltilia is corisidei'eil responsible for many cases of chronic 1>ut for few 
of acnte reiifil iDfliuumutiuD ; Furbrin(;ci' bus repoatt-Llly obscircd mild 
desquamntivc noplinti* <Iiiriiig iwcondftry <ty[>luliti. Tlint malaria produoca 
ocutu oa well us chroiiig iicphrilLs must he iiduiilt«d ; iiccurding to Iho n-- 
ccnt obsi^rvnttons of Keinch and Kiener. it CHUiiK>i< iu AJgiem nlmost ait 
many casen an does scarlet fever. This form of ncut« uepbuitU fi«quently 
bucouicH L-hruuic^ 

DwfnmtiA.' A typienl rase of nriite nnphriti» am hnr.lly cscnpo recojj- 
niliou or he coiifountled with other affeclioiia ; evea when the tjiitiid chill, 
vomiting, etc., ore itbitL'tit, the dniftsy uiid the bcub^, bjiuody, and alhiiini- 
noiis iirino rcmhr tiic dii\^noAiti ca&y. Yfit not oU coses are tj-picol, and aa 
aroifalt nvutv in tlarumutioii of the kidney i» oftvu overlooked or diiscovcrvd 
only when ummiie K^-mptonm become prominent. In acute nephriUit fol- 
iovem'^ scarlet fever «^pciidly the dropsy may he incoiiHidei'able until the 
uffiicUou is wi-11 inttdibliuhed. In uot a few oiuwh ulhnmea ix ubuout from 
the tiriiio temporarily ; luid in the fihaeiico of these two prominent Hymjv 
toms^-tfdema and nlbiiminurin — the physician who does uot use the ini- 
croHcone is not in n position to recojjnizc the ri'tnJ iulliuomation. 

It tins bcon owtortcd by Mabotnod that there in a prc-albutniouric 
tttAge of otTUto nephritis, indii!al«d hy the liigh aiteriid t«»»tim and thu 
eiicape of hiemoglobtn from the kidneys ; and that if this sta^^e Im> recog- 
uized, the derelopment of reunl iuHnmmatiou may bo nverted by es4.-itliig 
the skill iiud ho\T(.d4 to bn^k action. The htt-iiiogLobiu am be dotocted, if 
no ftlhiinipn be preBent, by the foIlowinR teat: To two or thri'O drops of 
urine in a siuoll test-tube, one drop of the linctiii'o of gtiaiac and fotir or 
five drops of ozonized uthor uru added ; thu Lubu in Khakcn ; the etlier col* 
]cot8 tlicn At the top of the liquid. If li:cnio|;iohi n be present this upper 
layer of ether exhibits a blue color, while the urine below ix colorlcw. 
Toia teitt may be of valuR if the uriue bo frequetitly exAmintKl diirint; and 
Aft«r An att^k of scarlet fever. The possibility of preriniia soarlatiiM, 
even wit'iout aD{;uift or esimlhem, tthouid be made the Hubjcc-t of iuquii;, 
parliculnrly dnrin;^ an epidentin of the ditmnse. 

A nul infreijiieut error in ilia^uosia is the assnmplion of aephrili* in 
cases where simple coiig<.-sltoii uf thv kidney alone cuHtu. If this be tlte 
TMult of Tnivulw hcrirt disoiwi', tho two proniiiionlKymploiiiH— ujdomaand 
albuuiutirin — m-e iiaually ]>reseut, and « uonsiderulilf uunibiM' of ciiKt* is 
observed iu the sediment Tho distinction can, however, be made witliout 
difficulty iu most caseK; the existence of the cAnlific lesion and tlie cri- 
dciiocH ot veD0U8 con|];Riti»n cWwhi-rc togctlu^r witli the (^RKluid develop- 
ment of Uie xyaiptomR indicate thr dejiendencc of tliA ivnnl diKtiirbaoee 
ui>oo the Itcart ; moreoi-er. the dropsy of acute nepiiritis aOects the fane 
IIS soon M the fect, vrhilu that uf cnnlinc; discnxe cxtendit from tl>e feet up- 
wsrd by wntiiiiiity. Tho pereimta->o of albumen is ufliuUly greater lo 
aeubritiit thsn in reool couifestiou, and blood-corpuscles are more aumer- 
IS 




VH 



mSEASKS OF TIIK imiWART OKOAITS, 



■oiu in tbe Becltment The microscopic exaininftlion of Hiesc'limcntimially- 
aJTords (.■oDL'lti(ii\i< uvidHiire iw to lite anturo vt tlio ivnal t-omplniiit ; wbile 
' voiigeHtir>n of ihv ii'u\ii*-y |iix>ilu(reH imiiii-n>iiH li^ilino ctuts, mtlamiuntioii 
furuiahef> epithiilLil and ;,tu»uI'U' cnstii In aliuiultuicc 

Hemorrba^-e from Iliu kitliic^v ftjllowiiiu einhoUtim an<l inftiMion may 
nliio EUggoiit. thi' (ixi«U'iio»- of ttcutf n<-}i!irili>v Tlie difttinctioii ift HOtiivUmv« 
rendered l*S8 easy l>y the Himilaritv in liihtorv bctw-t-cu the two ; thun em. 
' bolism mny boffin wilh deeiilt'd pniu in tlie loina,phiU. fovcr.nnd romitiug. 
If tliis occur dHriiiK *'^'" ''"'"'w of voiioiis con-jestioii of tlio kidney. tUal 
BimilKiity to Jitut* Lt-phriliH is vyen greaWr. It will be found, howwrer,' 
tluil (lie Kcdiniuiii (loc-H not contain tbe tsasta ehiuwtevistic of r^ual inflani- 
matiou, mul ttiat tlio nercciitii^Q of olbameu is not ({rcuter than cui be 
fii nil til led by tlic bluuif pn<8«<tiU 

Anotiici- iliflicaUy in diiigiioBis nrim't from Ibc poB^ihilitj' tJmt n piwcnt 
ncutu tici)tjritis iiiny l)e an esat^rbation of a prLvioiiKly csistitit; chronic 
n^iphritia; for l.his affection may have lfu>te<:l for somo tiriM^ tinsiiKp^ctecl, 
aud it [iredinposeH to attacks of nciitc rcual iulliiiiiiuatioii. If tb(.-r<.- be uo 
previoutf lii-itor^- ix»intiuK *" •J'" exisrtfiicy of acute nephritis itii nrnpiition 
may be impoHsiblo until tlic iiiont proiioiiiii'od Rj-uiptoms of the acute 
alTecttou liuve nubHitled. FiiioUy, carij tuunt bb lalceu U> diNciiuiiiiatc. dut^J 
ing thfi conrait nf a fpbrile affeotion, Uctnepn actual nephritis «iul f<-hrila 1 
albuiLiiiuirin ; ia making this diKtiiiction tbo micnmcope is iudifl]>«iiaiit>le. 

I'lvyiiomn. — III many cttsH-s thv pnticiit recovers pL'rfcct bpolth ; yet this 
ftust dMw not justify a habit nf favorable pi-nguosls, idnco ctwi mild cftsea 
may develop unexpected and serious coiuplicntiona. Moreover, a chrontc.j 
nephritis may bo u seqnel of tlioiiculc inllHiniDalioD. A faronil>le progtioKtsI 
must therefore nlwnyK b« mntU'tviUi oaiitioii and rcsei-mtion, and can b«^ 
mintuiiicil ouly by uarcful daily exaiuiijatioD of the iirioe aa well an vt tho 
p<iti«nt'* pciieral condition. During convaleficenoe rebpHOR ai-e fi'eqnout 
and may be oi.'caBion«l by mlighi provocation, mirh iib esposui-e to cold ; 
nftcr scarlet fever childrru require especial cnre to pn;v<;nl liiis accident. 

Tre-almfnt.—Thci tri>altn*>nt of a patient BHlTeriHK from nente nephritis 
ia dctunuiiK-d I.iiKely by tbo c'tiulo;,'y of the affection, ox well na by tho 
condition of tiie kidneys as indienteil in the urine. In »oinc cases it is the 
remilt of malarial or syphililiLi infeelioii, or it may liavo been produced by 
tbo U80 of niediciuoB. Thus Barli-lit uarriit*'** a cn»f in which tbi.- ii|ipoar- 
ftnc9 of the urine lad liim to Kiispnet and finally diKcover that the imtleiit 
vratt tiMiug cftnthariilex ; tlio ilisconti nuance of this nppiicntion was followed 
by immediate i-ptnni of the urine to its normal coiidilion. Iii every caw, 
therefore, intpiiry should bo made tin to the ptwsibility of lliPHe specific in- 
/cctioiiH, (u* wo!I OK cmicfniiii}; thft dipt and tbe dru^ which the patient 
may havu ust-d internally or externally ; such inquiry may elicit infomm- 
tion that itbiill k-ad to (tpocinl therapeutical m'^OKures — the iodide in a 
syphilitic individual, quinine in inolnrittl roiiditions, etc. If the patieait bfli 
a child or youtli, careful iiHpiiry will oft#n elicit a liiiitory of recent sonria^^ 
Una, pcr]irii>s im n-r ognizod jiiid inanifested only by sorcnewB of tho thraat 
or a doulit.fiil nwli. 

Ceilain Reneiiil menfinres — roet, quiet, and wnnnth — arc npyilicable in 
nil c-itsen ; the inflfimed rcnti! tissue nx well as the secondarily disturbej 
<lij;e>itive tract piiifit by rin nnirrilatinp diet ; tliis should consist fhicfijii 
or cxeluHively of tuilk ; if the pntient tire of thi» alone, e<;t:^ broths, anil it 
little meat are pcrmissiblo, notwithstanding the exeetM of uitnigenoua 
rDSteriftl containwl thei'cli). Hest in lif^ is an absolute necessity, not only 
for Uic comfort of the patient, but also for the avoidance of certain attend- 



DISKASKS OK tUE KIDNKV. 



195 



tut diuis«r8 ; Urns Uio ftnute dilatation of the lioart, the trnnsailatioDa in 
TftriouH KvruiiH cavities, aud iho iirrrat of the cutaneiMta taunt uuii, arv Um 
upl to o«oui' and to entaU sehous wiuuqueuocs if the patient remain 
wormly cohered in bed. 

There arc bo lux us known oo ateaiu for arresting the locnl inflanimn- 
tion in the kidney ; like iriottt iicuto tD&amnintiou^s uephritJH HppoiirH to be 
a seU-KiDitud tliwuMv Thu eilurta ot the pli^vxiciuii nnr tUorsforo directed 
fir»t to Meuuriiig the vicarious excretion of tliR couatJtuviita of the urine, 
iind M-cond ia tb« removal of the producla of indiunmation Iram iho kid- 
ueja. 

The eicretion ot the urinary fuiistitu«iit»i can l»« aocompUHhed in Inrge 
part bv tlie Kkiii and tlm iMiwt-ls, wliicli am HiijiplrmviitiLr^r- to tJie kidnov« 
L'vcii ill hvaltii. Bj- m-uu»iug iLeiu to iucreoHol ti<;tivity, lio urea luid saUs 
which the inflamed kidnt'ys fitil in Ihtro piirL to excrel« can )k> climiuiitad, 
and their doloterious iiifluenco upon the tiyst'nn (jcnrrall}' prevented. 

TiiL- culimuouB vsci'ction is nMuUl.v iucreneed hy ttm uxu of warm liathii ; 
the ptiticnt in placed ovory day and allowed tn rcuuiin for twonty to foiiy 
miiiutoa iu a bath maintainwl at a temperatmo of 38" to 40^ C , is then 
roileil iu blaiiketu and allowed to pentpir*; for one or two hours. AlUiouj^h 
one ur more iKtunds of wntor esciipo fnttn Llii' skin iluriug tliiH tinio, tJic 
uriufi id uhuzlU}* inai-eased In amount, presumably fnini tlie abnoriitiiiii into 
tiie dTRulatioii of thn liquid and urea coutuine^l in tlic; aeroun and aiilma- 
taneouB spaces. These worm hatliH inny not be employed in evei'v case : 
Uioy frequently cuusi' fointiiwH, luciiljil »ii\iely, niid diQii-nlty of brt-utliing. 
or«ven eiuldru collnp^i' ; nnxmio attacks hnvo been brought on by tliAm. 
nppar(!iiUy from the sudden j'etiirii into the eircalatiou of tlie urea and 
B&lta contained in the trdematouH iluifL If tho piiLient exhibit in advance 
any dyspnten or failure of the honrl. tlicHC bntlt-n Hbotild not bo employed ; 
in thvir bIcimI tbe cold pncie — whiuh is free from tltc depresaiu^; indueuoea 
of the bath— should bn used. Tlie nntioiit ia wrapped in n wet sheet, then 
covered with several blankets nutil freo porcipimrion has been induced. 
If this fiiil, ad^*antilg(; iiiuy bi' dcrircd Irom Zit^iumcu't) ni«lhod uf wroppiiii; 
tlio nnticnt in hot olotlia. 

Iu urgent cases iu which the skin cannot bo aroused to action by such 
mecuureH. pilocnrpine must lie iidiniuiiftered ; uno-tweHth tu on^-eiehth of 
a ffrtda ot tlui nitmto or onr^ftli nf a gvuv of tlir hydrncMomlo may be 
Uijeotfd subciitaneonnly. Tlii^t itniedy may iudiice not only asdimtion and 
vomiting, but even danjierouit depremiion of the heart and cEdoniaof the 
luu^s ; these ill cfToctH cun Iki to Komo v\ti-nt iivrrlivd by cul miniate ring one 
or two teoMpuonfub! of briuidy liai.t an hour before thi; iujuulion. Yvt tho 
rcmndy tnnnt bo uned with extreme cuutiou whenever tho condition of tho 
lieart or luu^ ta uusntis factory ; it in not'OWorthy tliat the diaphoretic 
effect of pilocnrpine ia Icsii certain vrheu tUo kiducvs lux) jnflnnied tbiut in 

bMdtb. 

rtbe bowcla whould be stimiilated to free excrotioii. Thia can be oo- 
oomphahcil by the fulminiatration of itnudl doses of podophyUin (one- 
twelith grain) ; more decided cfTect is produvrd by tlio compound jalap 
powder, ton or twrnty t^ruius of whiuli luuy be adiiiinittloreil ut iutvrrabi 
of four hours until (reei pnr);^tion in iadiieed. If the coae bo urpioDt, nnd 
eymptoiiiM uf um-iuiii llimalifn, the itioflt active cathartics — clateoium and 
oroton oil— are reijuirod. Mercuri- shnuld be iivoiilrd. 

A most iniporliint part of the treatment ia addrened to the kidney 
itjiclf. U liiH oflvn ti(^-n nr^itil that tho inllutnod kiilnoy, like- any other 
inflamed tiwue, itiouM be afibrded perfect repoae ; to this end it hm been 



196 DISRABES OF THB URIKART ORGANS. V^| 

I^HHd that oxciMiH of liqiiMs uid lUI diun^ticn Bhntikl be ovoided. Tliia 
pUn in excellent iu principle, except in &o far bs it ignores the tmt-t tbnt 
ODC o[ tbti chiot dongeni to the intein'ity ol Uui kidney, us well »s to tho 
life of tho pfttiont, Um in the obetniction of tlio urisAiy tubulea and ciip- 
Aules of th« gloiuii-uli by tho nccumulAtion o( cpitbvltiU cells nnd rnstik 
Oliguria ig n pronouncod Bymptom, f8{)«(>i»lly in thn nt-uto uepUritis follow- 
ing MMirlet fever tuid other infectious JiseaHeii ; aud ili4! ditngiT of tirRtnis 
iDcroAsea, gnnemJly npealiin)^, as the amount of iiriiifi dituinialies. The 
raosoB for this olijjruria is found iu the accumulation of cells and nuclei in 
tlifi lubuU'H, but especially io the capsules of the tufts : iu the latter locality 
Um cntarrh and iiccumuUtioii of mis ia otlea so gn>at as to comprint laid 
praoliciilly oldil«ralp tho gloiucndi. rendering tlw-m iniperuindilr to hliMjd. 
It is erideut, therefore, that nn clt'urt iuu»t bo made to keep the hlooil cir- 
culitting through the glomnnili find to socurc a free tmnsudaliioii of water 
into tho capNiiies so as to remove the prodacts of the catArrli ; the neces- 
mty for tliis fri-« t-xcwtion of water ia ospcdnlly great iu the acute nephti- 
tiB of the infootious diauiseB. 

A consideration of these facta Iciwts to tlie adoption of just that line of 
treatjuent of the kidney which ia enjpirioally fouiid in praclice to be most 
bODcBctnl : tho "bject should be to lucronAO tho nrtfcriid jiroiwiirc in the 
IddxKn' 011(1 to fupply th<i blood with an abimdance of water. At the same 
time it Li deiiirahle and quite prartimlile to refmin from stimulatint; the 
HMretiDg cells of the eunvoluted tubules. To nduiiniistcr tur]>entiue, jti- 
ziiper, or KquIUs would bo diaastroua. since tlii-Ht- htiiiuihttci tin- already id- 
fluned (wcrftting KtructuroA. Tbo onlydiurotica whose employment is both 
tiDobiectiu liable and ii:ipi>rulivo are rtiyilaliit and teatT. Tlie former, by 
ita KtuQulation of the he»rl and of tlie renal urlcriolcB, iucreasi* tlie wte- 
rial pressure in the renal vessels, whereby an incren>i<'d trnnHudiition of 
water oocuraiuid tho glomeruli are kept ]>erviou8 ; both o( these results 
nre furtheivd by the preannee of water in large quantity in the blood. 

Digitalis should bo administered in nitire than the ueunl quantity. If 
the tincture uitist bo used (it ia not alwayrt reUnbIc) from thirty to forty 
minima should ho pivpn in the counic of every four linuni. until tho 
(lunntily of urine ia decidedly increased ; this amount is too large to be 
homo by the already imtahle stomach, uidess divided iuto duscu of five 
or ten niinimft caeh. Tlie pulse shoulrl be oarofnlly ohserrtd and n decided 
deci-ense of itfl fretpieiicy should be the ai^al for Oiniinishing (he quan- 
tity of the drug. If practicable, the infiision of diffilalis should be use<I 
i-alb(-r than the tinetui^ ; two to four drachms may be given to an adult 
nnd a correspondingly anmllcr do^e to a child. 

The patient slioiild drink an abundance of water : and in order to 
Hocure his eoinpliunce with this dii-ection, it should lie prescribed not as 
vulgar driukin<;-ivat(.'r, hut as nii alkaline minctnl water, or the " cream of 
tartar lemonotle," niiule by dtftsoh'ing n siiif!ictcnt iiunntity of bitortrate of 
|intnssium in hot water, jiouring nflT the clem- aolntion when cold, and add- 
ing slices of lemon and nui^nr to the taste. It is. howerer, desimble to 
avoid tlie ndiniuistration of potassiiiin salts, sinee the recent inveslijintions 
of ileischer, D'Eftpiue, luid others indiciile that the nceuuiulalion of these 
Killii cnnstitutes an important factor in tho production of ni^aimia. It ia 
tiirrefore better to aubstitnte tbe hicaibfinato, ncetate, and tarlnte of 
flodinm for tbe more popitlar potai^»ium sall;^ an diuretJcH in the trratment 
of npphrilis, aente orcbi'ontc. These alkaline Bolulions are benrHfial both 
in incvenainp the excretion of water and in disBolvitif,' the intlammatoi^ 
I)nxlucts with which (he tubulen are eucutnbered ((reiluii-cU). 



i ,.fc. 



DISEASES or THE KIDNBT. 197 

it was formOTly cuatomfipy in npply cuj^s or leech^a OTer the r*gion of 
thfl kidney ; >l »* pi'oba.ble that tlieBe itioimurcs, L'nip)uy<,:(l ul lliu vvrjr uut- 
Betof tlte alTectiou. ore uiKrfiil ; but the HBine efTnct c-tn be pro<Iuctitl by 
Uifl Kpplicatioii of poultice* or liot fo me u tat ion a to the loins. Tliew may 
bIro be mode lb*; wliiulv for tliu i>cliutiu»Lmlioxi ot uu iofiuion o[ liigitidis, 
if the drug bo nget't«il by tlio xtomncb ami rectum. 

Tlie piiiiiiouitor}' symptouiD of unetuia reuuir^ a iiioio vigorous om- 
pluyiucut of ttiR priiiciplcti olrt-oily (liacuiiHed. The inte-itiiial tract sbouUl 
lie »4tiiauUtt«l by crotoii-ail or clittci-itiai — one or two drops of the former 
or a qtmrtor of a {^i-mu of tlie Litter btiiu); lultuiniHtvnid by tbo i»outlL 
TUd tikiu sbouKI b(4 tixriKil by Uie HuboiitiineouH injection of oniutbiitl of 
■ gmia of pilcicarpiuu ; or four ouiiceu of tUv iiifu»ioii of juboraiidi, uisulo 
from one tlrorLm of tbo lcavc«, sUuultJ bt> Rivcit hv nioutli or roctuiu. la 
Uie abaeuce of tliiti n^etit a Lot-iiir bitib or wtit-p!u:Jc nitit>t bo used. If cou- 
vulsions have occurn'il uikI tliL- p!ili<-iit bo pk-tliorio, vcni^nt'ction iiiny bo 
proctiHtiil, Tlie cdiivuUions am often bn r^mt rolled by the inhalation of 
ohtorofonn or by the ailmiiiislmUoii of cliloral (twenty to forty (jraiua) by 
the mouth or rectum. Tito iujcdioi) of W^o O^scHof luorphiao— half a 
i;nun at once, reifatoil iii two or tbreo bount if ncocssiu'y, until two (^niius 
hiiW- hi^'n given — hum hecn Hucceaafiilly practiaed by l>x>itii!t aud Bortliolow. 

Tbo choice of uietuurcs to U) L-mployed iu treatiDf; uremia is to be 
det^^rmtned iuri^ely by thu <!Oiiditi'>ii uf tLci piiliM.' ; for if there is dcuided 
CHrdiat- nciiknow, sliowti by a ttniull. rapid, and fi<rb!c piilmi, liot biitim and 
pdoairpinu nrc daiigfroiiB, In this case the phytiiciiiu must ivly upon 
active diurcaiH. tlie wet-pack, eroloii-oil, aud cardiao HtimuliuitH, espceialljr 
digitalis and ojitnpbor. If, on tbi- other Lund, the pulw in stiniiff imd full, 
veuesocliuti iu udidtJt itud cup8 or leoclieM to tb<> U(xk iu cliiUIivu, nru iii- 
iliotlcd. A fair sul>Htitu1« fur voiieMiction is vbloi-ofoi-ui njU't-UHiH, tliough 
etbtr uuist be strittiy uvotdud, Attvi* the pntif^tit nwakcus somewhat fi«m 
the unuiuic cuuiil, iidiiiuta;;u Ium beeu durivctl froiu the iuluihition uf oxy- 
^a — six to ci^flit litruct evvry tlirue hourtt (Liignivu). 

Viob'iit aatbuintio altnclu may be [elicvetl liy hirKB uiu»tard plasters or 
di7 cupping over the cliest ; sIbo by luorphiue aud cfiloml, if the cuiiditiuu 
of tho iionrt permit tbvir uw. 

Fnuiuuiifud aileiiirt often recpiires trealuicut, and oui be rehvved by 
fnx' (liuivKi.t, iliuphoi'EiBia, and luiline oathartica It may boL-oiuu iieramMU^ 
to alford a lociil oiil.lot for Uio transuded eeroun fluid ; tlio pn^ctico of 
miUciug inuisiouH iu tli« Kkiu of tliu ustruuiitii^ti luid uf tho geuitidii ix liable 
to tbv objctttioii that it fuvorx Lbo devtdoptuuiit vt gtiUf^reno rikI '!ryiii]>- 
e\a& Pnibably the Ircmt nitthod coiisiHtH in tho iDacrlioii of byp;)dcruiii: 
n<<i-dli>8 (w liiL'b Kliould be iiickel-pIaUHl) iu the skin ; thewj aro held iu posi- 
iitiii by lullidxim pln*t<T uiid connuctcd vritb cihtjw rubber tubuM whith 
lire coiiilnrted into biMiuN of nirl lubzed wntor. 

After tlie tmbHidcuL-e of the acute B\-Tuptoma. extreme cam ia ncoeamry 
to avwd uu ciiiiiccrlKitiou uf tli« roual ioflniuniation. Tliv ulbiuninuria aud 
the costs persiHt for ucekiior onrii mouths Afl«r Ihofevtruiid u'deiaa have 
diftippoored ; duriu^' tliia time escr.<utivo bodily CMertiou, iinprudcut expon- 
ure to cold or drau;^bt«, or over-indulgenc© at table may pi-ovoke a relapafl;. 

'Xlie judividuiil in riiuL-h dvbllitnt«d by uu attack of auuttr uephritis; 
Um diiwpiKMrnumi of tho ni^ut« ayiuptoiiiM nud of Um [;i(.-(tnc imtability 
lid tlierefore be followed hv tbo ailiuiuiutnitiou of t(ii;E('& Irun is 
iy mluoble ; quiiiiiiu and mail litjuors ttbould also bo pnacriWd. 
laoii, brandy, etc., nbouhl Ik! idluwod but HjKiriujjly, boouuoo o( ttiur 
irritODl eflbot upon tbe kidiieya. 




198 



DISEASES OF TllE UR1NART ORGANS. 



Varioufl iTmcdica haTO been recommonded for tbe purpose of redndn; 
the qiirLiiiily of nlliunwt] fiior«t«d b; the kidnejn during convalftsoenoB 
from ili*3 lu-tito t(irm as well ns in cbrouic Q«plir!tia; among tli«ao are 
fuchttiit nnil tbo tiiioture of pantlmi-ides. Tlie former hm been esteourely 
Irtctl mid founJ to be viduelc^ ; an to tlio Litter Unrtholon* Hnv§ : " In aeut« 
ilciiqitiLiDatavv nt-phritiH, iiftvr lliu ^ub^deiiue of tliu oviitrr G^Ill{>tolIlH,{;OlM) 
FOsnilU lire <ibt-tiii('(l from caiiUiRridftft. The loital oniiditiou in which this 
remedy i" eonirtJiblo comiiHta "in livpcr.-L'iiiu* with losa of viitt-u)«r tunui^" 
I liave xecn one case in whirb the adniitiiHtmtian of 6\e drops of the tinct* 
tiTO three tiru^a a day. after the Mvcrer svmptomB liod subsided, vl'ab fol< 
Liwi-tl oil tli« thinl ilu.y by n docidctl ngffmvntioD of 1 bo Kyn)|>toRi8, tlte - 
urine xliowiiig n pmiioiinc^tl incrcaiw in the aiuonnt of blootl, albiiiuen, 
nnil coats preaeiil. In Uie a)H«eii(^e of other discoverable provocation, huh* 
picion attached to tlio contbu-idnt ; tbu rttucdy i» candle in eufficteut 
i[uaMit.y of areiLnan;; ncnito iK-pliritiit in a pvcivioiinly Imalthy kiiiuey. 

(.'iJTividbiriit, Adonic v«r»nlij«, luiil (■afftnu hure thu-n fur fuiled to fornUh 
the aiit.iripateil benefita Nilro-j;]y(*rine. no stronply rccniniiiemleil by 
Robson aud indorsed by Bnrtliolow, is worthy of a triiil ; one niitiini of an 
iihtolicilio »nlntioti — itiut pikrt to oii» htitidrMl uf til(-ij}ii>1 — nmy b<.; mlminis- 
tered threi?! tinietin (hiy if it pi-oiluceiiounpleaiuuit efl'fclA, nuchas lieaihuiLie^ 
etc. It ix usderatocKl tJut tliia remedy muat bo hftudied and admiuistficecl 
with great cautioo. 



Cnnosic PAitc(cmdATo:ra Nkthritis. 

Etiotoyff, — In iho tiiajorlly of ettnte. clu-ouio iiephrlliA (paronchymfitous) 
nritrs iniiuliQUHly nn n primaiy nffectioii ; it has usimily eiiated sniue luontha 
b*fore A positivediaffTiofliaianaaddornvciift wcil-gTounded siiepicioii euCer- 
tuincil. 'riio rrciijitiilioii of tho eliolof^y in themfoi-e not postylilt* in all 
ciwex ; hut it lioa Im-rii eatabUMhed that tlip disease iippearH as the ctTect of 
cdrtaiu (Miusee, aiooug which the following strv luotit proiiiiTieut : 

SffphUie and malaria. TUo (lcp<.-Ddcui>u vi th« diitvueo upou syphilitic 
InfecUoii in whown Ijv tiio rapidily with which, in many ll,^-]>hilitip iniliviil- 
ukltt, il yielila to iodide of piiiaasiuui and merciiriids. i-emediea which in 
other persoiiH are quite inettectnal. The especial Irwqtipncy of the diiKUse 
iu certain uialnria.1 distrii^ts and itaint^reaso during innlnrial «pidi'n)ics have 
boru often itotio<»l ; it luwiiitt J)^>'lnlbh^ tlinta uompanitivtrly tthorlHujoum in 
n tiiiilfirial i«^oti laar l>e ttiiftirienr. to aron»e a chronic nephritia. Tho teD> 
deiiry of mahtrinl inllueuce to induce nephritis varies in different districts ; 
thus Hoseimtoin saw the rcuol vumplicatiou mrcly in nortJicru HoUuid, 
while ou th« ojisteni shore i>[iMourhi of all thn oasen ol ohroni*- nephiilig 
wure in lii^ upinion prudui-cil by malaria. During an epidemic obHerved 
by Hei(1f<uh»in nearly every rjww wan followed by ncphritiH. In Algiu^ 
nudaria is. aecor<hn<{ to Kelsch and Kieuvr, productivo of tiiimcroiw casca 
of clironie rciml indniuiitiiLiim. 

JCrjitjiitiiv to I'lilii and wimIutp. Siinh erpoauro ocoura fnim Uvinff in 
diUup dweHin^'B tia well as m moist and cbauReable climates ; tUft diMfiU 
is CKpociuUy frequent upon certain wR.-cofiHtn. 

t'hroim- giipi'iiriUion i» Hufllciont to indiieo chrnnio nttphritia ah well aa 
amyloid (k-gtrne ration of th« kidney ; either or both of these affections may 
therefore be olisprved in liie Buhjeot of c&ricH and notroaia of bone, con- 
minHHion, chronic nlicenition of iiiiicniis or eutanpotis siirfaeeu, ete, 

'iliK alnute of alailiniit: ilriiibn in jjeuerally couhidered responaible for the 




SISKASSS Of TUB KtD»ET. 



199. 



occurrence of chronic n«pbntiflL It weuiB probnblc!, howoi-or, tbnt tlio 
effect w nut iinnidilUto outl ilirect, but is brought about hy digestive di»-.. 
turbanuuH ioiluced bjr the ^Ucoliolicn. 

Tbnt cfirviiic poisotUnif xcUJt inercuri/, arsenic, and Itad cnu iiiduco cbroDio 
iDflaniiniiiiou of tljc kiduuv itt cKlrcuvlr probubli^ 

lu a c'um^nttivcly smuU immber of (■use:* rliroiiic roiinl inflammation 
can bo <l(!rfiiiit«^ljr Irac-ed to au an acuie luyihriti^. This j>i-olougnlioii of an 
aculo iiiU) i\ chronic reniil iulliimiuatioD »eema to ockui' with rvlntivo fc»- 
({uoncy Tifte-T scarlet feT«r, erphilia. mtdmiti. and cxpotturo to col<L 

Uaiiilual owriTi'littiji^ni.r in iiilrntfm'unt j'tf^i in duubllcrM n:it|)OUHi1>ld for - 

many cmteK uf chiiiuic ii<-phriti8 as w«U itti of cirrboalR of tlie kidoe;. TIuk 
in nn iilmitiiL iiuiwi-Hiil Uy^'ieuii! error in Engbud and tbo Uutt«d StaLos, 
though it in imputidblo to d«t«naiiio mth uocurocy tbo oxtcLt of it« iiiJlu- 
ecce iu iirodiicmg the diHOuHe. 

Chruuic imr<!iii:]ij-iii»toUM ii(-p1irilit( ix rurvlj' obocirvod iu j'outli, being 
prflcniini^ntly an iiflV(^tioi) of adiilt life ; the B^iiiploms iwunlly upjwuj btt- 
tivocn the twentieth iLnd fiftieth yeara, Iu it fuw i'lmoA it hua bocn ob- 
aerved iii cbiMrcn itdlicted with coiigc.uitul itj~^}liilia ; in ouu rt-purlcd bjr 
BrtiiUt-}' thu tiMiinl fi'f^nn of chronic iKipljntLa wcrede'clopedbyachiliJ four 
iiioutliH old, tlifl Biiljject of coui^eiiitol syphilia Clironic euppiimtioa soema 
to pi'oduce iu chiidrc-li the oniyloid <U'g«»eriifio« T»thcr than chnmii: iii- 
ttatuiQatiuu of lli(< kiduoy. Jilales ar« more fri^qtiently attncked tlmu f6> 
niiUr.s — II fnat wliicJi in <luubtleea explained by the difEerences iu tho 
occupationi) of Uin tiexee. 

Alurhki Anatomy. — Th« onntomical np]>«iiritiice6 vnry extromoly with tli» 
[>eriod of the diiwtwp. Tbo tyjnuul kidiity of chroiiui DVphritiH i.i tliiituwK 
ully dfsigiiiitttl by Kuj;Utth niilhora the lur^e wliita kiilncy. XbiH is not, 
bowovnr, tho only form observed ; for this large bidntiy tiiially undorgoos 
contractiou (if the ptitiont survive loug enough) iulo tho hiuuII gmnuW 
kidney; yet the Kj'uiptumii — whicb are d«tei-miii«(] by mnoy other factom 
tliuii tbn condition of tlio Iuibi4-y — do not utceasarily uuder^o a change 
correHiKHiding to tlie nlteration in tbo renal Hlructuro ; hcucc all i^'adatioaa 
between tlie j^r;^ while iiud thu red ooiitiitiit^d kidney aro found [mhUiuoi- 
totii in CAsi-s wliii-h priHimt a. morn or lens pcn-fi-ct uliiiicid ]>i(^tur<: of chronio 
inrendiyniiiloua iK-phiitis. Wiijnier, auppoiUiil bvmiveittKicrmivn pabboh 
I Offista, beliorp-i that the Im-ge wliite kidney reBuftaas a rule fromaoom- 
blOAtion of clirnuic imphritix mid umyloiil dc^rimcmtiim. 

Thv brgu \\\i\Ui ki'hu'VH (AVilkM) may be fi'oui two to tlu'ee timca the 
UOrui«l Him iLiid corroHjximlin^ly iiicTfiuied iu wei^-hL Tb« eapBule ii^ tense 
and retnwts wheu tho urgim ia laid op«a ; it is often tluukeood and whil«, 
iu certain spoLs piirtioularly. The kuluey itaelf ia of ii ypllowii*h color ox- 
oupt wlifp: thu veMMilit urn deeply in JEfutetl ; thisiiijcotiou in conAiied rhieflj' 
to the medullary jwrtlon of the orgno. Tho yellow color of the cortex, ia 
intensified in a)>uU and atripcn fiorr(«ponding to jtortiouH oftbetubulm 
and KloDicriili nroiiiid which inflnnimatory products hnve nocunmlatod. 
That tbr< ydlnw Folor io due to fatty t)«fieuenition ia evident upon i^imple 
iuap«ctioii aud i* c|onii>ri8trntod by tli« nppeiinuioe nf fnt dropa upoii the 
knife. 

Upon microscopio exAinination the attention i«i flopecrially arrested b; 
th« pronounced de-^e Deration of the renal ei<ithellum. rhc epitholiid nt^Ui^ 
ohielly or even oicluKivtily of tlie convoluted tubuluH, i-\1iiliit lidrauced fatly 
defeneration, manifei^t«d not oidy by the prnwncA of t^muules and dropH 
of fnt, but alao Lv the coaleBcence of ocUb which tre^ueutjy obstruct tne 
luiuva of lliu tubule cutircly. 



200 



DISEASES OP THtE UICmABV OltGANS. 



TJiR intenititiid connPctivR tisnue exhibiU less pronoiiiK^d c1iang««, bat 
ia nevertlieleBs in a state of UifiamtnatioD. This ib indicated Itj tbo ]>rcft- 
cnoc o( iQiksscH ot ifucocytcu, whicb Hit; found chiefly urouDtl llio (•lotuerult 
and Dm coDvohiU^d tubtilex. A.n nHuni incrrcow) iu iho nmouut of matui'e 
ooHiiet^live titwuc ia also vi&ible at diflererit plHoe& 

Tile gloni«]-iili, too, proBcot cndeucca of ictlainniatxiiy nction. Some 
oltiie (^apsulfs arc filled wit.1i n granulnr ftlbuinino)i» ur fntty Hubstoiu-e by 
'irtlicb tlic ttifti) LhfiiiiKdvcit ariitMiniHTsesi^il ; tliocpillx'liiil coll» uro BiroU«lt, 
oflsii iirolifomtiiigr, and frequfiiMv fixliibit fntty don^-ncniti*)!!. The wipil- 
Iiiry wnll« iif ibf tufis may alao eliow fatty cban^'e aud decided vwellin^ ; 
the clomcruli are usually devoid of blood. 

At a hitcr Ktutr^ of tlio (liseoso ths kidney tu much dcei'^aafid in size, 
boin^t {H-rlin]Kt nvcn •iinnlli.-r thitn Llio iiomial or^'iui. In IhUt (^tnditioii tbe 
(leBfiitniU'd i-pithelinl crlls have disiipjip.ired, Icaviiiji. ])erhnp8. giiuiul&r 
mftBsos ill thd tubules. The t.ubt>g thdmR^lv^a ai'a collapsed, ev^u obliter- 
ated by adhesion of the oppfisito mdci^. Nimy of iho |;loni«ndi exhibit 
Kioiiha- dia[i<;(«; th« e»|iMilF<Kai-o thiekeiif^l, tJit* inrfiii thc'iDKelvcK idinmlceii 
or ev«n 1 runs (on nt:d into a hoiiiog'flneoua iiwaa devoid vf bloixl. SomHinK's 
the capt^ulo ia tilled vdih a dark tn^nuliu' luoaa, which pri;»iMit» mi &iiiii1arily 
U) the ori^'iiml sf riK^turi-, but whioJi in dt^c>oiiipt)H(>d with (•iTvrtt^iM.-tnce tipon 
the tttltli(i<)[i i>f iiilria acid. Tlitu f^roitiilur tttasM in the. nwult of ciddficatioo 
oosi86(lii<<nt upon the pri^viotiA fatly degeneration. 

At tbia staRe tli6 mtorstitial cotmectivo tissue ia mueh inoreaaod ; tlie 
mwspH of yoiiniro'^lM [iresetit ia tb« large- wliitn kidnry have bocono tj^tis- 
fonned uiio streaks of ri«iu«jtive tissue whicli frpiiiiently «xt«ud to the 
Bnrfiioe of Uie eortical jiortion and produce L-icatricial depieiwionsu In coa- 
TCOuence of tliiu new fitrniation of connective tiiisiic, tbe «tp6ule of the 
kiutiny in dacidwlly iitlhorfnt. iU surfiu'f imcvou Jind «veii {.'miiiUm'. 

The mif'rtiscopicr appt^raiiocM tjf thi-fm ki<liifyrt varj- acf'urding to Iho do- 
^ne of Hliriiikin:; which baa occurred : the aji)K>aranc^Fi chnrncteristio of 
Ute hir^e whito ^idtipy remain to a {p'^alcr or less extent 

III lb" lU'j^titiK oLlicT than tlio Icidm^v viiriium diiiiipoH lire nbiwrved; tb© 
wroun mvitieii contain fluid nnd RoniftiineH pun; the Innirs frequeaUy 
exhibit catan-hal pnemuonifv; the iutestine is inflmiied and the lower por- 
tion pcrlwipst ulc<-rat«<l ; tlio heart in dilated or lyjicrlrophicd. 

Suntjitiiinfi. — In a few c4Whii clironic nephrilis 18 n continuntion of on 
acute iuflaiuruaiiou ; in thc-M< Iiinttanaes the albimiiiuirii* nud dropsy may 
porxiHt in alight dcKTco after apparent convalescence from the acu te attjirk, 
luid may hccromo {;radii:illy more pronouuwd with thi' hipou of lime. In 
other cHhi'M iin iiit^-rvid iif Nnveral mouths or yenrs may i-liijii«i Ix'twvnn tlie 
subsidence of the acuto ncpiiritis and thn discoveiy of the (rhrtJiiic form, 
during which period the patient apparently eiij'nys perfect health ; liniUly 
a RnKbinl otn.-urint-ion and pallor, with pcacral d<'I>ility and ]>crlmp8 slight 
dropsy of thu (eot. dirout u,tt«ution to tho uriuc, uhere the causu uf tlie 
<lifE(rulty is rcvrah'd. 

In tlie majority of cnnen chronic nephritis is a prunary affection and 
lie^DB insidiouMly. At present dropey and albutainiina are ret^arded as 
the first positive Kv-niptonii^ .T iIk- atTedinn : but in manr, perhaps nil, cases 
the diHoaae hnaesisted fi>r -i-iiu time Vmfare theitcsyiiiploiiiN ai-e discorered 
or even diacoverable. \\'hilo a diafmoRiB of chronic nephritifi «an eaareelj 
be mode until the clinracteriistjo fcnturcH of tho iiruie are oliserved, yet 8UK- 
piviim of thin condilitm nbould l»e amiined by vurioux other symptoms. 
ThuH dcbihlv, ciuuciatiou, an uuuaual and persistent pfdlnr, occuiTing 
witbout eridont cause, should bo regoi'ded as aa imperative liidicatiou for 



DISEASES OF THE KIDHET. 



201 



the examiiution of the urine — not oiioc odIj', but Boveral times at iotervolii 
(jf itnvK — as noil an for au iuquirr into the liiHlorj- of the pativnt as to the 
previous occuri-euc« of ncute uepiuilis, 8y[?l>iliH. niaUriA, and tlie utber 
knowD euuecs of chruiiic ruiiuL iiilliiiumatiuLi. Tho earliest Byiaptoins of 
chroni'.* tn-plintia aiii ofton Rutili as ini»l(?ail ili« pliy^mii n.i Mell na the 
pntinnt iiilo a suspiciou of disonae iiv other organs ; thus it lias repeateiilv 
happenpU tlmt jKitientslmvo Ijeeulong treated furiuuunitii. tteii«ia!il«l»ilitr, 
elc.. witlioiib uuy mmpk'ion of r<-iml Ji>M<fi»M> ttitd ^viltifxit Any t-xiiiitiiintioii 
of tilt; ui'iiir, uutil II ^niduul iuipulnDvuI of viniou li.is letL Dm piitiful (o 
cousult All oplitlialmic Kpecialist ; thedificovGi'j'Df the so-ralleil albuminuric 
retinitis liaa led lo an examination at llie urina, wbicli waa fuuiid ioEul«cl 
with aJbumcu. So too a cliroQic diari'hiua \ian provtid most u1»Uui>te aud 
htiH ilctiod ospluimtioii niid trdRtin«nt until tho cnmlttioii ot tlio urina Iiu 
been discovered ; fn^ijueiit cliills have bet-ii contudereil walariul until ollui- 
miouria or (cdema kia been detectfiL Chronic (jiuitiitis, iot^rmittent dys- 
pepsia, "biliouii" att»c}i»4. nstluDaticBoiziu^s. palpitation ot tbd heart, short- 
nem of bruatb, ore luiiuii^ Uir HViuptoinH M'hii^b luu^ Ixi cauned hf elircmiA 
iiiflainiiuktinn of the kidney oven befom iIioibj has beeoine npparent, Thene 
it is true, tu'o more frcijiiently mialeading in cases of roual cirrlioeiB, siuce 
tbiit latter couditiixi i% t^ a rule, uot uootapruiicd "by the <i:duuiu wbicb 
iiBiiftily iitliwtit thii ntif-nl iiMi wiriy in tlio coiipw of ohronii; nephritaii. If 
M© wouJd make it a rule to exaiuiue tlie iiriue at least cheiaically iu ever^- 
pftae. if tlie fact were ffpuerally appreciated tliat sufb csaminntion is at 
least nfl tioccm&ty to a knowledge of the pntient'ii condition as tlko f^ehnj; 
of t.bu piil!t<-, it. is pi-»liable that i;bri>»iti iittphritia would be ofteiier detected 
at an early nUiiie. lii every case of olMcure difficulty affecting tlie nenernl 
Dutiition of tlie paliont or auy of tlie interriRj orgaDs, repeated eitainitia- 
tious ot thv uriutf, cbviuical and microwopitro), arc abwdutely vtmcutiaL 
At present it happoug htit too often (but iio suHpieion of rPtml dineaue i» 
entertained until the jMlient in nbu-iucd by ttio Hivclliu^ of bis feel, 

Aniaa;" the etirlicst Hmptoriis of diroiiiii nophntis is miaciatioii ; thin 
is UKually lU'eomimniod by u decided impairniMit of %ti'«>ngtli. MUiPliiiiMi 
amou*jtiug to »bM>lut4i debility. In many inilaiioc?* there ocrriir, eveu at 
an early flta;ic, derangements of 1!ie alimentary ciutid : the apj>etite in ini- 
pured, the digestion pooi', mid the bowels irre;;u[ni'. It boiuetiuieti Imp- 
pens thitt the ciuaciulioti and debility arc ri'f^irdcd as the i-c«ult uf tliia 
digestive ilinlur banco, or conwrnely. where, n» a inattor of fnct. lioth ar« 
secou'.luy to the more profound diaturbauoo ausociated with reual iuilun* 
tnatioD. 

I>rop8y orwura in almoHt every eaeo sooner or later. It is oftan notiead 
at first IU the ft^et, apparent in the OTeuiti^ and dixappcariug duriug tlie 
nijiht. In utbcr iiiHtAuces it may be general from the be^unint;, involr- 
ing tbA «ubi*i)bkneoi]M tieme of tae face, trunk, and limbs, and tilling tli« 
serous saon even before the iikiii is^^mittlv kwoUvo. Ill still other iiiHtauc'iNi 
tht dropsy is ronlitied to one or more lonnlitiei). the scrotum beiny often 
involved. (Edeni.i of the glottis coniitit uteu a dniiKeruiiH complication, 
usually occurring tu conncctiou with t^encml dro]>iiy. but Kometimcs (ospe- 
cially in nwoa of 8>-]jhilitti: orij^in) spx^oariiig biid<kuly uud without ex- 
tensive tuileiiia. 

Acute intl.im mat ions of seroun niend>ranes fi'eqiiriitly occur in the 
oaumo of tho disease and oonietim^s iiaber in tba atbu^k. Bronohitis and 
pfutunomai, (vdcma of tho bronchi and hin;;ii arc kImi obsiTv^-d, the hitter 
■omelimes befoi-p th« general dropy ix exci^ve. The appetit* is uaually 
inpttiMd : indigestion with or without vomiting, oud obstinate diarriuea 



309 



DlSBASSa OF TttE rm.VAltY OBQANS. 



in<licat« derail geuieut o{ the oliiucQtarjr funntiou. Itiip^rment of risioa 
ii hvifatiat ; it umiallv occurs (^fatluoUy, and not suddenly, sb in acute 
iivpUritja ; it is a(t«u oxploiiied by ibe appooninva of tli« reliiuL, wbicb in. 
dicatfia loaalbEed iuflftttiiiiutioii. CntarrLul or jnirulc^iit itiHiitmiinitoi] of 
the middle car in an ora-u.sianal coitijilicAt ti>u. I*roDouDcei) imllor. eiiuciii- 
tion, and debility iii<lii?ate the iiuiierfect state of nutrition wldcli prtiToils 
Etlirouglioat tho body. Tli« i>iilsc and 1<'niperntiire may rcuiain uonual, 
^lougli occasional olevatioiiH vl llw kiuily heat rtiM truummitly ulwefved and 
tlifl [lulae ■• at tixnea miihII itnd fi^ililf. 

Cnnliao bypettropliy ocrui-s not uuly in those <^nwH in which reiin] dr- 
I'liuBitt is develupeil. but idao wliere iid such I'luiticc in tlie kiiliiey in per- 
cwjitil.ilc jjost- mortem ; according lo tlie observatiooB of Ewald and Ley- 
fleti, it exitith !□ nbout om'-UitU the f.-sHos of hiiKo whitct kidutiy. though 
novel* in tlio iiriiiiG dcgmo iim whftn nsnociittcil with rnnnl cirrhcMifi. Acuta 
dilatation of the heart, usually tmiiDiciit, hna been uotiL'e<l (Ucittbr) aocom* 
panipd with dyKpntEa and cyanoaii*. 

In n utirtaiu jiprcentngp of csvws 1iyi>et'fi:'4&h«wn and pnrR«th«siA io 
Tiuions ytnTtA of the buily constituli! i\ proiniiKnil, nonitttinit-n indeed 
the liiTtt Kvmptoni. O^irasioniJIy the piticnt <!iini]>lainH that joints of 
fingers and tncH necm to be jiHinb and d^nd ; oi* they tnay be the neat of 
intolerable iluhiug. 

Tho urine fnrDiah4>8 moat chnrn^t^triatic and important Riirns in phiwnio 
nephritis. Tho (junutitv it na\ially diminished, sometimes even to 300 or 
40U c.c Sudi uli{;^uriii is. howev»r, trauHienl ; the qitmitity varieu ex- 
lr«ni«Iy, nniJ fiifiy t<'ciijM>nii-iIy oxhtriI that <if }i(.^nUh. The upcvific gravity 
Yuries iuTeraely na the t|UAutity, aouietimea reuvliuig 1.030 ur ovta 1.040 
when the olifim-ia is pi-onounced. and at-ain ainkint; to 1.010 or l.OOo when 
tho urinarj' excretion is more profuse. The nrino hna usually a dark 
browu or redtlinh color luid in turbid ; the liubithty depends pcu'tly ujKin 
tbc anatomi(<-al cJcmcntt of tho kidney and iirinnry <>hanni:'lii prr-iient, and 
partly upou the ncid ui'atea nhicb are kepi RUif]>eni1ed iu the albuminoua 
lluid. Tbi! urine coulaiuK albumen, oflen in lar>,'e ainuuLt, which may 
roftclt from two to four per (ionl. by ivoi^ht -of tti'i t1ui<l ; tbti piin^iitago 
Tiriea OK diiTereut duya and at lUflfcreiit houi-a of the s»nie duy ; it occa- 
aionully liappens that the urine ia Irnnaientiy free from albumen The m- 
notion in (wnimoidy ncid. 

The uriuiiry soltda ate nnually cxcnUtd in Irnn than the nonual auiDiiid, 
arm at on early singe of the iliMaKu ; thb ih ewpeciuUy tnif. of urea and of 
the pbospbatea. That the activity of the kidney is aeriously inipau'ed ia 
shown by the alow excretion of various lucdicaiucuts, whutte jiresencit in 
tltn urijie ran be detect*"! ; tliia tardinew of cxorrt-lmi hiu< ln^ttn t-Kpci-ially 
demouelruted in tho cano of tho iodide and bromide of polRewmn. The 
fact is one of great pnicliwU importanoe ; for there may readily oivur a 
I gmdunl accumulation of remedies in the blood of pntieut^ KutTi-riiig from 
[icbrouiu nephritis : tlict iutministi7itioii of uiirrotiL's, for v^uiuiple, in the 
uaiuil doMr» and at the onlinnry intc-rvola may rexult in nnrnotic poiiiuu- 
ing in coiiMetgiK^ncie of the diminished exci-elory activity of llie kidney. 
Jaiusveld and Stokris have discoveifjd tliat diiriug plironic ncplirttirt beu* 
zoio iwid ailiiiiuistertxl by tho mouth ia not convrrlijil into liippurio acid, 
although liiMibhy kidut-yit alwaya eflect IIuh clmm;e. 

Allhouah the ([uantlty of urea exereted ia usuaHy lesa than iu lieoltb. 
unnniio jKiisoninff is by no mennit fic<|tii'nt Th« rxplauntion lien douht- 
lesa in th(! fiiul that tlit; (juautity of urea producei.1 in muvh letut than ia 
health. Tha patient consumes lean niti-ogenoiut food, and tissue metauor* 



OISEASU3 OP TUB KIDNET. 



903 



phnsiii it Ipss aotiva ilinn in tho normal condilioii ; licnee. altlioufih the cs- 
cri'ti'ni of ui-eu Buil salta is less tlmn llist of a liealtli_v pernnii, it i.i umiollr 
8uffloteitt to prevent tlio iiccunniliitiou of these uriuiir.v in>,'r(.<iientH in tlie 
Ijinoil. Mucu urea nni\ uriimn,- snUn arc sliW Blorwl nway in the <:»deiiia- 
toim fluiil tlirouf^liout the boilv — a faiHt of pmncical iiK{xirtitiii^o ; fur Biai'- 
teU bug oUservetl violent \i!-*inin or>nviilnionti imiuc«<i l\v profuse (liapbo- 
RUBM (WAmi ImlbH) ; tliniirtnmc inioxicatiun in tliis ca^e Li bmiiglit iilxnit 
by the return into the lilnoi) of the droptdcal duiJ containing urva luid 
BuU. tliB a1>t3oi']iti(iii uf lliix lliii<l being promnl«il 'byoxccNsivH ptrHpinttion. 

Tboiiriiio pr<^ipitjitni a thi<-k white KetUmeiit ; luicrosi-ojiii? piamino- 
tion ft)iow4 )iu nbtiiKlanrn of tul>e-caaU^ at first cliiefiy li^vniiiie but aftn** 
want Rraniilni*, fatty, andepi- 
tiwliaJ lis well. M u iiioro 
Btlvuiicetl Htflge, broftd. iti- 
(lenbid cast* of gliateniug ap- 
peataaoe arc obBened, sug- 
geitiDR tho arciyloitl dejjtm- 
cnilion. Yot this ilcg^miTii- 
tion <;:»iiiot bo aseumed upon 
the prpsetloe of ocuaRiona] 
casts of tliU rarinty alone, 
niiiue tbsyare foiiu<l iu casta 
of siiiiplt' I'liniriid nophrititi. 
Oil the other band, the same 
oauses whidi product' chnjii- 
ie uophritis am nlwi jm^iduc- 
tivu of (imyloid cbftngp, bo 
that tho two often ocwur in 
Ute Kaiuo kidncv. 

Tin; cpithel&il cells from 
tho kidney wbidi aro found 
in tlie mdimont of chrouio 
jtephritis are iiot tisually rec* 
ogiiimbin im Kiirli, uiuco tbvy 
are far advanced in fatty det>enemtioii. Distinct cpithoUal oasts arts com- 
porativt'ly few, wbilo bi>;)ily gRiiiuliir rasts (derived from the cpithelinm) 
lire wry QtnnuruuK. Loiiciii-yt^a iirf iitnially foiin.l in nbumlnncp, fiml voi\ 
corpuscles can often be diacovered ; in exceptional caaw the qunutily of 
l))nn<l ia lar^e. 

Tlie [dmrnlnntro of liyidinu nnd pmimlar ca«t« Ins been ab'caily referred 
li> OH cliiinn'Uirintio of clironic iii-pbrili» Lii diHtinctiou from o!1»t fornw of 
ronal diitoilw. In a few caaes this featiiro is, liowi-vcr, idis<iit ; Acberinmiti 
obserred aucb au iusttmcv, ta whtcb, during the liidt three uioutba of life, 
tabe-Qiuts could rarely b« finiud. nttbmisb tliey hiu-1 been prE>vi<inKly abtm- 
(Innt ; upon senlioti tU« pHw?s<if lim LiiluvyM were found toconttiiti >wT»ir)d 
dificbnw of yellow dliuiy liipiid. foiiml upon niicrosropio o^nmiiiation to be 
ItUnd with tubo-ooal» which bad settled tu the pdvia and had sot escaped 
with tho urioe. 

t*our«; flfid Duntion. — Tho diiieiute is frequently fatal within nyoar.bnt 
luM bdMi known to last for six and o*en eight years. It in often oompli. 
«ftted by acute exacerbation, or ratlier bv tlie ocuurrenco of acute nepliritis, 
to wbteb the obranically iiiflAmed ladney ajipeais ecnecinlly predisposed. 
Sitrh altnekn are accompanied by tlie npj)«irance of blood in conwMmblo 
({Uiuitity in tbu urintt. Uu iliu* otluir hand, rsmitnons oftcu occur ; tlie 




Fla. II.— Snllnlcal Cram Cbruelg rwnghrinUow Xk^ 
lihrlUfi runtAltilbg hfidlD4^ gimaiLlic uit) fitUjr omaa, faUf «^- 



.304 



I>1S£ASB3 OF TItK UKIK^ARV OROANS. 



■Kentioa bocmneti more abaodant, tlie dro[)«r (UnuiuBhM, the olbamen 

Ppfffj— ttora ibe ui-inr^, and tJic patient'H f^tucnU i-ondilion iiupiiivvs ao 

'ttuoh as to ^ncoum^o tli« Lu|)« of rc>(>ovcry. Ynt oiUier from mhuo im- 

jinnUnce on tlic purt of Ui« putieut or bom iiuknovru causes, the ftjmp- 

toTiis of the (lUuiuiG luniollT recur with Uicir ori^iial force. 

Tli« fatal temimatiou may insult diivotly from hdv one of several tfoin* 
Ijslicatioiis. lut^rciim^iit itiDniiimnlionA of thu ncruus iiienibnuic« or of llie 
^infTM finiqiieiiMy cut. short thtf life of the imtient; «ni':^ii>el£8 Hud gmif^rviie 
of the akiti imiy foUiiw iiiciiiiutix for tlie relief of thi" drojisir. or KpoiiU»irott6 
biirBting of tlie nkiii ; intleeO, they may otvur without any HoliiiioQ of con- 
tinuity. ThriHnboma of Tt-ius follow(>d by embolitim iu the Uihkh or the 
brain ie soinctinws oVhht^-piI ; siifTociition may irwiU from vKtcnisivc »u<l 
sudden etTiisiuu uf Ht-rum iiiU) the pulmounry (dveoli, the bronchia] ttiWH, 
, or Uie glottis ; otitttiiiatu tbtu-rho'a and ilyttcntery may hasten the exlmiis- 
Uioa of the patieut ; anil gx^aeral maranuuH iisuidly occiini if tbe patient 
'Escape & fatal rvsiilt frmu these complicatiouB. Iti coiuparativ^ly nre 
CAWM ili'aili rcKultit from <'<Ti-)irrJ ln'inorrhngv ; mii'Tiiin is less fi<(.*({iuiat 
than io reiiaJ cin-liosi-i. 

Iu other insLniiL'€8 the two most promiiieut syni))toiiiB — dropsy and 
nlliutniiiurin — dimippcrtr almnut onUrcly ; t\u: urine i* now cxcrtU-d iu ei- 
oess fttiil cniilaitm inily a trace of albnnieti ; the patient's geiieiRl condition 
improveo. Theac Bspna usuftlly indicate, not the nuhsidence of the rennl 
affection, but its transition to tUp romtilion of no-ralli'd inttrstitinl iiitlnm- 
mnlion, which may jieiinit tbo iiitlivtihial to livf ttir smial yoKi's iu coiu- 
jimiilivo <-iiiiifiirt, but w Mirt; lo tifrinintitc! fnlul!y. 'J hi* ilevf!(n^tuirnt of 
iucreiu^cl ai'bei'ial tension nnd of hypertrophy of tbe heiurt ooudruis the 
belief 1 but suc-h traiiration in ocuuning. 

Waffncr bus ronciifly ilciwribcd iinilcr tlio nnmo "cbmnic heiiioiThapic 
Briebt's dincime wiibovil a-ib-tim " a fiirni of n'nal inDriinnifttioii tlmriicter- 
iz4Ml by rcenrrinK' hn-rafituiia. {which niny last for Btveral days and bo ob- 
Bcrvcil at intenals of weets or inoiithH), and by nii entire nbeence of 
(fdeind. Dnriu}! tboxH iutt-nala tbd iiriu*^ itseiublcs that of renal elrrho- 
LttK llic ^u^^i'ilI huiULh i» not iniitfiiidly iHoiturb^ ; the dieeoM' itiny 
'list two or more years. Aufrecht resnrtls this oii a chi-onic iuteistitial 
iieplirilis wilb jH-riuds of htimorrhu^iu inflaiunicition ; thiH vonceptiou 
iiieetx u seriouM obji-utioti in ihu fitc;t Umt curdiui' byjiertrophy ih iiHiniUy 
sbseat. 

Bartpk deupribeH iia "itttackc of interL'urrent acute iiepbritia iu the 
cntirM! of rt'n.'d cirrlu'sis "' (i i-otidition which FdrbritiRer's in vent if^ttt ions 
,lead him to re^.-ani its "nonte heinnrrlingic Bripht's diften&e during; chronio 
picphritia previously devoid of Bymptoma." Neither tlae history nor Die 
cncatiiinutiun of tlio urtut^ rr^vculn a chronic inflammation of the kidney ; 
there uiny bo even no albuminurin ; the phystciiiu is couHult«ii eitliei be- 
Ciiu^ of Ihu hemorrha^ie atliii;k ur {>t) ntroount of koiiic Ronij>li(viti»K ufFeo- 
tiou, espocialiy cousumption. Tli« acute retial «yinptoiDB may subeide aud 
Lthe urine hu(»)in« pErfec^tly nuruDil ; the di>4^io»H of ohronie nejihritut 
fvest*, Uiii«ifon>, upon the poxt-inovtcm oxnminAtion. Tho caBO ooiDtniinly 
lestilt.t fiilaJly lit ail enrly dute, though rather from the coniplicating dis- 
ease tlmu from tho nephritis. 

Diagjumn, — Tb« recofinition of olironic nephiiti* is usually easy nU*yr 
the dropsy luw hecoaiu » iiuticvabti.^ syiuplom. From acute nt^phntu it vi 
diftlinj^'iiLMbiiliU by the liititory olon^ ; hIho by th^ tibitenc.c of blood from 
the H«<.hRicut, extensive dropsy, and nature of the casts, It is to be re- 
memb»rL<d that an acute jiephiutis may coiiipUcnle n elironio rcnal inflnm- 



DtSKASRS OF THR KIDNKV. 



so; 



matioti, m wliicli onae tlie diagnosis nitU upon tlio Kj-iDptocM aiwl prcnaud 
bistoi7. 

From rcnftl ritrhoBia chronio nepbritia is distinpuiBhed by the tact that 
the toTtncr in rarely a<:«oini«iiac(l liv ilropKV ; in it tlio oxciftion o/ unno 
in «>KC(-»MTe, tltf! nlbuiti«n hIi^IiI, and tho Muliniciut stidUI ; moreover, byp«r- 
trophy owl dilatation of tb<i ht^nrt itnil nn abnurinully tt^iisC piilae nro 
aliuotit couslaut ayiiiptoui^ of rcuul virrliosis ; olbumluunc i^liuitia snd 
ui-fDUio attiiL'kii freijucntly oci'.ur. At a Inter RtaRti, when roiilraotiuii of 
the ktduoy hiM taken pWe, tlio symptoms are practically indistingiiinhnblw 
trom lliuau of reciul cirrbusin; for Ibo disi'iuMi is cascutinlly ideiiticAl iu 
bothoaaen. A preiinuii bintoi^ of dropity, proiiounrfil allmininiirifi. etc., 
abovs tbat the piegent affection is a se<{uel to chronic uspluitia i-aiJier 
than a primiry k'sion. 

Thn •liHtinotion rif vlironic parenclijniiatoiu nephrititi frotn ninplo amy- 
loid ilcgeuei-ation of the kiilnej is often difficult and even impossible. 
Etioloj::)'. (n-niptoni)), and uruinry appeoranceB may be identical or at lenst 
indifitingiiiHbAblo in tlio two; moreover botb nffeciions ai-e often present 
' iu tbs some ctwe, iniUiccK'l by a cmiiuion CiUUfii-. Iu ri'niil iutliimmatioit tbu 
f, Oksttit obaervcd in Uia urine u-tually kIiow dnnidod initv <lo^''ii(^ratioti of tbu 
ppitbelluni, which ia loss pronounced iii the amyloid condition ; in the 
latter tbo cit-rctiou of uriue ia oftBu grtutcr tlijin nonnal, wliilo in the 
L former it is l^'ss. Iii clironic r^nal intlamuatioii tbere is tumidly an nbuu- 
\ donf a«diinetit of cosU and cpilheliuta, while in tlia amyloid dv^^i-iienxtiou 
thera may bo no aiipredable sediment. Enlargement of the hver and 
spl<?en and n pFi*8i»tcnt dinrrhwn aro nioio froquontly Bymptonia of the 
aniyluiil di.-mgu ttiaii of rbronic nephritis. Ytit iiuiio of theso dilTL'rvnticii 
nan bo rolled upon for a positiTQ di'i<,'noius b^twfieii tlio two atToctionii ; 
fortuui\b>ly Hucb tUfleivntial diagnosis ia not abaolutelf esaentinl in treat- 
nifnt. 

I'rtivioun t« tbo fipponranoc of ilrop*y, Ibo recognitioD of cluunic n*^ 
phritiii is difllculi; aud unoerlaiti ; in a few oosea pei-ustent albiuniaurin 
and thf presenoe of jjraBuIar caiiU iu the aediment roTeal the cause of tbe 
obaciiro dcrnngonwnt of nutrition mid fiinctioiiit which la itnually prcMint ; 
but it inunt be i-emetubcred tliat even peratttcut ulbuuiiiiuria of alight 
desrep dons not. in ibn ubsoiice of j^rnnular ensta, neoeBHarily prove the 
existence of renal iufliiinnifitioii. If tlioro bo decided loss of tit ah. debility, 
p'?rsistont diTin'buri, irritabiljiy of tliu alumach, or otlii-r iinpiiirtiiunt of 
fiinctirtti of ob*'nn) origin, eiirefnl and roiwatod cixainimiliiMi of the nrina 
bUouIiI be tnadc ; i\ history of previous eyphihs, malaria, etMirlet feror, or 
ropi^ated iircgiianuicH cODStitutcs au oddihouid rcaauu fur lbuiY)ugli ex&in- 
iimtion of the uriiiis. 

Attvnliou Ime already beeo direot«d to the fact tbat onneral arterial 
anirmiii, with or uilhout Tenous con;<e!itioti. may cauae albuminuria aud 
t tedema of the leot 1 thia condition is hreqm'iit iu cases of valvuliirlicart dis- 
L ooair, ubrouic niohrial iufticLiun, advauoud (^ouitumpttun, flu. Tbe uL^eeoos 
of pr^iiouii'^nd ranal liisoaso caa be determined in Rui^h <-ai»eH nnly Ijy n 
mii!i*oscupic oxaiuuwilimi of the Balimeut, irhioh reveals tbe ab6«noe of 
epitbslial and gi-aniibir costs. 

Prvrjnogi^ —IliiH ia ^nnernlly imfaTorablo ; yet instanoes of recovery 
fi-om cliroiiio nenbrilid (or ppihapH amyloid dei^eneration of tbo kidaey, 
fi-oin whjoh tbu former afTectkiii is often iiuli)Jliu>^i8lmblo intra vitam) are 
well autItenticnlo<l. In tlucsc caM^ th<! rcntj itfFiHrliou accnia to bave boon 
induced by Rrphililic nr malaria) alTection and to have yieklei] to nKcific. 
troatmeot In sucb inetaw'es a return of the symptoma id apt to follow. 



506 



niaKASKS OP THR TmiNART OTt<lAX3. 



thou^i thcBA cnn be ngnin dtttpollMl by stnilar traatmaaL It. is therefore 
CxLromcIv iiiiporlatit to um-^rtjiu) if powible the prasence of sucli infection 
OB N ^itie tn progtiosia as w«U as lo treament ; and to retuvmber tliat u 
cbroiiic n^hritit) due to s^biUtic inferboD oiul yielding to q>ecilic treat-] 
uout, mar occur ia ao iuiUviJuul who htm bvm for years cDtircly frre 
from othor cvidr-iitxw of tlio ejiecific tauit. Tlio rennl eyinptoms may exist 
vritbaut nny otbrr iiinnifcHtiLtion nf KViibiliR, iintl Bitoply in ooiumdu«iicfl of 
«5ix>snre to fobi or eirora in diet. Eichliorst r«IiU«« the following onae : 
A mnn ft^qiiii-f^d sypliiliit iit tbo iigo of t«-cnh'-liv« ; tax inniitliR liili^r nlbii- 
niiniirin iitiil lliu rnfion of ohrnnic pareocbyinatouH iiei'britia were ob§ervei1, 
but diwipjiMTinl uuiler tlio une of icereuml inuDetions nnd wilpbur bnths. 
Four yi-iin* luler & FclnpHv of tlie rpnnl nfFection njnienrpd witbout |iprr<-p- 
tillo cavjBe and was a^in ciu-ed l>y iin(is_i-i>biblio ri'Divdiv?. Kifteeii yearn , 
nft«r Bciquinug itjpbiJiB, and ten yfiortt aflor the but nmnifotiTntion of tlio 
infection, tbo patieiii hnd a tliird attncJc of cbrooic nepbrilis, promptly 
nured by tlie iodide of potamtiun] aud iron. In ihe absence of tfaia or 
other KpeciSo infection, bnt little hnpn of n>cnv<-T7- can bo entcrtaiDCtl ; a 
companuirely sudden onset of the diaefiBC, the early njijieflronce of drop»rf, 
nud pronounced tdbmniuuria offer n Itetter prospect of recovery thun the 
more iniii<ii<iuit iliuI vlironii^ ntt.ick. 

Trvatmenl. — Ibe therapy is OelcnniiKHl by the etiology of the disnaso 
in th'OBfl caoeM in which it can he trBe4?d to a definite and speoifio infection. 
Tbo exiittcnoo ofn syphilitic or itiiilai-iiil Initil, er^n tJtouali it haro l>eeo 
long InU'nt, in nn iii«li<-:tliun fur the une of reuiediCH especially B(]a|>t«<1 to 
tlie relief of these attiri^tionn. In aom« ensea the nephritis can be tnw><Nl 
with consiilcrable prvibnbilily to Home other morbid con<]itioD, Ibe removal 
of whicb niiiy pi'rbiipiK be fullowcd by recovery trom the rcnul L-omptaiot ; 
IhtiH it luut n-pentcilly linppeaod that n nrplinfis dovolopt^d in ttin course 
of chronic Huppumtiou, Uua aubsiiled upon the cesaatioii of this discharge ; 
and Bardt'lebeii enw a recovery offer lunputation of n leg vhich had been 
tbo Bi^nt of obrojiio iiiippnni.tion. It is jiist possible Ihnt the mini cotu- 
plaiut in tbeso miripcal cawii\Taa not inlliininiatiuii but amyloid degeu- 
eriitioii. 

H tbo jicpbritiK cnnnot b« traced to any one of these dcfinita and 
remediable morbid condition!*, there appcan to be no way for inflticncinf^ 
direetly the condition of tbo kidneya. Tlie indicntiona for treatment aro 
in that owe : firsts to improve the condition of the blood, by Biipplyiii}; the 
iiseded iiif^rodicuta and by reinovin;; the iirinnry {OiiHtilueiils with wliich 
tbi* rrinnibilin[f lluid is cncniiiilM-'rc-il ; nad hcc^uikI, to provoat and ndii-vo, 
8o far 03 possible, the coiupbcatiosQ vrhich frequently accompaoy the com- 
plaint 

llm fint indicnHon. the repair and nmintenance of nutrition, must be 
neciirpil by a proper diet rather tlinii by inediciii«H, Uiough tliesc have an 
important Bulmi-ilinate position. The ivfrulation of the diet ia oft*n 
a perplexinj:; matter ; for the ftlimeutary canal ia ao irritable tliat iho 
moMt tiutnliou8 diet provokes ffastric nueasineiia. voiuitiu;; and pur^ng. 
If Ihi^ Rloiiuioh and Vioivels pemiit. the patient nhoiild pnrtnkc lilifi-nlly 
of tish, e;<^'H, nulk, Yi-^ctablCH, fmita, and fiit meat, and a^Muiu^ly of lenu 
meat If tlio ittnnia4>b bo too irritable t/i pomiit a mixed diet, or if aitch 
food eeem to agpravate the symptoma, careful experinieutation must 
disoowtr what mitntious articles are best retained and digested. Au es- 
etasmly milli diet liaa b4<en much reeonimenrled, and hFie proven es- 
tmariy beneAcial to those patients who nui onnifoTtiibly di{^xt tlireo la 
four quartd of unfikimmed milk daily. The quantity of urine in increased. 



DISEASES OF TlIB K1DKKV. 



20; 



the ncnouiit of ftl>nim^n <1iniii]i«lie<l, fTAHlric and itil«titiiiftl cotnpllcaliauiii 
nro RiibiltiP'l, luitl tlie (^n«nil condition luucli iitiprored. UnfortuuatHy 
manv pnticnlH cuiiiiot endure sudi diet, «veD witli the Ailditiou of coQii-e 
or cosuiiCi "B re<;oiiin)ct»(l*d by Wapncr ; yet by conibiuinK otbvr lood 
with milk nt first, the piitieiit's stoiiiocli cnn sometiiaex bo (>dueftted to 
tlie exoliieivo milk di^^t, 

WlmtflvtT iii-tinlfls lit food bo selected, care Bb»ul{l be taltetit liAt nl- 
biimeu ift ftuppliod ia nbiiiidiuicn ; for the i)nti«<iit in miflmni; n, coiiat&nt 
driiri, innovintiuK pcrhnpa In two, thrcfe, or cvt-.ii fcmr dntc-htiiK of nlbiitnen 
daily. This loss of milrilioiis luitterial must bf 8«i>j.)lit"d, ctou if tho 
ftlbumen etcrotod 111 the onne ini^refiA&s 8om)>^t lint upon midi diet. For so 
iouf; ax the blood receives from tho stomacb moi« idbumen tbitn is loet 
throngh the kidneya, the MBCt degree of albuniiuiirin is 11 niiiiur item, 
aiuce wo hftve do proof Umt th« pfiMtngc of iklbuciMD into the uriits nggni- 
Taten iu any wiiy tlie reiud nfTf^ctioii. 

AnoDirr titipoi'tant it«tn i^t thnt food ithould be sappHed at iikortin- 
t«rvalri and in coLupirnttvclv Kmiill qiii]).ntiti(>s. 

Tlie KiibJL'L-tH uf ctiruiiic nepbritiM »n> inrHriiddy anieoiic aad derivo 
much benefit from the continiiou.-t lulminiitlniHon of unn. Tho tinctiiro ot 
iho oltloridb combined vrilh sweet epirits of nitre ia (^ucrolly wtdl boriM ; 
&n to aitfien miiiiins mny lie aduiinistered three times daily. If it oause 
distresa at tbe iiloniiich, RMhiini's mlxtiiro should be trictl; tliiM mny ^ 
preicribcd im follovra : 



1'inct. ferri cliloriili . , , . Z >]*)& 
Acidi ocet 3 ij. 



^yrupi sinipUcia, 
Aquiu , 



.ad. fvi. 
Liq. iLntmou. U'etntitt. . 
M. S. Tablcopoonful three tim«8 a day in half n gloasful of water. 

Tb« citrftto of iron and quinine in Also n Rood form for the ndministm- 
tion of this remody, AdrantaRe may bo derived by combinint,' HtrycJinine, 
quiiiine, ur (tentiui with the iron ; the following pre»cripU»ti is useful 
iu sucL CMOS: 

Feiri redncti ^- xv. I ExL nocia romiicis. , ... gr. iij. 

_ Qiiinin! BulphatJa gr. xi:. j 

M. I'iuL pil. na xx. S , one before Tnoala 

TI10 dmia ujhui tlic njRleni, oo[a[>dn>inti>d in Mmie degree by food Ull. 
clruga, ran Iw luueb dimiDiRhed by bodily rent Tliiit iit a tiiusl important 
item, the value of ivhich is readily seen by compnriu|{ the nondilioti of tho 
palienl uiid of tho iiriuo during n period uf ai'tivily with that observed 
during an inloi'vnl of ix<Rt in boiL Aiiotlitr a<1viiiit»;n) dDrii«d from repose 
in the avoidant'e of middon c-h»n[^M in ti'miK^riitiirc. It ih not iiil«iidei1 
tlmt tbo pnticnt hIiouM Iip ronlined to a clone room ; nirnnd n^rrpittiou iiro 
(Hiw>utia.l. htit they should be Befiured with the iea^t poa&ibht expenditure 
at tore». 

In onler to iwlif>v« Uie kidneys of fuuetioonl activity aud to Hecure the 
oxcretton of the urinary ingT«dient(t, ihu Kkin and th" IiowcIh Hhould he 
kept active- Except in the Inter Rtoges of tho diacaae, a miffirieiil ilttfrne 
nt eiitaneoiiA Activity cnn be secured by warui oloUtiug and frequent wann 
bnthuig. The inttcint nlioitld wcjtr fliuiit<il next the nkin in all aeanoofl, and 
aboiiUl most carefully aroid exposure to onld and draughts ; iti<levd, if cir- 
Ruinslancea permit, he Hheuld reside in a dr>', wann climate which docs not 



208 



DISKASE9 or TinC [TRlNARr OIEOANS. 



cxliibifc sii<]<1»n cliaug^s of tempcraiurv. It mnj bficomo ii^chbi^- to ne- 
cure odditioiiul c^crolion bv tL« skin ; ia ihia case pilocarpine may be 
administered. Frequent warm batbi and rd ot^cosioniU wet-pack vill ilo 
much towaril promoUii^^ cutaneous activitj witlwiut tlir ilcpreB*ing aud iji- 
iuriouH cflectfi of more TigoiuuB meaeurea. {Het Tr«atiUi-ot of Acuto 
Nppliritis. p. 194.) 

IjiixiitiTK.t should not be employed until it l)ecoineH evident tliat the 
akin alon« Ls iiirapable of supple lu cut inR t'omplctel)- the renal fiiDClioii ; 
for tlie uileatiual tmei is uauallj' in a stato of irrittttiou, diorrlxBa being a 
frequent feature. WTica tbc drop»v litis become «xce«Mvp, liowcvor, it ia 
If necOHsar V tii pr<HliiMi ptirgntinn ; tiiia kIiouM also be indiiood al llic lirat 
rlulimation (if uni^Tiiic poifiouiu^. Elaterium — on^-eigbUi to onefoiirtli of 
a grain — or a drop of rrnton-(»il miiy be oc^oiuoanliy cniploved ; for more 
habitual usp, Uie eonipouiid jal.tp jjowilev or HiinyaiH wntpr is lees objec- 
tiniiiible. Fn>o purgaticiti nipidly uffeets tbe patient's stn-n^li lui woll lis 
t)ie (1n>pHy, and sboubl be discontinued ho noon aa the ini]>erativ« indicuk 
(don for ila(jm])Iiij'ment baa passed. 

Aa to tbo kidnoya tbcmsolvcis but Uttlo ciiu bed one. By rcf^Utin^ 
tlio dint iiiid liy proliibitiiig nctiro exerKise, tlionmouiit of urea produced 
can be Itcpt ivl a miiiituuiu and iho demand for secretory iiclivity iii tli* r«. 
mil rella noiTPspondiiisly rcduct'd. By liin int;e»lion of an ubntidanco 
of pura water, tlie urine in diluted ami the proiluols of infLiinniiititm re- 
uiovL'd fnun llif i-npHuli-ii aud luliuli-.i ; tlie piilit-nt nbmild drink bsbit- 
u.'illy a niilrl alkaline wnler containiiifj: but liltic if any of tiie pntnssinm 
salts. Tbe iujportance of this measure is scarcely appreciated auion^ us ; 
our mintnil wnters nro but loo ofH-n ]>i-nncril>ed pntndccnotifly and rtn- 
piricaily, without an iiilctligent niiprRRiation of the objects to be nttairiHl 
or the meauR for Attaining; them, Tbe sufferer from chronic nephritis is 
bcuefitcd by tbe free uae of ou alkaline water vLicb does not contain an 
4XCMS of mineral iu^rrodJonts. Under it« uho diHordcm of the stomacb 
and intestiiii! are much improved, tbe albumen excreted is diiuimnlicd, Iho 
diTJpsy decj-eases, and the excretion of solids is oft*rii increased. Without 
ifnionnj the other factors which exert a lionfficial elTcrt at the diiferent 
Hpriiipi, it is certain that the free ukc of the wati-rH nl(iii« is a iinmt 
vahiahle fe,^tu^e in treatment. This Uan been often demnnslrated of 
tlie Vicliy, Carlsbad, and Marienbad waters ; they can be ftiken in ^uan- 
titles suflicical to pmduce a marked ctFect upou the urine tuid upou tbe 
general h<'jUtli. ■nithout irritatintj the ink'tttitica. The waters mory bfavilr 
Indeu Mith laxative sails— siieli as Hmsyadi Jimos— should be avoidetl. 
The effi'cta of the variona mineral watei-s of the I'nilcd States bavo rot 
been ao carefidly studied aa to permit a positive sl-itprnfuit as to Iheir in- 
dividiial npplicationa ; those of the Arr«dinii Hpring, Waukealia, Wia, and 
the UutTalo Lithia. Va, hi-« amon^ the bext 

If the patinii can be pemuaJed to ilrink an abundance of bucL mild 
alkaline water— tbe quantity being rfgulnted by the cRVctn in *acli in- 
dividutd case — no diurelics are nequireil ; iiljjerwise Ibe cxin^tion of urino 
nbouhl bf! furthered by Hsiuf^ the citnite or acntate <if |>olasHium, which 
may be ronilnned with the iiifuaion of digitalis if tha heart's action bo 
feeble. >[alt )ii|Uors are allowed in modenite quantily. but wince and 
wluBkrv Rbmdd he einplnvcd as uttninlnutjt only, if at all. bi adminiKlt-ring 
ini^diciiic:* n» well as foinl extreme care should be taken to avoid irritation 
of tlio stomach. 

Vnriona remedies hare been nt different times asserted to possess the 
pow«r of diniinisbing th« «xcr«tiono[olbuiuen iu cbrooic nepbritia ; tjuinic 




DISEASES OF TIIR KIUNKT. 



209 



fjuad gallic actdfl, encaljrptua, ergot, niLi-ic nciJ, aud more recently fuchsiit 

ad nitru-i^lyvcriDft iiavt becii cinpluTcd fur Uu» puqioHo willj, at hfMt, 

^doubtful HuooMia PoHsibly encli o( tlie rcmediiis liiui (.■onftrrPil bonelit iu 

pnrticiilar cases ; but their promiacuoua employ mm t liua ceriaiul;^ failed to 

Biibslintiato tlio (iLiiiuH nimfi; for tbem. 

Exceiwivfl .Iropay rcqiurt^ tnocliftnic&l relief : ihe fliiiil in tb« kcfous 
Lcaritii-soiiii !>(• niuioved l>y llie tiHjiimlor, nii<l in tli« nuljvuUiueoua tiasua 
|l>y Hnutbey'fl tulws or tii('keU|)]ated livpcxlertiiic ne«iliRH. IncdfliniiH info 
[we skin abould be nvoi'lei). mice they promote aloughiu<; nml erysipolas. 
^ ExcoriatioDS, wbicb fii-qucnlly occur on tbc scrotum uuil tliigliH, ato be 
ofloii boiilpil by (lii^iiit; with llif* uli-uie uf -/iiK'. 

The jiattiriiL should b<- iiii|)ri'HK(Hll wUb tbd neprwrity for a cwef ul ob- 
BervaTico of tho hypcnit; ami ilipt^rio rftqniremeiitH of bin iiiiforLmiatc nit- 
uftlioTi : for in thia way he will seizure th<^ (;r<.-ate*it probabiUty for nvoidinjf 
thd (!(>iiiplic'jttti>ii» wbivb no frttcpiontly tj^rmiimlo Ihii rnM. 

Dixni'derH of tliH ntotiinnh And boxveU cifteti complicate the raM and 
render Irentmeiit more iliDioult, These diflordera iire oflt-mlue to (sd^iua 
^of tb« iuttrsiiuol nm\ gastiic mucous tacnibriint : th(.~ir buoi^cwtful laanago- 
tent roquir«a the iise of ueAmima wbtcb diiiii[ii<«h Uie {^<uoral drop-iy. 



ClRIIHOSn OP VBB KlDSKf. 

Renal cirrbosia, or dironic intenititial nopbritis. occurs either aa tlie 
fie<)uel of «brnnic ]mroncbynutt'>iis iiophiiti)* or nn n priiniir;' alToclion. It 
in prm-ticiUly inipoHtiiUo to .U-tpriniiH-, i-xi^cpt by » hiiftory of previoiw 
radeina, nJiether or not renal ctrrlioun in a given case is priniftry or seo- 
ondary. 

htiologi/. — The diwMo in obwrrod almost exdwnvtly in middle or ad- 
Tnncod li^ tbongh it in ociiomDnally found in yoiiiiQ persontt, in obildreii, 
and evwn in infants ; Buhl reoorda a case iu n child eighteen moatba 
old. 

Tiw MusiM of the giirnctinii aro ohictly (v<rtAiii intliirtneos pociilinr to 
ndiih life ; several of these ai-e well lUK^ertaitied. Oout is a frMguent pi-e- 
cursor of renal drrhoiria, which ia iinduuhtediy caused by th« same fartow 
that induce tbo gouty coiitbliou ; po<iiiLbly the n-tetitton of uric nctd in 
tlu blood, deuontttmted iu vm>ni of i^xit. may bu thu exciting cuum;. 

Hiah living, with or iriUiout, Win ilovokipment o( gout, is (H-rl(uidy n 
siifHcicTit cause, pceounuibl^ tbniugh the iiveratimulatioii of the kidneys in 
the i;lSjrt to remove tbo oxcennve iiitroKenoiis waste materinl derived from 
the fowl. Itio nbuHO of alcoholic liquors is frequently followed by rfttinl 
cirrhuais. which, uith mri-hoMi* of tlic liver, in oft^-ii m-cn in Ihu Imbitual 
rlrinkcr; the Gernmns nre inclined to doubt the frt'^iufncy of this nlTcc< 
lion na a result of idcbolic excess. L^ail jjuiitoiiiiiK in » fretjuoiit cause ; it 
is pnasible thitt dironic poiimninK with other ineliilsiunyal"" pnxluce it. 

Chronic inflAiunuttion of tli« urinnry ]Miasn<;(iK. pyelitis. <>yiititi«i, and 
■tricturc are someiiines followeil hy rciinl cirrhcMiii; tho conufi-tion be- 
twoon tbo two in not clear ; ]>nSHihly there oocuni an cstension of tbo in- 
tlAmmatory proo«8ii, thoiii^h the autopsy does cot as n nile siipiiorl this 
new. Some aulbors aro iuchucd («> nacribo th" r»-nid^iffi)i-ii(iii to the in- 
juriouii inlbience on the kidiieyH of the variotw bnlsatiH ami oih which are 
I OODttnonly lued in tho trejitment of iuihuumatioua ot tbe bladder otid 

Varions constitutional conditions nko prodi8ix»e to it ; Hynbiliti, ras< 



310 



DtSEASBS OF TUE URISTAtlY OltGASS. 



laml fovem, clironic (Ii8«A8« of bune. wliile more freqiiruMy p]t>JiiciD(T 
aiiivlniil clmugo QV fhinmic piiri-nclij^nntouH iirplintix, ore altto iielt) nitfMjDsi- 
blir foi' ifiinl ciirhoBis. I'rom tbe fretjueuc^' of tbis affectiou in meu of tlio 
iippur I'luKHt^M. it biui b«en asHiiined that prulon^U iiic-utul anxiety ifi mifK- 
cicjit to iiiiimxi tlm (li»cii«p ; yvt it is fs]>rci«lly ilillicull to <Oimiiint« the 
otber powible intlueiicett to wbicb such iudividiialK, frE^iiuciitly pvcu to cs- 
DMBes of vnriuiu kiudB, arc Mposed. 

Hvroditorj inltuciice is by most writers connilered an important etlo- 
tf^cHl fiictiir. It is c«rl»iii tlut viuiuiu luembfrx uf tlie saiue fiuuily lire 
bvqiiently the Hubjecln of tht; afToctioii ; lliiin Kii-bhcirHt tii<-nliniiK n f:itiiily, 
Mveral meinbenf of which hnw coin« uuder bia o«ii ubeervation : the 
gTudtnotber dieil of r^nal disLUiie vritb iini?mia. the mother hastuvl for lif- 
U»n y<!iirH tbn HymploniH of rcnn] cirrhoBis, two sons <lic<l of iii-iitnia. nn<l a 
»iaiij::litt!r twotity-two yean* oKl Iiii-t the Bipna of rirrlioBis of Ihe Lidiipy. 
Wliiie the fairts are umioiibtfl*), it may ha a question whflher the predin- 
poinnf; influence in llie ditferent luciubtrs of the sniiie fnmily i» hereditary 
or (KiiiHtniM in Ibe couiuiou exposure to other cuuuiv n-Hultiiig from a cam- 
mon inoiie of iifa 

In ft eoQsidernhle niiiiibcr of eoeefl no antecedent cause or predisposing 
infliiVDCti fan be diHooverei). The renal affection apiieiLnt to be merely one 
iimuifitstutiua of a general disense of the nrt«rie« Uinni^liout thtt body. 
Uince these cases are especially fregueut ia advanced life, it haa become the 
oustom to reKiu-il HBiiilily itaelf ns a predisposing influence or eten a eauHe. 

JUorfiiii Aiialomit. — The anatomii^ ajjpearanccs ^aiy extremely accord- 
ing to tlio 8t»ge of the diiKiaM as welt iis with tht etiologictil iufliieticee. 
Wliik djronic int4'r*titial noplii-ilis ie oliiuf-Jly a iinii rfpiirdless of the 
•iioloOT, several distinct types of morbid kidneys are recognized anatoiiii- 
Clillv. (leirtlideul liirfjtly upon the cause of the nfletl ion. 

The two most i>roiiiiii(rit types arc those drFi;.ai^ltd by Kii^lisb nuthora 
aa " the red contracted kidney and the "(ji^mul j llluv." Th* foniier 
of Ibesu pre»eut£ the anp^aiiinees obRen,'cii iu iii^i^ -i iaiuiarj--i-en)J cii- 
rliutiiii, wliilc tJio latter ih nsnolly found as the rontim-l iti^' sUigo of tli« 
large white kidney. Numerous tnuiBilioiial furi]i8 are found. 

The red csoiitraRt^il kidnf<y is niiieb reduced in Ris» and weight, m^as- 
uri 11^ oftj>n only one-half of tb« iioriuiJ. The surface in reddish brown, 
tinevci), and granular : the prominences of thia Kiii'fiii-v inity be nf uniform 
size and (p-niimlly diffnsoil, or of rnrvinp dimensioim and limited to cer- 
tain locwhties, Tli« protubwmnccB exhibit tliei'ed<bBh-lirnwn color cbarnc- 
teriHtiu of the orcnn, while the ^Hsnrefl between them are of a grayish or 
white lint Tbis ibfl'erenee in color corresponds lo the diffwreiico in 
Btnictiiri>, the pi-omiueuces being compoatsd of rfuid titsiiie, the tiaaurefl of 
connective tiHsuo. 

The capsule ia th icltKiieil, opaque, and wUierent to the pni-encltyinji. C8p6* 
cially OTiT tliu cicatricial depressioiiR ; the blood-vcaiwls of the cnpHiiIe are 
frequently enlargi>d and commuuicate freely with tit<i vessels of the fat mi%sB 
sMnounibnt; the organ. The renal vessels At tlie liilus often ovhibil an- 
Atoinical chanpea ; Uie rennl artery e8|iecin!ly i» apt to bf thickened aCMl 
uiu'd ; occnHioiinlly thrombosis of the renal rein is obnerved. 

The cortical HiibBtiuicD ia rcmiu-kably narrow and at points almost ob- 
tit«rat«d. Both thin and the (nerlullary pnrl exhibit numerous cysts, tareljr 
exceedinff the she of a pea, ami filled with a golatinouH or seiui-puruleut 
tna«& These may bo located also upon the surface of the kiilney j)rojecti(iK 
above the (rflncivil Uvfl. Tbo [n^hiH nf tbo kidney in uaually large aud 
oft«n exhibits catarrhal or even purulent iuflammatioo. 




DISEASES or THE KIDNEV. 



Sll 



Tbo gouty kicluev, aa well aa Uial wltu-li [oUuwb cliroDic poisoning viiOi 
lead or alcohol, nrc«ent» cwwntiaUf the luuno fcHtui-ca. In cusea of gout 
there ar« often fdund iufarcts of uric ncid uud uiiit^o, which u-ppiw as 
i;rnTi<fli NtrijifH in th« inuduUiu-v purtiuu Kud whilixli pnintw in thv t-ortvx. 
TUi'do iiifiirtts are located diieflv in the lumen of the urinary tubules, but 
iil*ii ill Uie interetilial connective tissue. 

Tliese cliaDRi'i* aiv ulworvod iu Wtli liidiieys afl a rule, though fre- 
(|nenth' mora mlvaiicfKl in one iJitin in th« otliKr; ind(>c'd, diAi<r<?iil por- 
tiuiiH of til? winio kitliM*jr mny «xliil>it ^'n-iit <]ifTi!n-rit4M in the stage of tlio 
Atlvrtinii, fioiiie part^ even of biiiall kiduevH iiibLining; an npproxitualcly 
normiU appparniiflo. 

Cp<:>u uiicrnitr'.opic eicaminntion of tli« kidney, the most prominent al>- 
normiil feature in Ilie excess uf interstitial cuuucrtive tiatue. Tliiti is c^i* 
(Ii>nt not ((im|)ly by tho tncrtMHO of tho intortiibukr miuuva, but hIho by tlw 
diMi»pearan<*e of the proper kidney etrccture in eertiun portions of th* 
orRHu. nhBro it is replaced by broad bonds of cMJiinective tisstie In 
othiT 2">rlioiiH there are found niaiwcH of brown f-ell* indicntiiig llie con- 
tinuation of the c^oiimnrtivo litvttie ff^trmatioii. Mnny of tho (;It.>intrtiU ore 
shruiikeu anil Hurmuiiiled by n Mtratitic<l rapHtiln niany tinif^i tlie normal 
IIiicknoM ; other I nfta nro completely obliterateil, tlie Hpaice being occupied 
either by a lufisit i>f eonnt-ctivu tiisuu or by a homut^eiieous, byalme struck 
ure, Tbn cells of the tiibuloa aro gninnUr. and in many purls absent lUt*- 
cether, tlie tubules beiii^; collapsed and ol'Uterati'd. The cywtn «0 often 
found in cirrhotio kidiiei's luise partly firom llie tubuW imd niHly from 
tb« glotiienili. In tlie former cn«e tlio lumen of tho ttibule it nt some 
porlion oonprened by connccttro tinnuc, aft^T which tho canty above Ibis 
point becomeB dilated and filled vrith a oolloid, (rnlntinou<i mnterinJ vbieU 
appears to result largely from metamorpbosia of epitholiiJ cells, and iu 
which Icuciii and tyrosin are frotjuecUy found. 

In thiii form of rpnal duoftM ib« blood-'vasaoU aro ftlu-nyn tliickesod, 
cliiefly by a new formation of connective tixsue jual uiidt-i- tlm internal coat 
of tiie tiitinll arteries— "endarlenitiH oblitentns ; " thi« thi<!ke&iiis may be- 
eomo fto gre»t im to occlude Ute liiiiien of the vcwwl entiroly- The vaecnlar 
wall preneula in many ciutct a liynliiio appciinuicu resembling the ninyloid 
degeneration, but not re-ipoiidiug to tfae reatrlion willi iodine. This form 
of tbiokeaiii^ alfccfs e<ipF'eiAl]y tlie middle and outer coat uf tlie juleTieH ; it 
baH been deacribeil by Gidt mid Sutton nu " urtcriocapjilary librost&" 

In tha ranal scleroitiH which ia Komndary to chronie ptirencliymatoui 
nephrida, the kidney preseula a numewhat difierent apppnmiioe. The sur- 
fuue La more uneren, the tjnuiulationa larger, llie color yellow (from tatty 
degeneration of the epithelium), and the cvats leas Duinerous. llicrosoop- 
ioally less cont)ectivi> 1u»uo is obwrred. t'lio granulntionti present do not 
neCMHuity depend iipr>n diffbM intentitial thic>keiiin<7,«iiico tliey are oflen 
found Id cmms where but little iucren(*a of connective iJiwiie im obaerved. 
CoDveraely, tin absDiioe of ^Tannlattona does not pmve the abaeiiM ot io- 
teratitial hypertiv»pby. sinee. as L^yden hrm shown, the ]aTfffi wbite kidney, 
prsMoting a smooth nurface, ofttm HbourK cxtenxivd inrrojwo of Ui« coddco* 
live tiwao and the aymptomii of chronic interstitial iinpltritia 

K^nal cirrfaosis is Accompanied with abnormal i-undiLionfl of otluo* 
organ^i. Forcmonl amoa); tbtHo are the changea obeerred in tbc circnla- 
tory appamtua: tho heart ia found in n etjile of dilatation and hyntF- 
tropliy. uHuatly of the left ventritde only, though aomi'tinira of both Midea; 
fatty tloiffocralion is often present in circumacnbed areas. InflammatioD 
of the lie-art-musole in the arms of obIiterat«d blood-vesMls is also ootieed. 



014 



DISEASES OP niR rRINARY ORGANS. 



El 



au 



wrll iw o](i ; 



And 



pf ricnnUmn arc often the i 
tbirk<'iiins aucl ciiieili<^ntit>ii of 



of inflaintnthon, rocrnt 

, ,, - = — ''"' wilvcs. faMy degen- 

eraiwnitor the etnlttctinUmii ncd ttortic wnll are not iufruiiutnt ; IniDHU- 
rliition, «]ni(I»tion, timl «fltir«ion8 are fuiiml in Ibe jierioiirviiuin. The 
Jitfyer vi'saek cBpfieinllir tJiose at tlm \>»iu: of ihr. bmiu, are tJiiclifriifO, tlicii' 
oftiil'io ilimiuialicd, md lUo luinftn sonieliiitci* ublil^rated (eudartftrutUt 
nblil«*nintt). 

ilift ollior aorous uieinlimn**, particiUorlv llio |>l«iini and pcritoaenm, 
■re ot-oiwidHiiliy foiuid in n atuie u( iiifimmnuljou, old or r^i^cnt. The 
lunRN «xliibit (^titnlial inllu^uiumliim with f>r witlioiit (vdt ma. Tin' uiuo<>u« 
int'»d>mti(^ '■"Pe<-iiilhtlie brom-liinl niid iiilesliiml.nniii ii Btalcof catarrh, 
ofleu Hli(i« iiijr blnixl (.stnirasfttioii* nnd i iiitofititiftl) tiifonitinn. 

. " . '"" '"■il"i<"i'.tv o\hibit§ evitUtici- (if oii-rliuBis. Tiiickiiiinj; wf tUe 
Krai^hiinid iiiii] ilurii, ntiin»tiiiiini uifliin] miitioii of the snmc, is olit-encd ; 
CBcIMHA of tm> bmin in nii ticcauaonal nppcdriXDrc. Ivxtrarnsatious nitiiiii 
i!* ^''''"" "'"' '" t^'e ittiua muT usuiilly ho diwovored. DnrltlH iiswrts 
tbe [re<|iii-iit nci'itrmtiiw of tliickcninc of t'ho nraDiiim IxincH. Amyloid de- 
ffWi'llI lun of Ihn kiiliiev nn well aa of the Bpleeu Had liver are uuvmuoual 
iiiwniri|«iiiinu'nt.H of r«niii cinlioais. 

Hijnmtomii. — Th*. development of iiitflrslitinl nephritis &■ a eoutinnntion 
of tlio clironio pni'^nrliymaloiui iuAammHtiuu, ia i-l-v(?ii)<h1 l>y tlii; ^^nuliuil 
(llM^>in!ttnin('0 of tho drupsy. the diiuiniitioii in tlic prrrentsge of alliiinieii, 
tilB inoniinod excivtion of uriiies and the n]>{H'ani.nco of decdded ouxliav 
byji^rtrophy. 

Thn mure froqiicnt (rhmnic intcntitial nepliritis which iK^ginn, not as a 
Bit4|)i<'l li> an Aarlit'i* KtiL^e of I'onal in tliinii nation, but ne a primary affection, 
is i'Mromely inidiliouHin its appi-oa<;h. At iin iidviutccd 5l(i<>c i'<.'Uiil cirrliosu 
is mnrkod by evident and uiitDUtAl;nbli> «yiiiptoins ; but d nfing tlio «nrlier 
piu't nf its cuiiPM! it in often unrocoguized and even uimut'piTted. For tW 
tij-mptj>iita canHRd by enrly cirrhosifi do not attract uttcution to tlie kidney ; 
in f(icl, the disease tiiAy appear primaiily ns an ftfiectioti of the nrtcnnl 
irrxicin, so tluil iho syuptoma caiucd by it may be oxlubitvd by arterial 
dwmnReniftnt* in otlibr organs, niiia n pntient mny din siiddeidy from 
ttei-ebiiil licniorrhagey and tfao poBt-iuortein i-eveiJa cin'b<»tie liidueya, 
Uiou-'h no Duspirioii of renal or ppilmps i>f otlit-r discnsc liitd bci-u cntvr- 
taiiiH. Aiiollicr mtlTcrx frnin iiidiycutiori, and hns frcunt'iit henilachMt, 
pi?rl)ii[i8 onr(itii|n»iii4-d by i.'pistfixi.t : the biller Hynijitouia Wl> iiefeiTed to tlie 
gastric distui'liance. niitil iilbnnion i^ disrnvcred in tlac urine. In fact, tlie 
greatest direntity of symptoina may be niaiiif(«tod iu inirioua oi-gaiiK aa a 
rwuH of that ondition. 

I>enuigetti«ntM of the pireiilntory oraaiia may be ioiiR exhibitt^d vrithoiit 
■^rmptoniK whinh (-fdl i»lt*iiti(iii t<) the kiiliieys, Tiie patient coiupliiiiis for 
montliaof notiiins: elsQ than a constmit and anuoying pidpiuitioii v( tlio 
heart. eKpeoinlly frequent aftfr pliyuiMd ex«rtion ur menial oicJt^i-iiicnt, lut 
oftoii orcarritip uHUioiit npprpRiablci i-nuM^. Kliortnesa of breath without 
diai^vcmbl* I^Ki<in of th« Ihoraiitt Qr<:;ana \h alnn an early syinptom. I*«r- 
aLttAitt hen liicbci, <-j«p«!cially hem it rani a. or neuralpia may call for troat- 
tnenl ; tbeso are often accompanied by vninitiuR. wbtth occunt jmrticuliu-ly 
iu tht* morntnc: — a combination of nytnptointi timi may, nndcr certain cir- 
oaiiiHtiiiirvK. Ifiiil b> !i pi-i>sunipiiun iii jirt^fjnancy, 

Clininir rheiiitmlinTTi ulTcciiii<: the joints oh veeW oh thv muscles, nnd 
oft<ni iinrompnnieil by piimjiyiiiiiti of ahnrp pain ; profueo and persiiiteiit 
hlecdin}^ n.t tlir none, hflmorrhiif^n from Uic Htii-iitiic^li i>r bowels ; dy«j»psia, 
chronic diorrbiua, nod fre(]ueut voiuiling— any of these may bo n^rdodi 




SIS&ASE8 OF Til£ KtD^'£T. 



318 



primAry nff^ctiniiH until tlic Rubic^qucnt hiKtosy of tho caaa ov n vloeor cx- 
uiiiiDutiun revtmlna l«)iion of tlie kidneys. 

In otiier iiiBtaiic*a tLo liret byuiploius may Iw ftiiliiro of the Ki^lit, 
amounting perlui]."' ^^ coiupUtv bliadiieeis iii one or butb oyca ; Uiia luss of 
Tifiinn miiy l>o t<iiil<I<'ii, l>iit m tiioii' frequviilly a (^tikUulI iiupiuriuciit, ibo 
true Datiiro of whicli m ri.s:'(>|.'iii/i!il \>y cxtitiiiimtii.in with tlin i>jilitliiilnii.)< 
Kcopo. It ooour.-! ill niroul niie-foiirtii of t,lie enfies of i^mil ciiThnsii*. (ar 
mora fitsqucntJy, tlierefore. than in other fomia of rc-nnl discAAP. IConrin^ 
ia tbd ears accninpAni«il liy rv fp<-lin^ of fnlutDcs*;, nu>t (ienfne^H, proiluo&a 
liy naiiy dilT«rwut cauwi, ura in soiiio liurtauueH uttrilnitable to tliB diiwaw 

in nilnittiat). 

Pemisteut nud I'ecuiTiii;:^ bOTuwn^sa (from cliroiiic oedema of the laryn- 
ffoal muooua luombi'siii-) lum b«oii uol«d by W'lddt'iibui-^ ui> a, prvcunor of 
Uie more proRuuDO^d Hyiuptoiuit uf iiitiMtititiiil QvplinllN. 

AtToctioQB of the n«rvous fiv»t«m of the moot dlTcrae uaturo originate 
ill tliiii mane eonditiou : hoodaobe, hcmicmuio, linro been already men- 
itoued ; n proininpiit t^iiptum miiy ho itiitnmuin, ofton so prx>uo«iiicc<1 imit> 
re([uire th« u<te of uiodyues. Xeitnilyiitii of variouH purlious of tli« body. 
oftnn in lh« s)iap« of obfttiuat^ scintioa, may Ion;; he Ihi: only ia'inifi>»l»tioD 
of ttic lateul disease, Epilcptifoiiu couvulHioti-t. jicx^iluoed by clirooic 
nnvmic jmUotiiiig or by ;^«iiiiiiiu iiieuiii[;itis. are Mtmetimeii noticed. 

Caws :tro nx'orilitil in whii^li tho iiidiridunl wiis tmiLcd for wttt^ka far 
Biipposvrl miiUmI ]KiiM>ning ; tlit: ftviiueut ditlLs ami fwcr tiiiuiift]«(«d 
werw ultiinntely di^cuforcHl to oriKiniite in chrotiiu uniitnia froin reual oir^ 
rhoais. A<4thiiuiti« nttAcki lU'u rai^oj^iizcd as odo of tho etu'ly BTinplonw of 
thin (iLsuriitT : Kbui-tnc«s of brcatli ia tiftCD mva bcforo and iiflcr the stuge 
of nnmp^nwitory cniNline hypci'tropby, aod may oonur fiadtk-niy durine the 
exiat«iice of audi hypertrophy from acuto dilataliou of the heart. !□ a 
certain Diiniber of nises U»re occura (general Dmaciation and debility 
withoul. Hppan-iit ciuixc!; thci-u iimy bu no nymptoin pfiiiiting to m U-iioil 
of tho kidney or of other orgima uutil an esainination of tLe uhue ia 
made. 

Indainnuitions of intomiU orgnna am fmqiicnt and often nvcrlooU^I 
becuuMs tltey are acconipEuiieil with leas fever aud cuuctUtiiliunid iliMturb- 
Aoea tliAri 1.4 aaually the caae. Thia ia enpecially tme of lobar piiGUiunnis. 
pBTMnnliiis, nnd pliMinxy ; any oiio of tbcse may o«8t in the Hubjevt of 
rennl cirrhoKis wiihi'iit ocTiutiomijf; suob pain or ri^o ut teiiipenitur» M 
wotdd diroct ntli'iition to the part in qua.'slioii. In oiin punuinid ciimi a 
taauof sixty>throe, long tUo subject of reoal cirrhositi, but eujoyiu); very 
fiiir lienlth, ootnptained of imus«u, Icmh of appetite and general iniuaiiie : 
tbo tcnipoTatiiro vnut only US).''', tlioro vsut no complaint of paiu. nor did 
ths urine cthihil any tIecidcHi rbaugo fruiu Ug iimiuI condition, llio foo- 
bleneas of the pulao, cotitTOKting strongly with itii preTioiiK tciiidon. lod to 
an exnininatioD of ibo heart ; an exTonsive exudntton in the |>ericardiitni 
was detected. At the autopsy, two days lator. the diagnoaia of pencardilui 
wiu ran firmed. 

t'rvmia may manifest itaclf in niont divert vraya: wroetim«e it is as 
dyapepaia and chrnnic dian-htsa. with or williout raniiting; Bomotiinea it 
apponni aa asthma or obHlinatii bromdiilis : a^in it niny bo manifested by 
ooiiruiaioDa, which are indeed uonasiotinlly the first Hympliuua Icuding to a 
Iborough invoatigatiou of the caae. Any of thfao minditiona in an iudi- 
\-)diinl more than thirty yeauvof age^ should be a signal for repeated exatiii- 
luitiotui of tiMi urine ; on tho other liaiid, cv«ry ]iaticDt known to sutler 
froin retuil cizrhoaiB should be submittal to a thorough examination of in- 




or TUB UBUfABr OROAJKr^ 



(«ni«) offtMi* — tlw hoart nod lungM oapecKBlljr — wbta % i e mfon r j faili 
lir (Jl* liniOlll U lilMHintnl, ' 

Hltii''< iKtunof Hiww wj-mploiM }iohit direrily to the kiilaeT'&s th*i 
of llio •linriilly, or Wl lliv urgan itt wliivli tlie (.-rtiernl morbi<l twiitiitiofi ' 
Im ilriUw^lml, lliu iitiiiniruiLiiiii nt tlio uriDi^ m but loo ofim oTerlooked; 
II tnmlt'. il I'ltiinmlit uii>i-t<lv III te«ting flidnglc H|H.-ntii4'U lor slbitnwiL 

PRiiiiiiiHtioii kIii'Ii riiriiialiMiiMBtiTe xewilu, which may W regwdcd bj I 

|i)i)Nt<'iiiii IM ivnitiluaivvnroottmtbBkidiuoyH nt least ore Dot at fsalt; In^ 
Alltitilloit U lttfr><f(iii> tfirect**! lo other i^>r<Tg,nn, aihI iLe real dlAcnl^ ><•- 
IliHlu* fill II liiit)[ liiiiit iiitilborirftrKL Tlicni arc Tiiriou^f objective stbi|h 
lithm wlitcli iiii\) |i'<mI (he jthjuiriaii, or «vcii titfi jAti^tit liiin»«lf. tosaspeeft 
iTiml illw>i(M> itiid (liu<t mutte an eariy euuuiiiaiiou of Hit. urine; aiaoop 
Ukimi Aiv rrmini'iiry <if tiriaiLtioii.pN|HMuUyat niglit ; aligtit HioelliDcof tbs 
ttwt I llniiiii>wi iif IW I>*il'''> jniWtioa of the tein]mml arU-Ti««, pallor Rnd 
<tr,i iti<M (if |)ii< Rkiu. Tliintt ai»l ioorcwwd cicretioo of uhoc may lead the 
imhviil lu fiuir lliat liu i* tliit vabiontof iliiil)eb>«. Id comI>Am1iTe^y few, 
vivn-n I lio mm anuiitom known to the laity as no iodiattiaa of ntiiil ()iM-«a» 
- '1i' I ^ In |>nuH'iit; thit) rHrruni but rarely in primary retinJ rirrboNia 
A l< l,r ..uicllliif; of tliH f4)ct hikI nnkl4Mi, cftiuong nn unusuAl tigbtaeesof 
U»i b'lxi, iiiny OMOitpK ditci-l ion ; luoru itrunouuceil dmimy i» scvn oaly 
ulioii, fniiu Mtnin riLihim c>r tlio circulation, often tnniponinr, tlifl uriiiuy 
Mtaiiulioit diioa liot tittiiiii ilit iiMUfd amount ; suc-li rdusoa are fatty deffi-ne' 
ntltoii of till' lirjirl. i)"i'ii!iinii(iH, «udocnrditis, i-npovurv tu cold mid tuoist- 
um. iCvMi ill tiitoo ciiNT'H the {[^emn luid tdinlit allmiiiiiiuria, if detected, 
Hii^v Im> iiiistalieii for I'-niiscqiieiicrcw of iiiu cardiac (^onditiun. 

'I'lic iiiirlk'nt, iiici't ))]-()iiuiJuc(sI, utid coiiHtnnt mtDtitoiiiH of renal rir- 
ritiMi* nrv uliaen'od in tlio fitmiilatnry nj'Kt^ui : iijd*v«ii, [ho heart nud nr- 
(aHiw fiiniiMli iiiforiaalion tjuitc as ejf'iiilioMiit and FHWrntial ud ttie urine. 
Tlir i<(iiKUlioti of ibo ])u1m.-, wliicli ia liard, full, and quick, is often ntiiwlt 
•ufttoioiil to dir<^('t. att^'tition to tliii nrine. ArtunJ measiirenitrnts of the 
nuliM> uliiiw that tlit! timaiou itt n^aLly iiicn-iiHcd in IIma disftiH; us much US 
nfly piT will, above lti« iiuriiJMl : Hp)iyt;in(i|;n'Hldiic trneingaalfio tihow the 
nnttatiii-iil toi>nii>ti of t)i» urt^-ry by tbe M-cundnry ivaves. Tliin M'tidilioii 
i>f Ihi' iniW irt luwiKiatcd wilb livjH'rtninliy of the left TcDtricle «r of the 
4'Mliiii lii'iu'L Hii4-li liy])crtnip)ir ia in itM-lf, in tlio (ibBCDce of vnlvtilnr 
«U>H>ii4r, Hiilltcii'iiL to (irxiiHe a HiiHpicion of letinl cirrliosia. It iu iiiijHirlriiit 
in n-iimiiilHT tliiit ill lerlaiii caws the lu'iu-t trmy rsbibit iio liypcrtropiiy, 
Aven wiioti otlior phunu^trrimio ityinptoiiis an* pN-seiit. and whcu the autopsy 
IVvmlH iMtitnivlvil kiilneya Cohiiheim luut fUipbaHiibed the fact thnt l)ii« 
AbMUico of cnt^liiic hypoilmphy in the rule in thoHP caaeti in wbicb amyloid 
4«(l«iierAtion romplicates the reiinl cirrhoius ; if is therefore to beexpected 
tn Ihc MibjectH of proIoQi^) suppurotion, syuhiliit. tiiborruloaiis etc Tb« 
roMuK o( tlii« hyiwrtmphy of Uie benrt rdci dt)tca«o of flic urterifs is » 
llDri<«* of ayuiijtoiiis ipiile clwiracterijitic of tlie affection — palpitation of the 
konrt, "ruHli of blmid" to the liriid, con^^nttion of the face, dimnen. (T|Ui- 
ia, luid often h<''iiiorrha(r«> uithin thf emnium. Tlie M>-c^«d gntlnp 
jftliiti of iho heart — a doubling of the second sound — asserted by Po- 
to lie rbiimcteriiitii' of rfUftl oiirbosii^ baa been recently Hhown by 
Intael to occur Lu other afl^liooa alto. 

The relatfam b*lw««a renal cirrhosis and the cotnrtdent ctmlLnc bi-per- 
^phy bM bam the mbject of luuch dii^ute aiut iuresti(^tion for many 
ytaXH past. By some it uim be«u aanuneil that tho cirrfaoais was the pn- 
IHiy aSbction. iiiwl llutt >□ eouaeqneDce of the oocluaon of nnmcioua 
~ ' 'r-v«Bwls IB tbs kidneys, the bluod-pntssure was intwwJ and tbe hy^- 



UISKASES OF THE KID.XKT. 



313 



pertropli;r of tUo lioart imliiced. Others have nituntuincd Uint Uic gcncrnl 
dlMjiUH! *)t the urU-riea, lu otlicr or>^iiH as wvl) oh the kidiieynt. wna tlie ph- 
mai^ difficulty and causa nf (^tirilian fHilarj^imeiit. It woukl exceed our 
limit* to rectipitiOnte tte oliuervatioikB, cliuical auil eKperimoiitAl, wliicli 
hnvfl been addtiwil U) Huppurt eocli of tliecte lt\poLL(-Heti. KoLwitJiiftiLudin^ 
the leportflil ilomonKt.nilioii tbnt, hy triLriKivnt ligiitiin! of tiir rt^niil nrterios 
iu doga uuil nibbita, vluoiiio iiiteratiuiil iiephi-ilis and t«t.-u<>ui,l(trt- canliuo 
hypttftropliy have bnoEi iiKtuced (Orawitz, Itiruel, LewiuHki. dpnird liv '/.an- 
der), tbe weight of ovideuca iiidicates tfaat tlio origiunl nfTeL-tian ia HiiiiieiaM 
of nrteruiii tbruuKb»ut tliB huily. an a ooilMqufuuLi of which blood-pmasuro 
is incrciis&d (incl fjirdiao hy|)crtrop!jy induced. 'WHwitlier or not thi« gmi- 
eraX itittiuML* "f tliti urU-riiiM in a tvault of the ociiuuiiihiUou iu the blood of 
materials wliiiih aiioidd be elimiimted by t3i» ki<Iii«y, is imdetennmed. 

The dm^aosis of the renal |Hirtioipntioii iu tlie ^Dernl diaettse is ]iiad« 

by the chiu'ucturiHtiu appuuriuicoa of tUu uriuu. The qutuitity excreted is 

iaoroiutiKl SOI nt! til 11 03 eiiormoiiMly (Bai'toln roraidii n dnily nxcretion of l*i,0()0 

la.o.) ; from %\M\) U> 4,001) ac is a frGi|ueiit daily luiiouiit. In many ctwea 

the quantity excreted duriut; the iiisht is Riealci' thuii tluit pru«M.-d by day, 

iiiid tliP pitieiifs rest is disturbed by frequpnt call^ to iiriimtfl. Tho urinA 

it) ill cini»t!i|Uftin'i; of ita dilution e)( utiiiMUtiUy li^'ht c-olor, oflen with a greeij- 

inh tinge ; it in of acid reaction, uolesH rendered otiiprwise by medirution. 

The Bp«ctfic gravity is 1«** tli»n normal, usually nboiit 1.010, \-rtrying with 

tliL' luuouat ezoretudi it ia hijfhur by day thou at iii;;ht, currc»poiidiii(j to 

tUa lasmned axcretioa during tlie cUy. It is roiiiarkable thatdurint^lDter- 

eiiri-dnt febrile attacks, the a|>ecilic grarity reniaiu^ contrary to the ununl 

tzulG, below Dorm:d ; an ubiservntion of thus uorl ehotdd dii-cct atteutiun to 

' ttw poaatbility of r(!iiiJ cirrbosiit. 

The diiuiiiutiou in spaciftc graiity fteeiUB to be dependent eiinply upon 
the polyiirin luid not upon n decrease in the amount of Holids cscrctcd ; for, 
until the lattor pmod of the diaemw, tha Ainonut of urf-A ruid »nltA mmnioa 
ut or nt«ir the iicirinul ligiire. Thi- phoKplialuH are, however, retained to a 
cou-iiderable e:ttBnt. and yii^iiiclier olMwrved that )>hoHpbonc acid adtniui^ 
tered to n Hiibject of renal cirrhoiiia is not escret«d as coinpiololy au \>y 
hu;dthy kiduuv>'«- At n Litvr pt'dod of the disenm thvru is a rcU-iilion of aU 
till) Holid contilituonUi, incliidititr iiron ; indood, a RoiiiitnhntdiniiniHhed ei> 
croliou of urea ia ofteu oUscrred duriujj Uie earlier course of the ilieenae; 
|FIei«clier found that a palieut suQbrin'; from thiu afiV-ction cient^tod 1uh» 
^ WM tlian ft lieiiltliy pcrtton. whon both w«>ro iK'pt upon the eiuno diet. 

Thu urine iL-tiially c-otituiuM nlliuiuvn, though tliut niny be abiM-iil for 

, dayx or weeks at a time — aa absencw which imuietimeH RiifileatlH the physl- 

I atax who itt u^iustocncid to rej^axd non-albuuiiuons ui'ilie aa proof of the 

I Integrity of the kidney. Xho pruportiou uf ulhutuon is olwin'n smidl, um- 

I ally Dot morn Uiin (1.1 or 0.2 iter oont. ; yet Ruch n pcircontnge in ho large 

[ B quantity amount* to several (three to nix) graiiiuiea per day. It in notioe- 

I abln that till) urine oscrotfld durin? the nijihl i« more frc<]UPntly five from 

athuineii than thut evncufttfld during the day. a fact to bo borno in mind 

in delerniiiiiu;^ (he nature of the cumplaint ; if thi- iiiunilug urine only be 

exauiiued, it may be found nou-albuniinoua. yet later in the day it contoiua 

aihuin^n. Phyxical oiertion or ineulol excitement uoually muMft an in- 

I creri'iccl fxcrtttioii of albumtn ; and urwniio attacka or outl>real» of gout 

I ore preceded and followed for Rome time by iucrejuied nlbaniJniirift. 

Tlie eiciatence of renal cirrhoeisisDot excluded by lite absence of albumen 
Bvon upon nipeatud i-xuniinationii, tuncu a few cutcii arc on rL>ciird in wliicli 
uu aLbuinvu wm at nny time found in th« unD«, olUiougli the Hcctiou ro- 



sia 



DISKASES OP TUB CRINARY ORGANS. 



vekled nninistatiitble cbrliosifl Kni the B>-Tapl»ina other tliftn nlbamimirin 
wen: cliimicltrtrtliir, ludoiicl, Si^litichanU i-cconls a wrcfiiliy observed case 
iu which the tiritit^ wan nlwajs Dormiil iii «v(try reftpec^t unlit juM Iwtnre 
dmtli ; tlie autupHtr rvvt^nltHl }>rdiiouiicccl iitmph;^ niid iiillnaimiitiuii ot tho 
ki(]ne.v. 

But litUo or no seiliment is macroRna]iiGally visible. Upou mipToBcopi- 
col pxniiiinntirm, liinvprnr, tlifro nrv fiminl tii1)fr-<-]wlH, cliiwtl/ hjiiliiic, Wt 
ooootuouall; granular (l-'ig. 12j. Now aud then » ciwt otiKlilml ^illi cells 

fi"Or)i thi- tiriiim^ tiibiili-s, or 
■with uric apid. urates and 
o\ulut« of (itkiuiii. is ol>- 
w'tvikI. During tiikHKlcnt 
exacerbatioiis of the reuiil uf- 
f<!i-tiun. and iift^jr itr.vmic op 
gouty ftttjiclm, n conffMonUe 
mituber of cpilhttlinl costs 
ond r^nil (>pithf-lifil cells 
mAy be found in th« urine. 
L(4U(X)cr1ra. luid Boruvlimed 
I'ftil ijrirjiusclrH, lire [H'CitPIlt 
in em all Dumber. 

t'ourxfl and Iluralian. — 
Tho Rcnrnil apppiimnrc of 
the pnliinit nfti'ii hetrBi"9 no 
etipPiMnl ahnovmalily, while 
nt othor times tlie skin is 
unusu;dly pikle, dri-, anri 
lianh. A frcijut-iit htdijv 
torn LH j>creiKtciit. niid »udov- 
inff it^hiu;^. which is pn!K{>nl (lay mid ni<rht. and drivGH tho patient to de»- 
penttioD. In other ctLse-s iilmtinat« euu'iun is ileviilojx'd, 'wliirh j-irld>t but 
idowly tn treatmout and breaks out nfiT-tth without piovomliou. Tlie gen- 
eral nutritiou uuuully remains uniiiip.iir«i1, thou •^li em aviation Is sotn^timea 
obiKtrvt^d, mid llm iinlividiitd tauy -t'otniihuQ of ly^rroRponding lo^ of 
stfODK'h. AH 1ht!H*^ HTinptoniii oixur, however, less frcciufiillj' tiiid with 
Ipsa proniiiienfc thou during the coui-so of clu*ouic pnrc-nchyinatnUH ne- 
phrilis. 

Tlio diMeiise iu.iy last for many yctin ev«n after itii discoverv, xnd lias 
usually oxiHtiid for a t'OiiKidenthle Uoie bt^fort- the dtii|n)osis ia ninde oi its 
nature (itl-h iiunitocted. On the other linii<l the life uf the patisnt may be 
eat ahort, hy any ouo of the iiuuktoum i-iunpliL'atiutiH ro often uhF^^n'ed. 
among tbein unemin, cembrij hemorrhjtfre. influTmuntiim of the liiupi or 
■eroua membmuo^ cabu-rli of tlie iut<'Rtinal trtx^t^ or aidcinn of the lungs 
or (^lottia Koc-ovi'ry irom pronounced and undoubted GirrhoBiB of tliA 
kidiiey has never an yet lieeti reiJortecl. 

Among the most rharweteriBtif. though by no means most constant, 
Bymptoms ohsprved nre the (^hiin;'*''' whirh ocriir in tlm r^'tiua. 'i'beee lUftv 
be BusijertMl from thf impiiirm«nt of vUion of wliiobllie patient compljiinf* ; 
amblyopia, dimnoRR of vision, rauHPfp volitiinten. nud other distortionB of the 
agbi occur. Ait occAsional ineiilent is sudden and complcto blindnesH 
afiecting one eye utiU diwipixiiiriug in tho rourse of n few days ; in oiJier 
inst/inc(i« both c-ycn n.rp Miuinllnnoniiitly affnrtod, appnr«ntly from no snntom- 
ical ehange, but fi'om iiioipient uneniin. 

In the retina there are obecrved yt-Uow spota. which often surround tlie 




F». Ii_Snlim»in tr^ai 11. utt Clirboilji. 



DISSASRil OF TirK KIONKT. 



217 



OpUe pupiTI'i. but mnre fwqiiciilly tire IcioAted in RnJ nrnuiul tlie yellow 
Bput, wlttre ihiiy lu'o iirf.iiiy.-il iis m_vs nulmtiiij; fnim tliiji [mint. In otlicr 
eases tbe spots bitveaodelintte tti[jQ;,TapLtctil rektious eithei' to Uiu juipUliL 
Of to tbe mauulft Kit«a. Tli^ue spuU turn ucL-utuoutxl [mu-iIv by fatty df-^-iu 
*mtioTi in t.iio griiiiiiliw luycr* uf lilt! retina. iwiHly liy liyju'i titJiAy of iho 
nertp-tibres, both olifiiiges aiijmifiitly rcaiiltirig fruiu jiiiIiiokiKicul chunK«8 
of tli« retinal vefMelfi. jV-miIo from tliJR so-oallcd " i-<itinitia nllxtiniiniHui'* 
tli«re is observetl, in cnses of renal cinhoais, the njipcartuice known aa 
"ctiokeddbtlc," Uie I'CMult of Teucnis cangextion. All oftliew) nbnornmlilicg 
of tlip nttina may mibnde when <luo lo renal cirrfinHia ; the lasi unined. 
however, uucoxioitiilly icmjlts in ittropby of tliu ilink. A{»ii>lesy ul tbc ntiaa, 
OS wt^ll (IS of tho Imiin. in oft»>ii found in thcua enspn of ii^nal diseiuto. 

PniJurp of tho hyjiertropliied heart from fatly degeiie ration, or ncuto 
interiMirrtnt diwiisc. r^iuscs n cliaage in tlio cliniciil i)ifttij"c : Ihi; iiriao be- 
comp^ lf-«« pKifiiw. tlip flpocific fn^vity Boniowhat lii<»lirT, tlio inn-cotitAgo 
of albiimeu in iiiLTfitsiiil, <tig«stivu diitlurbaitceii arc ajfjjmvated, ]>t!rliaii!i 
uli^tit dropsy Iipcoiiips apparRnt, and iineiiiio Rymptonm Ihrcatcn. S?cond- 
ary ilihiljitinn of tho heart, causing dyHpnoea, OHthma, palpitation, etc.. may 
follow. 

DmynoftM. — Tli« difficulties of (1ia^r».iti tinm not from thn ntaoniblaiipe 
of tlio n'nipton)§ to thotiG pruduct'ii by other alYoctioiiH of tlio kidney, hut 
firom tile ftiul that tbcHu symptomn mnr bo ci>hibit^-d during n lon^ pviiod 
dliefly i)r entirely by other or^ni*. After IIm polyunn, aibUTniiiiiri(i,and 
tendon of tie pulse aro rcfojfiiized, the diaguusia is ea^. A Hystoiuatio 
exaniiniilioii of the nrine in cverjf caae of disease would often rciital an un- 
»n<i>r<>lc.I renal cirrliofiia. It la rewlily dtstitirruiMlioi) fi-oin acut<> and 
cliroiiio(^rcnt.'livniiitou!*uvpbrili»l'ytbfp[ofwiK;cx<.TcUyu ofuriae, itttctcnr 
odor, low MTonihc graiily, niiglit ijcdimcnt, and umali pnrcentage of alhu- 
me^D ; tho auttotice of dropsy, tlie presence of lesions in the heart, artcrie^ 
oervous syHtcto, and cyo an additional fa<.-toi-H in making up b dJA^'nusiM. 
During acuto «)<(Ui>(>rbitti<>n tlio iiriuo niny pri-Miiil tito eliongoa idwmo&riotic 
of acute inflaiuuiattiiy proc-ceut and dropxy iiuiy Iw preiieiit; indeed, tht-re 
may bt* an acute nephritis f n(nTftf<I nptm an undiscovered renal drrboaia, 
Aft«r tltO mtlMidcnce of this, however, tlio fentuEVS of tlie latter affection 
persist. In tho alnMmoe of ctir<littf! liypertropliy — either from liMnjtorary 
cause or from a eomplientinn with aniyloi 1 defeneration — the urine may 
bfl tlijninisliod and the perceulnge of nlbuineu increased; indeed, drop^ 
may exist in ^li^bt dc(;rcf). 

Tile diMtinc.tian frotn ainiplo unvloid dr^^cnemtiou of Die kidney ia 
rtrely diftirtdt ; for in Uie latter condition the uriue is less abiiiidant and 
oontwna a jj-reator pereentage of albumen : tbt-m is no cvidentw of eanliao 
hyperlronhy or rhanjjes in the retina, while there in UKiLiIly enliu;g6tncnt 
(« the apk'i'ii aiid Hvi-r j the bisttory, I<m), indioati-H thii orij^iu anil nature of 
(ho affectinn. The rninplifatiim of ren.il cirrlioaifi with amyloid dcpencn^ 
bon proihices a puz/Jiiijj; comliliou wLteh ivinnot alwnvt be rocogiiized ; (or 
thvrc may be no eliuus*^ in the heart or arteries, while the other eytup- 
toms indieat« int'^rHtitlal ucpliritis. Tli» i»ilyiirift may lead to a diii|nt<nsiii 
of dinbetea inxipidim ; iiide«<l, it ia proltabla that this niistake ut not rare. 
Careful connidenition of tho oUier fealitrea in the cose will vaaXj Ivnd to a 
corrcet dinKnetion between tlio twa 

Senilii atrophy of tho kiilney, thotijfli perhaps Indistinguishable fi-om 

renal «nrrhixin by jMfgt-rnorteni innpertion of the or^taii, is toaily ilintin- 

piiiHliiyl etiuii-ully ; for Ibiei ]>iirely senile atrophy is aecotnpftnied with a 

I diiuinishcd rather than an incrcaecd uxcrvliou of urine ; tUero ia no cardiac 



918 



DISEASES OF TOE UltlNAHT 0110AN8. 




li}^)«Ht-upbjriioriDCr«uuu(IiLrtenal tenmon ; albumimiria ia rare ami uncmu 
abspul. 

Iji his ardent search nfter latent renal cirrbosis, tiio pfajncian must 
^uanl n^iuii»t tlio tt^mptnUoii to niako IIiik iliu^uouiii iii L-mactt of int<-nnit- 
ieut or |)t.-i-«iMti.ut albuiniiium wlieu the oUier svmptoujR aie absent ; (or 
Kiii-b Hniiitiiiiiiirin may exial witUuut auy (onu of r^iial (li&eoae. otiiJ it* oc- 
cuireuce la usually pi'ecc<lvd hy B\iaptoiiis in llio circuliiUiry nnii di^stive 
or^iuiB tit li'iLst wbii'li oxjiliiiu 11il< Hit,riiil\uitji'0 of Ilie nltniirifu. Tbe coin- 
ciilriiro uf iiktviuuhI. iirteritil teit^un, pcrniHtful beatliu'lie, d^'Mptpiiia or 
■.litinimua with aibutiiititiriu, ^tioulil li« regarded aii sU-on^lj Hu^Keslirt: of 
renal cirrbosia and oa Rroutid (or iiuiiiitaiiiiiiB ii (.'onBUmt HUpenision of the 
patient. Vet it nuist bo jKliiiittcd tlmt, even witli Ibc uinrt cait'ful atten- 
tioa to nil (lin^itHiitic ]x>iut8, ciul-h <.>i.'(-iir in wliicli tlie jnfiieui-e or nWnce 
of F6ual cirrbo»iit cau ha ilottn-iiiiiiocl only after i-oufiiileralil« tiiiio luts 
elnptied. It is certain that iutermitteut or constant iJbuiuiourin, even 
aKHociutcd with a decided iucTou^c ut vascular teiiKii^u. may Lut for noma 
ttioiitliit ntiil tlicn (liwijipntir |>fmiiuioiil.!y. Poiualily Htirli rtu^e are reol^ 
iDHtances of iiici|iiont or localized renal cirrhoRLN or thti nlbuiuinuria lutiy 
oritrimitB in conditions independent of tlie kiduey, Kuch caat-H must bo 
diatiaguislied from tiione of gfmuue and iindoiibti!<l rennl cin-lioHs in 
whidt remissions liiNtin^;. jH/rliupn, ivt-eka or iiioidim uixur. duriii;; vrliich 
perinda no albumen ib found in th« urino. 

J'roijnosii^. — ^o instance of recovery from prononnced and undoubted 
reuiil (.'irrhuaia ix yet rvconlud ; yi^l tbt- alTucIiuii ix nut iiii'uiiipitliblH with 
iiinny ycai'ia of coiiipiu^ttivirly ^oucl lictUlJi. IiiHtu»ci-» iirt; known in wbicL 
patieuta Lave eitrvived fifteen aud evcu tvrciity years after tlie detecUou of 
the rauttl afl'ection, and tbe pbvHical and lutntal powcm are freciuentlj re- 
tainvd wilJiout wridUH infp.iimn'nt fur six vr eijjbt yi'iint. Yet the con- 
dition in Uitblu lo tti> luuiiy caiii[ilii.Milion8, often fatal, that no ncrurity to 
life IB affnnlci, (^r<ibral hpinorrlinge, uncuiio, cedemn of the lungs and 
glottw, rany OL'cur auddonly iu the midst of njipnrent health. 

Trmlmeid. — Xlie objtct of treatment 'vi in the uiiijuiily of oases mer«lj 
tliA ]>ri)b'i'tir>ti (if lti6 pnliitnt from Ibi) cousO(|u«ui'(!( iif Die iHiwiuo ; far tbo 
uatuie of tlie primur^' atfectiou is often undiecovenitile. Tlio attempt to 
arrest the increase at cuunecliva tiwiue in tlie ki<liify by remedies uddresKed 
to tbiil <ir[;/m must W, and as n luntter "f fuH in, futile, sitinc ihix cirrboius 
irt merely one reniilt of n coimliluliomU i-oudition. In tiiohe cnses in wliiih 
a definite cause run he a.-«nmpd. nach aa nyjihiliB or lead poisoniug, tbe 
admin istratiun of i-emcdies known lo count(<i'nct these Hpcritic iuHneQceB is 
occatuunall^' fuUovvud by hucccss. The iodide of {lutiisninin with or without 
the bii^lilorido of imnTUi'y h<i8 been known ti> iini'sit tlic morbid ehaiigb» in 
tbe kidiieya wid ikrt«nbe, niid tbiu to restore the individual to comjiarative 
htialtlL Since, moreover, a. Byphilitic tninL may lurk unsuHpecled and un- 
(liMnovered, the iodides luay be in almost every cusv udm in inter ed wit]i 
pi-opriety. 

In most instftnc.es, even in some of undoubted nypbilitio lUstory. tliese 
remedies produce no iippreci«hle effect in (irresling or even retarding the 
iiiorbid pnjctfaa. Certain otherdrn(;s have seemed at timcii iH'Utlk'iid ; thus 
iJiirtholow recommendu the chloride of t^nld. and aaj-s, " llett*-r re^ulta 
OTeu'"(th!in thti iodides), "iho iititbnr bolievc-B. iiio pri)curtd ffoni the 
careful and peraiatent ndniiDislralion of tlio (ihlori4lc of gold or of gold and 
sodium." " TlieBe remedies. inten<led to niTesi tbe h\i>erj)iasin of the coii- 
nwtive tieauu, nboiild be pn-acribcd with a definite rcilalion to tb« pr<:ftunied 
cauae — iodide of potjissiiim and bichloride of mercury, in tlione mlh a 



J 



I)1S£AS£3 OF XU£ RID>'ET. 



210 



ihilitic liistoiy ; iodido of potafiHiiiia in those poisoned b^ lend ; and 

rulti of jrulil and ui-Bcnic in iIiono t'lium of unkiiowri urifpii." 

Aiii'lo frcirii nucli uiiiatiures o! (J[>ul)lful iililitv, aotliii]}^ uiui Ih! tlono hy 
dras* ^ cliRi'li the increase of connective tissue in the kidiiej* or the de- 
fjEODoratiou auJ thickMiiii^ of Lho nrU-rite. Tlie trcntui^ut conmsta simply 
ta eSbrts to la lititnin Ihi^ nutrition of tin- jialii'nt, lunl to nvoid tlio iiutuvr- 
ooa cainplifMliuiia wliich Ij.Hftt him in tJie coui'^ of the ilJeoiMe. 

A judic-ioiiK ilii't nmnlitucos a, moat iiujxirUuit feiituj't! tif Uio Iruainicint. 
The food tihiiiiM lie DuU'itioui) iiud uleaUful, but cnatain no oioro ititro 
g;i>Tinni4 mutter thiiii is nec-esaai-y for fieijtli. Tlie diet umy coiiaial larRcly 
of luilk, egga, niid vegetables ; (at mcut in pontii^eible. but lonii inrjil ghtmll 
be Uikca npiriujjly. Wint-s nnd liqiiora of nil kiuilH should be avoided iiii> 
lem r*!niiir>>;l fi>r piiqwisrs of stiniulation. Thftso dietetic priticiploji, thiuj;h 
goutridlv (iiiijlionblo, uiu%t not bo regarded as iiitleiilde rvilea ; inilividuid 
wnntH uad pecTuliaritiea often r«!qutre tho uaa of beer or litjbt wiups ; tbe 
ob.^tiimto dyiipi'iwif* which »o iintioyn ittnl ditbilitiifps the person, niiiy bti rc- 
liuvud by these when olber measuit- b (ail. Ciu-eful obnf rvatiou of iha effects 
uiton the (^ftneriil conditiou and the ntntti of tbe urine tnust, oonBtituto a 
coasi-lembls factor in |iro»pril>ins t.Ini diet, 

Tliu boily should m warinly i.dutli<>il, tbe Hliiii iK-iuy protected by wool 
in all sniuons; tlta p-cab^f)t rar-^ atiould be taken to RToid exposure to cold 
mid moisture, ainco situple wottinp of the feet mny precipitate a uiiemic 
attack. Itositlencu iii a vrarm. dry. iitiil uniform climate luu Humetiiues 
BMinori to retard or even to nrrost the difloose. 

Btist of body aud miod in conducive to tho welfare of the patient tmd 
thfl aviiidance of oompliGatioiiH. ProlouRed lueutul exertiou and IntenBo 
eKciloiiient Tiiay, like flxcosinvB boilily ox<;rri>i(), provokv mpid pn>grcKH of 
the diamfiu or tbo outbreak o[ cun)))liaitii>ni). It ia not desirable to confine 
tlio p:\tioiit to liflil or to forbid uiuple tsemHS. esi-ept durintt tlio»o perioda 
wbeii the beart ia espacLnUy feeble. It iwnidy ueccssary to avoid excess of 
Ixjdily imd inmital iwtivily which a Imaltliy man may nndertako witb im- 
punity ; for tbo Kubjnitt of ii-tiid cirrliOKia i» im iiivolid, Lowuvi-r oLjcctioii- 
able nud iinfoun<leil thin ilc-i may aeom to him. 

Tlio loiM of nlbuiiieii eiiu be readily coiiipuiitiiited through tbo food, and 
does sot coiixtitiit^i »ii importunt fm-tur i>l tho coinpliutit. 

Aioori;; drutD*, iron, i|iiitiiiii;, iitid mineral ariiln mnv b« administered 
almost ooatiaually. After u lou^ couise of iron, boadacbe uud ttit^triu djs- 
turbince are imUcaiioni* for its diw^mtinimncp ; ii should lio rcijitwt^d (ift*r 
ao interval of rtsat Soiim eiix-riiueutiktiou inny bo ucRbmary to ilittcorer 
thf! rMo*t aiiitablo form for tho ndministmtion of iron ; the moat Rcnendly 
useful 1^ Uv^h'^m's miKture, tliQti;;ii tbe citiato of iriiu and qniriino miiy bo 
BUb^tituted for a lim« with mlvuntu^e. 

HtiHO of the eoniplicatiiiiis Vbliivh render tbia disease Bo dungcroiu 
ari^e from liypertro]>hy of the heart and dc(^ueratioD of llio viw<;ular 
vaMa. We ai'o notiiuunted willi no m4'nij)i fur anestiDg Pttlirr of tbme 
procenmeu I in fact, an attampt t<> pn-vnit tho cardiac hypitrlrciphy woiiM 
bo uujiMtili tblo and. if flucwiuf iil, •li«witi'i:}u», hinctt the coulinuci) activity of 
tho kidnflyiviiibniniiintiiined only Viyineretuted effort on tbepurt of tiif-boart. 
Tbe oitiv A'kfuty agamtit compliisnlioFia on the piirt of tbo nirr'iilalory orgitiin 
li*M in tho avoidance of plij-siud anil meutul exertion and excil^uipot. At 
a later period it laay bocoino nin^oMmry to ittimulato rather tlinti qniAt Ibe 
hMrl; for aflor a time the oompciiiaulory hj-pertrophy. which ut (iret 
enitbloH till kidnnyjt to exf^roto tbe iiHunl amount of sobda, faihi to kt>«p 
paoe witb ilio increaaing dcgouemtion of tlieiM ur;gaiiH, or gives pluuo to 



214 



DlSEASICa OF TUB VRINART OROA.N.S. 



4 



temftl or^ns — ^the heart atid lunga especially — when a temporary (iiiline 
of the lictJtIi is oberrved. 

fiinvi! iiuiHi uf th&m HVTiiptoniM jwiat <lir«ctlj' to tte kidncj ds tbe aounco 
of tlic (iiffit-iilt;, or ui tiie or^n in which Uie geiieml morbiil (xiiKlition run 
bft <letcut«<i, the «EanunAtiou of tho unno is but too oftAn oTf^rlookcxl ; or 
ifmaUo.it conmtit luvrcly in leMtiog aunglu p[X!oinieu forRlbuni«ii. Such 
«x&niiuatiou oHvu furiiiKbcJi ticgutivQ mitiltfi, n liicti muy be regaidixl hy tbe 
{thymniin tut conclunivu proof that tiie kUluevs nt least wre not at fault ; lua 
Atteiitinn is therefont ilirerte<l to otlier or^nns, oiiil tljfi real [)iffi<;iiltv n^j 
nmiiiB for a lonf* time UDdiscuverod. Tliere an* vnriouK obj<'(r1ivo ^tup4| 
twiuH wlik-b iiitiv Iciul Llie plij-sif^ioD, or own tlio [inlicnt liiiutx-lf, l« mispecf 
rt>iml iliM-ase mid thti» cauHt* na earljr exrwiinAtioii of tlie urine : among 
tbette &i-a freiiueii^^y uf uriimlioii, (r-^jH-piiillv ut iiiKht ; sliglit Hu^lliiiK nf tlu 
f(!«t ; liniiiiom of tlio r"'*"'t ]'>dsatiou of tbe t«aii)onU Brtcrici*, jMillor aod 
dryiivxK of Ikio ukin. Tliin>t uiid iiia)t>tkti(!d exiTeliuii uf untie vmy lead ihfl 
])ati<riit lo fuiir llt;it li« in till! 9ftil>j<^('t of diid>et4-«^ In (runijuiiittivrly fevr 
cues the one symptom kiinvrri tn Llie Iiiity an tin iiidiration of rennl (luteaae 
— drwpsj' — iti preiwiit; tliia oceiirH bat rarely in primary reniJ rirrhocia. 
A Hli^ht Kwidling of tlio fort mid uukU'S, ^^-miniig »n iintisuid ttgbttiess of 
the boot, may ewapc d(:I«i-tiim ; iimro lu-outmuced dropsy is swa only 
Tp-beii. from Boiuo failure of tlie niroulatioii, often tt-iupomry. tlie urioKry 
•ocrctioD docB not attain it» u»iial nniQUut ; mich cnusea ore fatty degen* 
n.tion uf tlia Ii«art, poricanlitJM, oudocarditiH. vxpoxiiru to rold »u<l moi 
niv. Kvcii ill tlifse oasss tbe <»denia uiid uli^bt Kllniniiiiuria, if detected, 
may be wititukeu for iKiusequenoea of the ranliac eoDdition. 

Tbe narliest, most proiiouncod, and coiiHliiut EyiDntoniB of renal eir- 
rbonx iire ob«<Tved in the cirouljilory hyutcm ; iiidccil, ihr lipurt ami tir- 
terieM funiisli informntinn ipiitfl lu* mgiiifieniit «iid eRMTitiiO (is llie uriiio. 
Tbe condition of the \mhe. whiob is baixl, full, aiul (piii^k, i* often of itseU 
Kutticknt to direct utu^nlion to tlie uriac. Acluiil mensiirciueDls of tho 
Pii1m:i hIiow lliHt tlie tiMiisioii in renlly increiued in t)ii« diHi'iiKe lui much ag 
fifty yxsT ct'Hi. iibove llip uoruiid ; 6|ilnjj[mogi7iiiliie tr^eingji nlso kIiow the 
nnnat Ural tension of tbe aitery by tbe Becoiidant' wavee, Tliis condition 
of tlio piil«B is HHtioL-iated with liyiit'rtnipby of tie left ventriele or of tbtfi 
entire liriu-t. Snrli bypi-rtrupby in in itjutlf, in t]ic iibHcnee of vnlmlBV 
diaeaai!, tnilfirieiit to nroiise a suspicion of renal nrrboftis. It in importaut 
to remember that in i.-ertaiti caaes tbe heart may esliibit no bywrlropliy, j 
©von wbi'ii oth«r cbariicterisUc synptome iire present, imd when the Hiito]>&y^H 
nveiiU couLi-ael«d kidiieya Cohiiheim baM t'iii|iha»iz4-d tb» fact that tiiis 
abmuico of onrdiac byperlropliy in Itir rule in tlioiu' fuaeH in vrliieb iiuiyioi<) 
degeneralioii romplimtea tbi- renal riribowfl ; it is tticn'fore to be expected 
in tbe BiibiectH of proloriRed sMppumtion. Byphiiis. ttibereiilosjn, eta Tlio 
remiltnf tliiti by|)i>rtmpby of tW bcnrt and diwiw of thr artrrint iaa 
Hcritit of syiiiplonis qnitc elianieleristie of llie alTeclimi — pnlpitaljon of tho 
heart, " ruati of blood " to the bead, eooKestion of tlie ffti*e, dixrineatt, ^pi*- 
taxis, and often bemorrbnirp witliin tlto cranium. The H>-called gtiUop 
rhytba) of the heart — a doubling of tbe Muroiid HOuiid — lutserted by l*o- 
tain to It) eliarrtuteristic iil n-uaJ cirrliotiiii, linii Immiii retiniitly iiliowa bv 
Fr&ntzel to occur in other affections also. 1 

The i*eliition between renuJ eirrhoais and the coincident eardinc hyper- 
trophy boH been the Hnbjrct of iiiueli diKpute and investif^tton for many 
yc&n p!Wt. By hoiiio it hits been assiiineil lliat tbe rirrbouH mut Ibe pri- 
BiAry aftieetion, and thnt in eoiiaeqncneo of the occJnmoTi of numerous 
blood-Teutfels in tbe kidneys, tbe blood-pi-essure was increased and the hy^ 



DtSKASGS OF TUB K1D»KT. 



213 



Srtropbv of tli« lieiu-l indu«eil. OtUen have mnintnined Uiat tbo genenU 
nase of tliv urtorifH, in olbvr orKiuis ah woU an Uiu kiclncj^. was uie pii- 
m&ry difficult; aikI vau>te nf cflnline oiilnrgcmout. It would exceed our 
liiniti* Ur i-ecapitulatf tLe obaerviiliotis, cUuii-al and experimental, whiub 
have Veil adduced t^) support cacb of tbeHe hypottic»os< NutwiUiHtimdin^ 
tbe rt-portdd domonstratiuii tliat. by It^iutieut ligature of tlie t^nol arteries 
in dogs and rabliilH, cUruuio iutL-nttilinl iiii|ihntiii euid M-ucitidAry cnixliiw 
liy]juriroph,v b.tve bitHii induced ((irawitz. Israi^l, Lewiitski, denied bv Zes^. 
dt;r), iiui wi-ipliL of uvidiiuce iiidicates thiit the uiigiual affi^olioii ih a dtaeasa 
of arterieH throiiKliout tbe budv. a.s a cuniH.-quirucu vi which blood- pre bsuro 
is incro;LHed snd oiuvliHo bvpyrtmjjliy induced. WitlbtT ur ii^t lliis g«ii- 
«r>l diiikiaHit of tlir urtcirii^!} is a i%»uit of tlio arciiiiitiliitioii in the blfxid of 
iiiftt«ri»la vrbicb siiould be pliiuiurtteil by tlie kidney, is vmdetprmined. 

The diti^tnottia of the renal pat-ticipation id the Reoend disease is niode 

by (he cIluTAcloriittir! nppeiirances of tbe urino. The quantity rtsi'rctcd i« 

^iuorenMd Motutftitnfs ciiDi-iuuiiidy (Bai-tvls r^col'llM a daily excrelioii of 12,000 

M,a) ; frum %W\i U> 4.UUI] <vu. is u froquutit daily amount. In many eaaes 

tba quantity excreted during the iiis^lit la greater thiui that passed by day, 

and ibt* ptti^nt'i rest k diiititibed by frvijucnt calls to urimiU). Tbe utiiid 

Lis in ci>nH[ii| 111- 110(9 of iUt dilution d anusuntly li^lit color, oftttn wiUi a greeif- 

fWh tinge ; it ia of anid reaction, unless reiulei-cd otiierwise by nieilication. 

The specific ijravity ia leati than normal, usually about 1.01U. varying with 

tlio amount pxcmloil ; it i» higher by day tlmii nt iiifiht, rorrcKpondiiiy to 

(Im lessened excrfltinn during Iho day. It in reiuarkiible thatdiiringinter- 

«iirrent febril« attacks, tbe BjHicific (fmvily ruinaiuH, ooutrary to thf usual 

iToto, below tionuikl ; au ob.^iervatiou of this sort should direct uttcntiou to 

' tiut pumubility of r4iu!d cirrboKin. 

The diininutiou in HpttcLtic. gntvity secma to ha de)>eiid&iit Mtiiply ujkhi 
the nolyuria. ami not upon a decrmuie in the amount of iK>lids excfolcil ; for, 
uutil the lattor period of tbe diwose, the amount of uivn mid salts romnioA 
at or uft^r tho noriiml ti^iirn. TIh> phoHpIiatiim tire, how<!vor, rataiued to a 
OOnsidcrablo! extent, and rieitinb^r tuii^erved that phoHplioric acid admitiitt- 
tered to a subjeot of renal (.■irrlioaia ia not excreted aa completely ah by 
ho.'dtby kidiioyi, At n lat^ir pn'riod of tbe disciutn thi>ro is n rdciilioTi of tiU 
the sc^id conti.iUif'iitM. including urea ; iiidi>e(l, a M>ni(^whntilitiiiiiiHbed »x- 
oratiou of urt-'H in ofUiii obsbrvud diiriii;,' ihu (uilier <:our>ie of the ditifaaa: 
Fleidcher found that a patient suGforing fix>m this affection exci-cted losa 
ur«a than a. hualtliy penion. when both were bept upon tbe same diut. 

Tho tiriiix u-tuilly t'oiittuini albumen, tbuu|fU lliin may Im> abwi'iil tor 
days or weeks at a time— an aboenoa which eometiiueH luialcads the physi. 
daa vbo ta accuatoued to regard uon-albumuioua urine aa proof of the 
iaXognty of thii kicUiuy. Tlio propoi-tion of olbuincu is alvrays umidl, umu- 
ftUy not more timn 01 or 0.2 per cent. ; y«t bucU h percentage in so Itfga 
a quantity lunDunts to ueverat (tbruo to nix) ^rtmmi.-K jrt iltty. It itt notice* 
»bU> tUnt tho urinn ox«reted during the night is more frequently free from 
albiiinoii than thtt evncuuied diu-iug the day. a fact to bu borne in mind 
in det^riniiiiug tbe EUiturii of thf irompliuMt ; if llif iiiDming urine only ba 
examined, it may ba found noii-nlhuitiinouti, yi-t later in Uie day it i^ontains 
alhnint^n. Pby>iicid exertion or mental excitement usually causea nu in- 
CtWOHiTd ■■x>a-i>tiou of albiiniim ; and iiriFiiiic riltacks or oulbn.-iikH of gout 
are preceded and followed for some time by increnwdalbuiuinurin. 

The exiHteut.-e of renal cin-boaia isnot exelu<t6d by tbe abseunc of alhunea 
OTon npoQ rcpvati^d rxitmiiiatioiiM, i^itice n fow cn«e8 are on record in vibich 
oo albumen wiu ut any time found in the urine, although tbe H«ctiou re- 



SIO 



mSKASES OF TUB CniKARY OR(iAN8. 



vealod inimisbikAUo cin-liosia and the symplfMnii other limn nlbaminnria 
were oIiunuTt^rintic?, IikIchx), Sclmcliiirdt records n c-arefuUy ylwei'veU ctuo 
in which the urine was ulwnys uonuiil in v^ry ruapwl uutil just Iteforo 
(leatli : the auU>|MV i'l'vuiiIi^I pruiioiiiH'cil ittrojiliv luul itiflrinuiiKtion of the 
kidney. 

But litUe or no seclim^it is macroficopinallv risilile. Upon miwoiwopi. 
onl <"xiLtiiiiiitli()ii, however, there nre fomn) t.iibe-cnsis, cliiolly hyiiliue, but 
OOcauooitlly grauuliii- (Fitr. V2j. IJow aud then u viiat. Htuihlcd with colls 

fi'Diii thi^ iiriniu'y liibiilcs, or 
with uiic aciil, iirateci aud 
oxaJiita of calcium, is ob- 
Mirvud. Diiriiip tnuisi^nt 
«ui{:et'battonH vf tliL- rcDiil uU 
fe<rtion, and nftcr iini'tnic or 
gouty nttncks. ft considerable 
uumbi-r of (-pilhcliul casta 
ami ronni opithr-lliU ccUl 
may be foiiad iu Uw- urine. 
L(!iir4}cy1eit, luid KomntimeB 
red cniiiiisclcu, aro present 
iu aiiiidl uuiutfe)-. 

Coursff u7id Duratinn. — 
Tito peiiflml njipeanitice of 
tlic piUiiJlit oIltMi bdiftj-B no 
espenal ahnonnnlity, wliile 
nt other times tlie skin is 
uuiiHuiLllir pidr, dry, nnd 
hnrali. A fmquont i>jrn{>- 
toni is perslHteiit and Eniioy- 
ing itchiu<j, which w prUKcnt day niitl ni^ht. and driveu tho patient to ilcs. 
jK^mliou. Ill othiir <uu>c!i obstiiiHte cc».*iDn ix dundojwd, whidi ^leld^ but 
dowly to ti'Riitment and breaks out afi'esh without provoralioii, Tlic gen- 
erul iiatrttiuu iixiiidly rt'maiiiK uitinipaired. though emaciation is Bometioiea 
oliHwrved, iiud th« iudividiiiil luiiy ccmipl/iin of com')* ponding loes of 
nt.renf^l.h. All thcftc symptoms occur, however, less freiiiieiilly and with 
Ipsh promiiit'uce thoji duriug the couitio of chronic piir«ucliyiiiatouf< ne- 
phritis. 

The disease may last for niauy yeftrs eroii after ite discovei-y, and has 
iiHuiJly «xistfd for a cotmidt^rahle time bt?for« the diagnows is made or Km 
nature even suspocted. Od the otbcr band tlic life of tlm jmtitiit. ui»y be 
cut abort by any ouc of the riiinien>iitt couipht'nfioiis so often olwerved. 
luniiiig them Hnniniii, ivrrbnd lii'niorrhiv^ri'. iiitliMiiniatii.in of tlie liin^ or 
serous nie [libra TiR.', caliirrb of the intestinal trnct. or o^dctun of the lungs 
ori;lottia llecoverj- from pronounced and undoul)t*iI cirrhoKis of tlie 
kidnoy hna never as yet been rcportod. 

Among the iinwl cbanicterntlic. though by no moans most constant, 
BympfiimH oh^itrvnd nrf. tlm changcft whioh occur in tlie retina. Theee may 
be 80spect«il from the iiupairment of vijtion of whioh tlio im-ti^nt cc>»iji]inn» ; 
nmblyopiiL, dimness of vision, musow volit«nt«s, mid other diKtortionn of the 
•d<7bt occur. An uccjujonnl iriciili^nt is sudden and <M>mp)clA bliiuliiesa 
affecting one eye aud disapiioaring in the coutbo of a few days ; in other 
iuatanceH both eyes njy^simultnneouinlyaJFeutfd.aiipareDtly from no onatom- 
iwU clinnge, but frani incipient iinrmla, 

Iq iho retiutt thi-ni aro observed yellow spota, which often surrountl the 




FID. It— SoiLniDDt tr-xa Hi ii&l CIttIioiIil 



I 



UKBAKBS OF THE KIDNKT. 



217 



€pptic pnpill-T, but mow frpqiiRiitJy m» IncaleU in and nmmid tlifl yellow 
spot, wlieri- they a.re uri'ikii^eil um rays rfwUdtiug fi-uiii tliin puiiii. Iii oHiei" 
coscH tbe HpatH liJivi: iiu dtifiiiilu topu^nii'IiiciU i'ulatit>ii» iriUjci' tu Uui papiUu 
or to the tnm-iiln UiUin. Ttie»o Bpnts niv oooaKJotiotl luirllj' by fntty drgon- 
enttioi) ill tUo gi-auular laya-s of tiiti reliua, partly l>y h^\ pei t i-ojiUy of tbe 
nervp-tihrea, both changes appaicntlv resiiltinK ttuni patLolopical chaitgeB 
of the relinal T^saelt^ Aside from thiHso-callcd "r«tiiiiti» lUbuniiuuricd" 
tliere ia obHciv-cd, in caaea of ninal cirihotas, thu uppvcmuicc kuovru as 
"eboketlJink," tlia rirnuU of venous ci»n{jP»tion. All oftiifisn nlinormiUitios 
of tin? nit.inii may HiiUKiiUt whtiu duo to wrml eirrbotiia ; the last named, 
however, oocanioiiaily icMultii in iitropliy of llio disk A)>"i)!<!sy of tho retina, 
as wt>U iiH of t!io bnvin, Lt often found in tiieso oiihcm nf i\'iiii.l diwwso. 

Pnilmc of thp hj-pertropliipd heart froiu f:itly dHj^tiitratioii, or Huute 
iQlercurreiit diwiwe, r-:iti^a a chsiiye iu the clinii-al pi^rfciiro : tlie urine be- 
comes k-sH jirofosf, tbn Kp'-dHc (tnivity BOiuewliat hifrher. tlio pei«entaRO 
of allunien is increiwod, di^testive disturbanctw »ns u^griiviuotl, pi-rhiiiw 
sliglit dropsy Iwt-otiit'B iLppan>iit, uiid vira'Uiii'. Kjiiipt/iiiis threaten. H^cond- 
ary dibitation of tlio heart, oiui»Dg dyKjtuu.'O, aathum, puJpitntiou, etc. may 
follow. 

IMarfii'jitiji.^'Cho difficulties of diaj^obis nriso not from tbo rosftnihlanco 
of the )<ii-iii]>toma t-o tho»o pii>ducc'1 I>y atlw-r ofiectioiiti of tbo kiducy. but 
from the fiict that these «yinptornn wny lie exbibitpd diirinK a long period 
chiefly or entirely by other or^niis. After the polyuria, iLlburaiiniri'L. and 
tt-nsion of the pulso am rccojfiiizod, tb« dia^uooiiit is cnay. A syflteuiatiQ 
»\aTti)rinIi(>ii of th« nrini* iii evtry owe of di^waae would oftfin reveal an un- 
BiiijH'iriid n-iird rirrhiisitt. It i.t ii'mtily f]iKtiu;;:ui3heJ fi-om ooute niicl 
chronic larendivmatouHnephriliaby the profuse usciftiou of uriiio, it«clc«r 
color, low Hpocilio {jriirity, blight BodiiiKfiit, nud wiioll pprcentjigo of nlbn- 
BUn ; the nbiH>nco of dropi«v, tlin proni?ii<^; rif hMious in the hefti"t, artenen 
oenrouH systeirj, 8tid eye art- sddilioiml fnctors in nialdiiR up a diuf^osiit. 
During apTite exuperbation the nrina inny prcHeiit the cliimgca cliniwt«ri«lio 
of aouto LnfUuimatory procees and dropsy msiy hn proiHuiL; indeed, tlioro 
may be «u jKvUt □qinritiM enffrafled upon ftn litidiscovrrrNi i-enal ciiThosia. 
After the ttidMidencu of this, however, tli« f(!»tureti of the latter idTectioo 
persist. In th« al^aence of caiilinc bypertrophy— either from ti'inpornry 
cauiHf or from a compliwition with amyloi 1 dc;;<'n(!rfitiun — Iho urine may 
bfi ditiiiniitlivd and tint [iimrontnj^t! of albiimt-ii increiixcd ; itiJeed. dropsy 
nmy esiet in slight i\i-^rit}. 

!nie distinction Iron aimple amyloid degooEi-atioa of tbo kidii«y ia 
rarely difUcidt ; for in th« latt'T i*oiii1itJi>ii flirt uriiKi in b'^w nbuiidaiit and 
oontiiim a ij;reaf«r pen-ontafiP of albiitnen ; there in no eridrncu of mr<liuu 
hypertrophy or clum^hi in the retinn. while there is uwially mhirgomciit 
of tin? splotn and liver; the lii»tory, t«), iudicut^H Uie orij^iii and nature of 
tlw aflvdiuu. TiiH f'um pli«it ii m tif n-iml eirrhoffls with amyloid deRetiern- 
tioii prodiii-itfi It puzzlinR (■nitilitiun wliicJi i-jiriiiot alwnya bo ren.'0),niiz4?d ; tor 
Uiere may be no ohiui^CJt in tlm heart or arterieH, while tlic otlifr ayiup- 
tom^ indi^nto intentiti&l nepbritia Tlie polyuria niiiy load to n, diatpioaM 
of dinlxttea insipidus ; indeed, it is pmbnoto that tliiK mixlake in not rare. 
Careful coiisjilomlioin of the other features in ttie case will cosily leud to a 
corront di«tiiirtion bniwcvn tlio Iwol 

Senile atrophy of the kidney, thoiif;h porhajw inditftinffuUliaWe fi-om 
renal cirrhosis by post-raorleni inttiM-clion of tbe organ, ia easily diHliii- 
fniislieil cliniimlly ; for thin ]nin'Iy (i(.-i)iie ali-ophy is aocouipAuiotl with a 
dimiiiinbLHl nitlier thiui an iucrooaed oxcrctiou of urino ; tbvro in no cardiac 



218 



DISEASES or TOE UKINAHT OKOAXS. 



IiypiTi-lrojiL/ nor iacrcaaed uieriai teosioD ; albonuniiria is ntre and UTGemia 
abneiiL 

lu bU anient aeaivh nfter Utent mial ciirlioAS, tlie physinim must 
fj^uonl ngainKt the tvitipUkticiii to iti&kfi this ilinf^nosis in <.-«aeB of iulKmiit- 
lent or persiftteut nlbumiuuiin when the oUier ovniptuoui arc alisciit ; for 
Bach nlhuiniuiiria Uiay eiiiflt without any form of rcual iliK«ji8e. ami its oc- 
ciurence is usually procedvi-l by Kiiuptoimt iu llio cii-t-uluUir}- iind difjestive 
ori^uuH nt Iwwt wlui:li explain the fliguiticiuine of the albutnfii. TLo coin- 
riih-i)(ii vt iiKTAiutul ttrU-rtul tejisiou, pemisteut hea<lacli«, d^'Mp4-p«iA or 
diAn'ha^i with oibuniiiiuria, hliould be regarded as stxoD^ly Hu^tetire of 
rnial L-irrlioua aud an untund for iniiiiitaiuiug a fOUsUmt siipeniauD of the 
paliciit, Yvt it niiutt b« a<lruilt4-d Umt, evi-ii -vnlli tlio iijokI carcfiil nttea- 
ii(iii to all din^ioAtic i^oiata, oases occur in wliirh Uje prcfM-m-e or ahaenee 
of Knal cirrhonia caa be detcnuluHl only after touHiilerab1« liuiu liaa 
clap«eii. It is certain ibnt iiitermittent or coDKUuit idliuniinurin, even 
naxocinlcd with a decided iiiu^aiuj of viutculM* XeimiDH, may liutt for tiouiD 
tuoiilhii and then diiiappoar pennaiiontly. Poatdbly hut-h ciuu-n arc ri-idly 
instances of incipient or localized renal cirrhosis, or thn olbuitiiiiuria ntay 
Ori(Ciual« iti cuDdiliiJua indeiKiiideiit of tht> kiduev. Nui'h canes iiiusL be 
distinguiHiutd fr»iii thu^e of [^-iiuiiio and iitidmibti'd ronid cirrlinnK in 
which reniistiions la»tiiig, pfrhai)% -BeckB or inoiilhs occur, duriiit; uhioh 
periods no albumen is fnimd in th« uiine. 

/'rt«/n'«iij(.— N'o instance of rvcoyry from prononncod and undoubted 
rennl cirrhuaid is yvl r^'corled ; j<-t IIjp affeclion ia not iiircinipnliblH with 
many yAaitt of cumjuimLividy ((Ood ht-ultlt. ItiHt-Luoies are kuowii iu which 
patieuls have survived dfteeu and even t\Tc<uty yvflD) after the detection of 
the renal aJfectiou, uud the phyitical and mitulid puwtfrM are frt^tjueutly re* 
tiMiicd without Kcrious iuapainnciit for six or ifi^jht yiiira. Ytit the con- 
dition is hablc to so many coiupUcatioiis, often fatal, that no seciinty to 
life is afforded. C«rebral hotnorrhai;^' unrmia. (Bdemu of the lungs and 
gluttiH, may occur suddenly in the midst of nppiu-cnt lit^iilth. 

Tiralmt-itt. — Tlie object of treatmetit ix in ibc iniijorily of cnites tu«re1y 
the protection of tliu puUitnl from the cousc-i|U«nit^H of the diHenso ; for ili« 
nature of tlie primary atl'ei:tion ia often undiscovemble. The attempt to 
arrest theiuoreaseuf euuuec;tivi)t!Hsue in tlie ki'biey by rt^iui^liettaildreMBL'd 
to tliftt or^^HU iniiHti )>•-, mid iim n itiidtrr of fiu-t in, futile. Kincu this (.-irrliotiis 
is mrrtilj ooe remiit of a coimtitiilioiial rondition- In tiioi^n csccs in which 
a detinite cause cnn hn assumed, sucli as syphilis or lend poiH miu^, the 
ndiiiiuiHirotion nf remedies known to counternirt thi'iw i^jiitrilit! iiitliit^ncea is 
oocasiontiUy followed by buc-ucss. The iodide of )Kitn8Hiiini with or without 
tho biL'hlfiiidi; of tiM^rciiry him lipcii known ti> arri'st the morbid chaiiries in 
th« kidneys and art<.>rie«, and tlms to restore the indiiidunl to i-onipiu-ative 
benllh. Since, moi-eovnr, a Hvphililic t«inl. may Inik iininii8poc1«'d and un- 
disiMivcred, the iodides mav be in alnioet everr aaic utlmiiiiKlfired witli 
pi-opriety, 

in most inatancveo, evon in some nf nndoubt<4 it>-philitic liittory. these 
romedies jiroduee no appri'fiablo ofFitct in arre«tiii{i or rvcn ri-l-rmliiifr tho 
morbid proct'Wf. CV'rtaiii otherdrutrs liavo seemed at tiniMi iKticilrial ; thus 
Kirtholow reconimonds the chloi-ido of p^ld, and aaj-*!, "llpttcr reimlts 
C<Tn"(thnn tlifj iodidi-n), "the auihor l)elieves. are pctwured fi-om tho 
carvfiil ami pemstent ml ministration of tiie ebloride of gold or of (jold and 
sodium," " TliPse reioedieB. ijitondod to nnest the hyivi-pltwin of the con- 
nective tissue, flliould be prest^ibetl with a ilcthiitc rctliilio^i to tlie presumed 
caiuie — iodide of polosoiuni and bichloride of meraorj-, iu those vith a 



DISEA3KS OF TIIK K1D^-|:T. 



211) 



Rjplitlitio history ; iodide of potae^iim in tiiose poisoned by \cbA ; luid 
clJoriiln of goM iLTid araciuo in tbo«e coses of unknowu origin." 

A^iiie tixtm Hucb iu«ti»ur«s of duubtiuJ utility, nothing can l>e ilone hy 
drii;;^ to clici'k llm iiicruiute of i^iiupctio) bssue iu the kidney or tlia de- 
(leiierntiitn nml thic.lioiiitii^ of Ujo arli-ru-jL TIip trsiitiuent coDBitii« sitnjily 
ID p|Turl<t Ui 111 liiitAia tlie iiutritiou of tli& patieut, and to uvoid the uuiucr- 
OU8 (■niiiplii^lioiLH wliicli beM>t him in the uoiifHeof tlio disouBct. 

A Jiiitictouit diet ronstitulrg a niuKt iiiij>ortADl fenture of the treatraani. 
Tlae food should b« uutritiuu^ luid ulcntiful. but contain no more nitm* 
g«>noiift mfttt#r than i» iicoPRsuiry for liwdth. The <Iiet may condst Urpely 
of tnilk, «gg*, auil vfydables ; fcit meat is |i<-riiiiKiiiblv, but loan mcdt nhould 
be tnken npiritigly. Wineii and linuora of idl kinds Khunld be avoided iin- 
leaa required for pm-poso'i of hiiiwuktion. These dit'teti<; jiriin-'iples, lhou(:)i 
genuraUy ii|)plicablti, must i:i<jt bu regarded na infl«xibla rules ; iixlividual 
WMiU and in'iMibiii-itios oftnn rcijitim ttio u»w of beer or liylit viinvs ; the 
obstinate dyspepsia wUieli so aiinoyaatul (b-hilitiiti-H tlm |»prs(>:i, iimy Iw ni- 
lievfd by Uietio wben other tucuiiurL-it fail (Careful (ibHt^rration of the i^fToctii 
upno tho {^iioral condition nnd tlio etjite of the urine tniub coimtitute a 
cunni 1<-riblo fiiotur iu piffimbi ii>j the diRl. 

Ttje body alioiild be warndy rlothed, the nkiii Ijeiny protectwl by wool 
in all 8enw>ua ; th« greatest earo tibouKI bo takoii to avuiti «xpi>aurn tu cold 
ami mointurv. xiiicu uiuplu wvtliug of Lbo feet uii.y prodpitoto u unemtc 
nttank. ItoMJdenno in n warm, dry. an<l tinifami oHinato hft« iwtiiotiinail 
aeeuiMl to retitnl or even to arr«st the disease. 

Rust of body nud mind in conducive to the -widfaro of tho pnticnb and 
tJie avoidftuiHt uf ciim[>limlinii». Pitdongc'd motitnl e\ortiou and intense 
oxuitnmi-ut luuy, like exceaaivo bodily e.ierciaL-, provoku rapid pn>(;; »;.■<» of 
the disease or tiie outbreak of compUcatiuufi, It ia not dcHirablo to conline 
tlie p;itiont to bed or to forbid jirnpl*> fxrrcise. except duriiift those periods 
when tht' heart iit ('Mpuriullv rnnbK'. It iftoidy u(!<n')wut tci iivoii) oxcrsa of 
boilily am) inrmtil nrti^ity which a iiealthy mitn may nmlerlJtkb with im- 
punity : for tlio subject of renal oin'hoaia is an invalid, howt^ver objeciioii- 
Kblo and uufuui^Lod this ide^ uay Hocm tu hini. 

The lo)t!) of idbiiiupii van \w rembly er)nip«nsRted through the food, luid 
does not courititute an iiuportatit factor uf the couplai:iL 

AinniiK drn^ji, iron. c|uiuine. and iniut-nd ncidii mny be adminint^red 
iihno^t continually. After a loni; course of iron, beadnoho ami gtislric dis- 
turb uaw arvi indicia tionit for itii <liHCi>ntiiuiaii(-'e ; it ithoulcl bit riiinwi^d after 
■II intervid of re»t Soiiio f^iperiinentation may be neoeniwry to diM'.oTw 
the luo^t Editable fona for the lulinini^triition of irou : tljo iiiohI ^euerally 
useful it BmIuiu'ti nii\turu, thoiigb tbv citriitv of irou and quioinc tuay bo 
aubatitutnd for a time with ndraiitAuc. 

Hoius of the coiiiplioafiona which render this disease ao dangerous 
arino from lirpcrtrophy of thu ht-art mid dvgcucmtioti of the Toacuhu' 
W4ll* Wi> nro iimiimi iited with no moiius for arwBtiiig cithrr of tli«M 
pTooomea ; iu fool, uu atleuipl to prevout the cardiac hyperlropby would 
be unjiutiftable and. if itucccasful, diHastrous, Hinca thocontiuueilocrtivityof 
the ki>lney o»u hemaiiit:un«douly by increased elToii^ on the ptirt of the heart. 
Tiitt only xafoty a^ainnt compliant ioit» on tho piirt u[ tliu cin^ilatory organit 
liea ia tlio avnidaace of pliymca.1 and mental exertion niid exeitrmi^nt. At 
a lattfr pnriod it may boooiue u^cvaattry to stimulate rather than "joiet the 
biiurt ; (or after a time the compf-naalor^- hypertrophy, which at firat 
eanblen the kidneys to exerete tixt urii-iI nniouiit of solidn. failti to koep 
pftOO frith tlio iticrtiwiiit; dbgeti«rattou of theiMs orgaua, or jjivcit place to 



330 



DISEASES 01' TU£ UKUfARY ORGA2fS. 



dilatntlon or dittr tle^enemtioa of the henrl-iniiNrlK. This fnilura of Uio 
heart iainiliciitod hy tlif><UmiiibibpclL'icretion of uiiiie atid bir Ihe increased 
perceatage of Albumen ; it, cailn for citriliw! aliuiulmiU), i^tipt-ually ili^ibdiH 

A uni^iiiic attack iiiiiy Ih^ e\{)i^teil, if tiic luiiouut of uriiie is dc- 
ei(l<i(lly (tccpeaitfid. Miuiy iireruoiiitory wkhs may ccciir ; Budi arfi mniicit- 
lur IwiU-hiu^ suiiden fnlKire of ai^ht, dciuble viision, int«uae cici-'i|)ital 
pMiii, cerebiuJ excitement, insoninia, etc 'Ylie occurrence of wiy of these 
dhuitld If-atl to nj) innncdiate exaiiiiuation of the urine ; if the iinioiml is 
dccrciLsi/il, the albumcu iiicreiiM.tl, or the Holidti lc«!!cncd, the ekin and 
I>owrl» Khoutil l»e stimulntcil witlinut waiting for iiroiKnint'«i3 uiiE'mic 
ftytii|itotiiB. I'uri^utived ntid a hot bftlh or wet-pn«k often xuflic-e in thn 
earlier Hiagea of tlio discofle ; at n httcr i>eriod it ia niecenaary to employ 
pUuciirpino Rubctiloneoiiuly. ns already directed. The inhalation of chloro- 
lonn ur aiiiyl iiitriti-, phlfirul liv the uioiil]) or lYJct.uin, or a l»y[Kiilerriii<'- in- 
j«clion of moqihine in large dose a, as practised by IxromiB, may be required 
to coutrol the convulsiona. 

In the trextnicDt of tlio iinRivrotts OQn]])l!<uttioiiit wliii-h nri«o in tJie 
coiirNO of tlio disi^aso — dyttjK'iwia, dinnJiiTFi, indaniniation of Ken^iiu imin- 
bnuieH, (wtitma, etc. — on* twet ia to be borne iu mind, namely, that Biiipo 
llio renal activity ia impaired, the eliminiition of dru;j8 is 1c«h rapid luid 
eumplete fbim in other cuiiditious ; heiiro powerful rrincilicB. ovpteittUy 
iiitrcHjf.ir-H, iiiuKt Im ciuploycd wiili tile preiitest cuiiliDti. Kunu' of tham 
cotnplimtionH, (-spt-finlly thoKo nmnifcstt-d by the dicestivo li-nrt, niny he 
averted and abnted by tlie dady use of warm bfiths, nvherehy the es- 
crotory activity of the skin is fnvorpd. The viuSoiw troubles orifiinatiag 
ID cembml coii{t«8tioii may Iw 1o Roino oxU-nt nvotded by seuuriiiit rejjulnr 
evacuiitiona frciu tin.- bnwel-t ; in case of emergency aiioh congention may 
rcquii-c vciicsccUou, though doproHsing mcusurcii are iu gcDeml contra- 
indicAlud. 

Fattt Dbbbneiutios or the Kidsbv. 

Tliiw condition i.-* usuiUly lut^oriuled witJi fiitty dpgeiiemtion of oUmt 
OTRanN, and i» found iu various amrntic and carhefrtic states— con- 
Bumptioit, scrofula, pernicious nna-niia after jjivifuse hemorrhage, chronio 
KUppurulion, etc. It in QbtK.-rvcd lus nil iicci-'iupiiuimcitt of lu-utu fcbrito 
alTectiniiR, cHpocinlly the infei'tioua didniuws ; it niny reanlt from gx- 
tenaive disen^o or injury of tie akin, snob as buroa, and m»y folhuv the 
proloHKod or cxccawvu use of rarioua toxic ngnnts. such as phoopbonis, 
arsonic etc. 

Fatly dtrj^encrutioD ia fre<]|uent: tn oldagowttliuutoUier apiKvroiit tmuMC ; 
it in tlion UHiially osnociatod with a siinilnr condition of the Uver and of tiie 
heitrt. 

This nlat<! of tlni Ijidney i« not usuidty n-wt^iivablc dnrinR lifo. It is 
often nranniianinl by .11 tilttibt albunuiniiia, and it in uiid Uiat in a 
few canea fat haa collected in appncinble quantity so oa to make a alight 
)M:um upon the suE'fuM uf tliu urine. 8iucc ttio fatty kidney performs 
fniriy well itn fmiclioBR. nn<l sinee ntber orrranii simikrly nffeoted 
(espeeiftJly Uio bt-art) are apt to fail earlitr tJinji tim Iciilnty, tlm con- 
dition of the latter consfiluted no impenitive requirement for iriedication ; 
niorf'over, ti-cntmont offorts a hopo of success only when it can be 
nnployeit for the removal of a kDOwn <»use, micli an ntia.ima or phos- 
phorus poisoning. 



I 



DIARASES OF TII& KlUKET. 



921 



St■pp1;tM■^^-lc NuriurtTW. 

This form of ivnal mdauiiiiation ^liffers frtmi Brigbt'H disenao bolh 
anatomicAli^ and otiolot^icuUy ; it is iiot n iliil'uHe buta drviuuticnbcd in- 
HiiiDUiiiiiou. 

Kli'if'iyj, — It innj remilt. oithor from dircrt cxt^'iiMnn i-f ii pnivimiii in- 
flaiiiuintion, or frnra Rietastaftia, tlio IraiiRfr^r of iiiHimiiiiatoiy cieniPiits 
from oUier oiv«us ^3 means of the blood ; also from direct meclmuical in- 
jurv to tlu' liiiln(\v. 

Sii|)pur,tlivc intlitiiiiiintinii by exteiittoii of tlio iiiiltiiu mntoiy iii-nrea* 
inmost frrijiiotit jifU-r o^iHtitin tuid pVflilii* ; it no fn-qmnillv fLillowft tlie 
laat-unnieil aOectton lli.il it id oftoTi t«i'ni€<l prelo-uephritix. 'Xhvd uiunc is 
pruperly upi>liod vn\y to nvi^v^ \>t Hii|ipiii'Hlioii m tbe kidney fyllowing 
m'clitiK. uiid ijrn(m>jt iuxtimtrt^it in whirh t.ho (li<wiutu In prixliiccd W ntlier 
uidiK-urfs. It may al*) Ikj induced by tbc (-\t<-uni()U of a pcrinexiliritie 
iiiftiinimntion, Ui6 I'esult of wounds or injni^ in th« rcnnl r*?(rion. 

Concrft.Jons in the ftulistnuco of tbe kidney, infecliousombnli from dis- 
tant foci <jf iiitliiinniatiuii, are ooi.'«»ioiial cauKOit. Jt ii poaiiiblc Uint CL-rtiun 
acrid diumtii'x. sin'li a» cnnllini-tdett, c-ii|mdiii. mid tui-|iciiliiii>, uuiy l>^ 
simple contiwt orovso suppai'ntiT« iuflamiiiatioQ in tLo pelvis and tlio 
kidney. 

Kii|ipiinitivo ncpbtniix of tiiotiinbitic; <irigtn may ocfxvr during; itny of tlio 
flsptiu lUneaaes ; it if) not uiiuhiihI in pyi«iuia, («'plirM'tiii.i, piicrponii fever ; 
but oi^cura Tvilb eB]>ecial fi-ecjucncy iti ctises of tdfrcroiM cnvloi-m-dilis. Yet 
it iiinyn1»o rovnilt fimii locul iiitliiiniiiiiLioiiH of septic orif^n williont [{oiiri-al 
iuft'cliun; Biittnlit-r luw dcw'i'ibi'd a intiurkable caav of piibrinimry ttb- 
tioc.««, vfitii Bfi'ondmy iibaetsa jti tli« kidnvy ; iji tli6 lutlc-r wei-o found 
cl'uitic Hbroa from tlio lim^, drti>otii«li-nriii<; tliQ'on^n of tlio locnl retial in- 
flaiuumlioti in uu ciiiboliiit fraiu tba luu^^. 

The oxtcuniim of inftninntaUoii fniiii UkiIiimuom mirrnuiiding tbo kidnoy 
or fi'om the lower urinary cbaniielH ia Ihe most freijueiit catiite of Riipptiiiv- 
tive imphritia. Thuti it u(.-mirii »» the result of jieoiui iibticvi*). tuberc\iloi>i8 
of tli« via1<?ltim abKncHit of Ok; liviT or of (ho «jilrcti ; moro fiicijurTitJy 
fri)iii inflaniniatioii iu tint bladilir or Was pi'lvis ot thti kidney ; and theno 
may be in turn iuduwiJ by nioHt diveran p!i.1holoi;ieal pivMC^tHCJi iind opor- 
ntivc piDccdiirrs in nny p>tilion of tho miliary cluuinel. Tbus tho pmscnoo 
uf Kluiiv^ in tbo bhuidur ur iu tlio ptrlvi;* of ^fl kidney, ucclitsiou ul tho 
uiYitor by n'linl wilciili. hyiMrlrupliy of tlio pniHtiLltt arc •tl>^ll^tilllc.■» fr)tloii'<!d 
by siippmntive ncphritia ; the numerous coiiditiona of tbo bladder stid 
tii^tor K'bieli ivqiuri' operative ijiterfeii?n«e are extremely proJuctive of 
niiiU Mippunttinti. I'nrr-Htii of the blaildrr as it occurs durioff diwiuto of 
tliB aitinid ourd and iu old aRu from bypcrtniphy of tbo praalate, atrittt- 
ureol tlio uretlirn, phimo^tiiii, f retjuoiitly ctdl for «ur^i<%al intcrfer«i«c, wbi«b 
laupt to bn (ollotrcl by Biippurntivfi nepbritiA. In prerious pnj^a ntten- 
(inn tui4 bcoti alrcibly diiiectt>d to the conditioD knovrn aa " uet^tive pi-t>a»- 
lure " — tiiat condition in which, iu c.tuDcquence of ob»tr»ctiim tti tljo 
orncuntioii of the iihiio, distention and iiii-reniHHl presnuro iu Uit,- urinary 
chnniK-'lM Ix-ltiiid the obstrui^tion oei-iir. Tlie nudden relief of thin in- 
«VJi.-*i!d i>rr«4nrr> by tho ronioval of the previously existing oWmclion is 
followrd by intensi' con-^t-fttion uud intliiuunatiun of lb<: pitivioualy tli»- 
tcu<k><1 cbnimels; henoo it bnpponit that operations for nliimoais, diYiaion 
or dindjiiou uf » narrow strictun.-. ibe evacuation of the bladder bv litliot- 
omj* or lithothty, crou (lie introdiicUou of a culLet«r, niay be KuMcivnl to 



009 



DISEASES OF TlIK TRINART OHCANSL 



induce thi;* inflwnmatorv pmoessi Tlio frwiuency of suppiirative nephritji 
nftor IIkxo Kurf^ical proetnlurea liaa caunei) thfi adoption of tlio nnino "sur- 
gic&l kiJiiej " to deski^ate tliis nSectioi]. 

It in wurtli.v of mle tlint altJiou^li tlii> indumniKtury procoRB Ufiually in- 
Tolrts tlic bliuUitT Ixrfiin! pn>('r'v<l>ng to tht; kidiiiry, yet iu some coses 
ecvcro nihI even fnUl inllamiiiiilioii of ilie Latler oreiui occurs without pro- 
noiinncfl inflammntion of the low«r iirinniy pHsHA^oa. In Homo feu- cases 
tlie foriuatjoD ot coDcrctiona in the eubetance of tli« kidney itself linit Im^oii 
followed by Huppiirulion in the orpin ; renal abiicesiCH are ocoasionally 
fnmiil in tlio »ul)jcnl« of JiubcteB. Untn rnsts am recortlod tu wliich enp- 
p»niliv« i^'pliritiit ajutcitra to bnve been tbe direct rcfiiilt i>f injury. «uch lu 
(1 blovr or wound over tlie kidnoy ; in rupIi instanp<?a t!io rciml iiitlninTiintioD 
is iiKiudly Aubseqitent and np^mrentty sconixlnry to mpniimtioii iu tlie ]jeri- 
DL'phritic tiesui.'. lu Ktill ulbcr cjihch uu cmisc uiii bo iit>«it;riL'd for tbe 
orifpii of tb« diKCiute. 

Morliid Aiialiiniy, — Tlus vikries wUb tbe stngfl of tbe afTectioii. Tlie 
size of tiie orpran may not be nbuormal. but jta suifat^e and parencbynia 
fir* sludded Willi {iraj-isb points, oflcii mund, at tim«9 linear, and vai-ying 
in taxx from tlio limit of tbe vittible upward. At a laier gla^e ab«ce«es art 
se«n; indeoil, the entire organ can be traimformed into a mftsa of ptu 
from tbe coolesceuce of tbe initial al>8ci3>u;(^]>i. 

Tbo cn|»»ile of tlie kidu<:y \n tbivkfiivd and iidlicr«Qt, »ii<l at limce per- 
forfttod by opt^nin^ whiHi may lend into nny of the neigh iionnp organs — 
ci>lon, liver, Iitiig^ amnll inteatiue, stoniacb, into tlie peritoneal cAvity or 
even through tlio nbdomiiiiil wuU ; in olhcr easps thu pus does »ol extend 
hoyoud the iiinRS of fftt wliii-Ii *iiv(-lop« tlifl kidney, but this mny be so en- 
lar^L*d iirid dis1«iidt-() ivi Ui toiiatituLe an extensive tmiior reudily peici-pti- 
I)le through the abdominal wsUL In many instances tlie pUH iinderKOPS 
cbeesy depeneralion, wliich may be ftillowrd by «?iil<'ilinition, at lensl iu 
&pob<. Soini<timca tbe clietmy luiw» ia more or Iubm <.'iinii)b-t<ly iibswrl>ed 
Bad replnerd by a growth of c^onncctlTO tissue, wliich rcHuLta in contraction 
aod deformity of tbo kidney. 

The extent mid Bubsequfnt cbangcs drptnd ImiT^ly upon tJie cause of 
thp mippiirntion ; wlun duo to inflammntion of the lower urinary pAvsiigfR, 
ooiiui-eUouB, or traumatic iriHuence. the intlnmmstioii is often limited to 
one kidney ; if crauscd by mctaatatic deposits, on the other baud, botli 
kidneyn ni-e usually nftected. 

"Upyu microsfopic examj^atioD u coimiderable portion of tbe renal 8ul> 
stonoe may bo found of nominl appenmnc^e ; in the immediate vicinity of 
the absceaaea tliere are evidences of aciiti? iiiflamuititorv condition. Upon 
esaminiiiK a mihoiy abecesa tiiere will idwivys \w found, iu cuscs of mclua- 
t.ttic origin, and oft«n in those reaultitig from iiiflnmmntion of thfi binddor, 
iutiKtU!i4 of niicrw'oeci in the walla of tlie abscess and mingled witb tbe puat 
If the obsfirx-er bfl ff>rt.unate enough 1« haw inclnded iu bis eection an in- 
cipient abaccHB. so small that the eont.enta do not fall out in tl)« pr«tAra- 
tion of t^e object, be will find tbnt the centre in eoiupoeed of a mass of 
th^HO apliiirical bacteria, usimlty constituting on embolus in n minute 
blood -vitsBel — one of the iiitertubular cnpillariea or a capillary loop in a 
glonienilus. Occasionally such an embolua is found before suppuration 
unB occurred : the masa of niicroeooei is surrounded by b zone of ititlanied 
rcnnl tismie, the epithelial cells lietny swollen and cnmuW ; a fvw scat- 
tered leucocytes are observed, indicating the beginnmg of EtbsccHa formEk- 
tioD. 

In metwrtatic suppurative nephritis the masees of micrococci are often 




DISEASES or nrE kidktct. 



223 



obseired a» fjnyiaii stripca, wliich tire found lo be blood-TeaaeU filled with 
thctiu orgaiiisius. In tlip dwrn which nriw by pxteasiou from the bUwIdcr 
umA ureter. th» bacteria axe oliserved nn yiini^ tilling the urinary tubiileii. 

The pelvis u[ Um kiiluey uHuuUy eicLibita morbitl unjicnrauooH ; it is 
dilated, the inucQU» membniiie is ewoUco, perhaps eroded and ooated irith 
thick tmiRus iiiid pus. Tlie ureter \A the hbiiL of siuiilar changes. CsJculi 
or masses of ]>ip« ore found in tbn pid\-iK and in thv tliUiod urot«r. 

Si/mptontx. — The symptoms -mry acconiiup nn the pelvis uf the kidiisr 
Vi or im nnt cxt^uHivcly iiiiplteAtfiil in the iutlnuiiimtor^ ))ii»i>(!kh, tho xvnip- 
toms of pyelo-iiephricia being BOtnewhnt tliffercnt from those of a euppu- 
r&tive in^uimiatiun limited to the kidney aluue. 

In the lntt«r ciwo Ihu rrpognil-ion of the iiftbction ■« ordinarily difRcnlt 

or impoifiiible. tjoloug i>s Ibe pus is produced ra miliary ubHcca&us ouly — 

Ik ooDdition usually coiiBequeat upon ulporoon endorairditis or other septic 

[ proceSH — no symptoms an observed wbieh direct atteotion especially to 

[ tbft kidney ; tbi^re mny be a cliill and ftver, but thenc occur am u port of 

t th* primAry ntrfM^tion. TI10 coUcotion of pUR in Inrgf^r i^nantitiea ia uiniAUy 

followed by the familiar sjTnptouis of such condition — repeated chills, re- 

mitttMit fever, profuse perK])initioii, emiicLition. und <Uu'rh(E:i ; while these 

syiiiptoins iiiiiii-iit« Hii]ipumliou in nomo internal organ, tlioy do not locato 

tl)« proceiM iu the kidut-y. 

Sooner or later vurinuB syniptoms may be manifested wtiioh indioikta 
that tlie rciiEd ti-wiio is tho wiit <if n morbid proir*.*. l*nin and t«ndemen 
upcm prunauroiii tho R'jiriotiof Uio kidiit^yarefi-etnient, tltmij;h by no means 
eoiHL-uit phenomonn. The pain is most severe in the loin. Iiiit raditttea 
towaril the navel, into the Rroiri luid domi the tlii^li ; contnintion of the 
crciauHl«r i^ oftmi ohr«;rvfd. Liiuitjilion in tho movtrmciit uf the lower 
vxlixtniity on tJiit (virrnMpDridiiit; xido L« an ocRiutional Hymptjiiit, moro fro- 
qtient nfler the intlammation has extended to the perincphritic tissue or 
tiio pelvis. Sometimes the imtient csui rest easily only on the opjxitiite 
tuila ; or li« may Hud Iviutt aiMroinf'>rt nlicn hn lies upon tho tibdoinen. 
Tlie pain is often uitonnitteiil or reiiiilt.fTiit iu cbamoter, and is aometimcft 
increiuu3d \a nn afronizins de^^ee 

K tumor mny be obnervod vrliou the suppumtion hna become extensive. 

.This is rnrcly seen until tin- pus lm.t hrtikt-u into thu pelvis of the kidney. 

■Th« distinetion of thi* from other tuniotH nliioh mny ooi'xipy tJw! name 

loialily is by no me&ns easy. The exteiil. ;md locntion of these tumors m«jr 

vaiy considerably, and they present no pL<cuh.ir aiul L-li.iract«rislic feature*. 

I>iHlim;t Ihintimlion in imt frctjuent. AhwnKt of thi> kidiirycJin tu>iiiiitintcis 

Iw diatinj^iiished from perinephnttc nbsceei* by the f«:t Uiat tlu- former Is 

rieaa profuse and is HUHceptihle of more detinH'e limitation ; from tumors of 

lh« splvon tuid livor by the nbsom-u of mowmrnt diirin^f roepimtion, snd 

by pal)wtiori, Kiu«o tho fingers cau be inserted between tho tumor iiu<l the 

Efpleen or Uver. 

Tlie tirino funiisbes aomo informntion; the most conetaut abnormal 
iiigredi«ut is hlood, which umy bu present iu micli ninount :u to give the 
urine a rnnoky culor, or in such Kmall iinantity as to ho riToytiiMibla onbr 
by 1)10 microftwpe. Putt may be absent until an absceaa of considerable 
size has opened into the pelvin : and even if present, the Bouroe of the puR 
cannot bo delinitely located, unless aocomp^iiiied by other elomeuts, such 
ns fm^meuts of reiinl tiitaue. Even tbou(^h them vxi«t u tumor in tho 
ronnl re^on. one cannot bo Rurc that pua found in tho iinno proceedJi 
from the kidney substance or renal pelvis ; thus Of:;le observed a cars 
)u wbicb a Xvtrgo ahsccia funuvd bchitiu tbo left kidney from cariea of tli(» 



224 



riSEASBS OF TUB VRIKARy OKOAXe. 



BecotKl lumbar rerlcbiB? ; the pits burrowed downvFord And broke into the 
bladder. 

Tho urine nlwiiyH coDliuna albiimcii, vrbicli may be lut (;;reatcr in ntnonnt 
titan i-1 nattiraliy fumiHlied by tbe pus and blixxl present ; in iiy(>li>-iii!- 
pbritiH,on the other hand, the amount of albiiuieii ofU'u exccodHtliiiL-nliMi 
would cocn-apuud to Ibv pus, ood nuiy bo ivtiKidcruble eTon wb<^u ibtire is 
but little Kodiineot. Tiibc-cnsls Mre o(t4tn fi>uiid, titniiilly ou}y the braline 
nnil ^'mttiiUir funiiK, ttiougli uccuittiiiially an cpitbdial ciuA or one conipo);«d 
wholly of iuieU'ria is liiscoverl. ' 

Li a few eases §innll poi'lions of renal lisnuo liave been expelled vilh 
the unno ; Wicili-rbnUl i«iw «ur)i n piece ns l.iTfje ae a pi^eoD's ecg ond 
eoutniiiiii<^ di8liii<-t tiniiary tiibulea. Tho diKcbarge of Hut-b jneoes Toratea 
dutiniti.-ly the uivit of tbu Kiipjiitratioa, but ia mo nrcly olmcrvod a* to be 
practirjilly iiiiavailAhle, 

So HoGii iiH the pus bits escaped into the perinepliritie tisHue, rarioua 
atlditionnl syitiptornH may lnj nmnifeittrd. Tlu^ pus iniiy hurrow inlo the 
sliin. wliifh lifcdiJK-s swolleu.a'ileitiutoiiet, and douchy ; or it may {lerfomttti 
the iTiteatuio, oauRing pumlent stools ; into tlie peritoneuin, etc ; indeed the' 
case then bccoTiiPs one of perinepbritic inHnminntion. In a few CMCB pik- 
ralyHi« of oiie or IjoIIi le^ has been uevn, apparently lh» rvmdt of an ai^j 
eeudiiig iiMirititt, origituiLing in or uround thu kiduey anil exteiidliifj^ to thi 
8}>ina] cord. 

In niosl cases of Fiuppumtion in the tiJney the pelvis beconiea aooner 
or Ktor in»>ilv('d in the morljid pim^cHK. In many other cjmen the intlatD- 
lualiuM lins ext^'uded from the jit-ivis to the kiduey. A Buppumiive ni- 
phriliH is, thereforfi, either fimm the beffinnins or nt a Inter fUme. a pyelo- 
nephritis ; the inchihioii of tlio i)elvi» in tbo i^iorhid condition reudeni tho 
diagnosis l(f>» ditticidt 



PiBUTB «» Prnij-jfiiPHBiTia. 

In every enae of prouounced pyelitis the inflnmtnatory prnopse cxtonds 
to the renal papiilie whi(.-h pruject inti-v the ikOvis ; atintomicully, therefore, 
tliero uiny Ijr- no (rroiindw for diittiii^oixliiii;; n pynlitin front pvelo-nepliri- 
ti8, but eiiiiicaUy Ktioh rlintinctJon la ignite hupoi-timt : an iiilutmnuilion of 
the peh*ia iinpUcalinK only the papillary portion of the kidmry ik distinct 
in syniplomatiilQ;ry, pio^^ioBi*, find tmilmi'nt fnjm one in wlii(;h the ijj- 
flajiiTiiulion oxt*udB to tbi- dcciwr portions of tiie oryun. 

Pvi-litiM iniiy he n jM'iiiitiry or fiei-oiidary affecliuii, and may piintuo nn 
aciito nr <r!irnnic ooiuse ; it i^t uiiually chronie and »ee»iiilar\',niiil, Lbi-refore, 
Uke evHtitio, n mjmplotn of other tuorhid cunditiona Its coiirue, dumtion, 
and l4?iTniniilion are detemiini'd krjiply bvllm nflVrlion which pvoduceii ii.\ 

Tin: iiillatninnlion Ih at first nitiirrlinl. Imt niav niptilly btrunio piirulent'i 
or hemoiThniific ; ermipoiis nml diphtbnritio iunantroationi) of thin aa of 
other niucoui^ nienibrnii<-H an,* ob»er\ed in the eonree of certain bifection* 
diseases. Yet diiditlieritie nyeiilia is f.ir less fi-eqnent than the wport of 
aatop^es in<lient«B: nlrerntion nnd nocroisin of the mucous inrndirane iM 
not uecoswtrily an rvidcncc of diphthi^ritic inflaniiaatioii, since tt is a fre- 
quent feature of simple purulent pyelitis. Some blood esi>npea into Iha 
pel lis iluriug Ihe oi>liiiiu'y catorrhnl and purulent iullniuuiation ; tlie <|n{Ui- 
tity is much (greater iu those cotiHtitutionnl eouditions nhirh inrltide b 
tendonoy to extriivnsation* in tlie mucou* iiioniliran'>« gtin>r>illy, prv^tmh- 
bly from abuormuJ conditions of the blood or blood* veaeela — bcurvy, per- 



& bly from t 



DI9KA9K8 OP TITK KIOSRV. 



SSu 



ia, liemorrlia^c sinnll-pst. OlUvier lina described under ttie 
nuntt-PSn^fl''*'''''' f''-""'f''>-j''f>'^'-''"'-'' N iK^ninrrliugic foiin i)f j>;k*<'liliH whtuli 
is peculiar to old as;e, and is apiKirently n. lowil maiiifrHtationnij:eiieni.l arte- 
i-uu diaeaflO; there «sist«&acleroaiBof tbo nrtehesi\iidc<inBei^ueiit tendency 
to the formiilioii i>{ tHuiu-iwiM. Tho nipliii-o of milijirr aneurisms in tho ppl- 
vie EQiicuusiiioinbmue in followed bj'llit* furinntiuu of dots, which are Hup- 
pusoil to prudutre an iiiflnininuLiou b^ nivc.liniticiil irritutioii. 

AYiVrff^f/i/.^SimpIe retention of urine, due to some medianical impeili- 
ment in tb« urinary cli&utiel, ia nufBt^ient to ])ro<iuce pjelitiii ; thia isilam- 
mution uttbnrcforonfrcquimtsequenfeofiirethrAlstTivtiiro, prostatic liypcr- 
tmpbjr, veaioid ciilculi oruuoplBsmH, pariHin t)f Ibi^ bluddi-r, liimora (Miijet^ially 
cftuorroua) of thfi womb, pregnanoy, cto. Tlio (imraoninool dcmmpoaition 
of tbe nrine ia not eseeutial for tlie production of pyelitis, tboiigb the in- 
fLLiniimUon ia much a(jt!raval*>d when siich deeotniHwitiou occutk. &o Ioiir 
i» tlui mirgcon rofrainn from in Ktni menial intcrfemicr in tho blniLit-r iind 
lU'etbio, tlie uri]ic retained in the pdlvis und blinldcr rarely uudoi-yws tbe 
animoDiaeal change ; lunl it huHi instninicitlal iiitertorcnco — tbo introduo* 
tion. of n cnlhetcr. dilntntioD of n strioture. remoral of a resiral alone, etc. 
— be intelligently [xtrfornicd, but little if niiy n};gravaUun of oithtr pyflitis 
or CTHtitiit n«fii nnwur. Wlioii, bow^vfr. mjcb op«rfttio& i» performed witli- 
out reference to the c-onditJoii of Uiie bladder, an itg^ravutiou of au existing 
liyelitim usimUy witli aniuiouiacal fermeotatjon of the retained uriue. in tbe 
■vgiiUir result («oe Urethml Pover). 

Pyelitis ii1m.> nriaea iisaMtuplc esteusioii of iiiflununiition, jnost fre- 
qoontly in the hliuldcr, but opi^asionally in Ibc kidney nr periuepiiritio ti*- 
Kue. Cystitis iodueeil by meebnnical irritation of n lilone, cvrn Viitboat 
ioBtrunifntal iutcrfeniice, usually jii'odui'en pyi-liti» itlsu^n (;umplicalioii 
which niftteriaily losafiia tbi> piitifTnt'it rhanro« for repovfiy nfter opemtion ; 
bence the eiirlie^L poeoible removal of the Htone is desirable. 

It in a futniliiir obHervation that pyclilia in a frequent nffcction during 
pr*^n&nt>.v a* m-^II n» in the pueqwral st/it^t ; ulso nft<>r gynecoloaioal op. 
erationa. DitTerent etioloi.'inil fwloi-s are i-osponsible for various coses. 
Thflro can be no doubt that tlte pyelitis wliinh nriginntea dunnRprej^aaoy 
is frequently produced by simple rc'teution of urine in consetpionco of 
oompretttiou of Uiv urcU;r» by tbu ciulur^rd uteruK ; wliilv iJio viwea wliioli 
ariiU! after delivery arn produced partly l>y tho <>xt<-vinon of pttlnc inflam- 
mation)} and partly by tlie auddeu evacuation of tbe urine previously re- 
tuint-din tbediKti-ndcd pehia; probably muny of tbo sn^called " idiopatliic " 
caiam of piiAr|»ct-a] pyelitis orii^anatv) in ttii^ wny. It is worthy of not« that 
enran when pyelitis M>t-u>ti unniiittakably to have Weu produced by an ex- 
tensioa of vewcid inflamtnation. the mu<'ouH membnme of the iuUtvcu- 
iag ureter may esbibit. little or no nbuormnbty. 

Tbe ttout<: and twvc-rb inffutious iliMiiseH cmy proiluee ai:i iutUimmation 
of the renal pelvis as of other mucfoUHnnembranoH; amouR these are cholera, 
small-pox, dipbtlieria, and the seplie diseases ; diabetes and tho wuto 
CiUft-iv^eatcritia «f niirslinj^B arc nI»o frcqucutly complicated with pyeUtin 
Tlui inflfUnmation -which occurs duriiii; tlio acuto infefitioiut dinca-ica in 
otteu GroupoiixDrdiphtlH'ritiv ; it pOKHCK>u-M<^>inpanitJve1y httle clinical aia- 
nilicance becnuMO it in often nvorlonkcd, and becauHe its imporlouco u 
OTei-Hbai lowed by tbu constitutioDal atToction. 

Foreiaii hoilios in tlie [jelvis— bUio<J-<dot», fra;^cnt» of tissue. ))aTiuiit«« 
— nroutio pyebti>^ either by direct iniehatiioU irritation or by Kcr>'iiiy oa 
■mdui for the foniiHtion of renul calculi ; colculuuit pyelitia id doubtlutis the 
BHwl frequent of all form& 
16 



3 



250 



018KA,8K3 OK THE fRINARr OBGANS. 



The odmiDifitmHon of certain irritiuit dnipa — mntlinriilps, Tmlwima, 
turponllno, «tc. — is cr«(lit«<(l » itli tlio reHponsibiiity for certain (doubtlMS 
run-) i'il-ml-h nf jivclilitt, iixikiIIv of t;)M! cniiipDux viirii^tv. Nvoi'lnMiis mnv 
aJko originate) tbn dtHnwe ; it is n rc{;^liir fentiire of <;iiii>oer or tubt^i-L-ulu&iR 
ot the j)&l\'is or kiilney. 

In a L-crtain nnmbGr of caaennD definite cauoe can bo osKigned; bencc 
thpjr are it'f^rrixl to "takiu;; coUL" 

Tiui !in[ili('iitiuii of Ui<: kiilucy may cnnnut mvrRlv in n eiitJirrli of tbo 
straight tnhiiCeii. nr may amount to a NUpfiuratiTo nephritis ; tho exteul of 
the renal iroplicaliinn m detoi-mined chiefijr by the oauiw. Sii[>|itimtiT« 
DOphriliii is cspecinlly frptpiciit ia thorn cwn« prwlucetl by iDUaiumatioQ 
nnJl operation in the lower portion of the nrinnrj* cliaiiufl. 

ifiirhid Aua/omy. — Tiio morbid appeuraiioeH vary luf'oiiliiig to thoirtjif^ 
nnil dcj^'ci! of tho inllaniiuation ; tbty are in ^'cneral tlioar tif catarrh of a 
inmiouH siirfaut-. Ulwratiun may owur even whwi no f(inif,'ii boditH nm 
finrttcnt. In oiisck cif ohrtwin jiyt^litiK rtipilliiry iiiiw fiiriiinlimiK [imjf'ct into 
the cavity, cnveroil with a ih^jxisit uf nniHn ami jih) itqihatpj* Diliital.iiiu of 
the pelns ia iiaiitil in eliroiiic luul freijufnt in acute pyc-litis ; it aectnH to 
ntsiilt fmm tjinijHiniry occluwoii of the ureter, cither by niiiipln swclUnp of 
the mucous nutnibrtum. or by phign of mucus. pu». and blood. Hydro- 
nephrotUM and [lyoui'phrocifi in Klij^ht dogn-w may occur ; i«do«it, cxtremo 
dtliitatioD of the ])f lvi» and connequeut atrophy of tlie renal tixtnie is a \me- 
sihlo result. Maaseii of cbeeay pus mixed ytiik urinary ualtn aid commuuljr 
found. 

When tlie kidney abio is Inflamed, it presents the morbid nppeanuiccB 
of siippumtivi' ucphritiri ur of u ibfiTusG intiamiuittion. at tirst aRV-ctin^ (be 
pjiniiiidi* unil HuhiM'tjUoiitly iiivcilvinff tl:<' '■i.i'lic/il pcirtitm ; chvniiir inl«r- 
sUtiiil iiepiiritia, and even complete alnipliy of the kidney niny follow tlto 
oocluBion of the ureter aiid pelvis by caseation and calcification of pua. 

.ftjmjjl'tmf. — Simple catnn'hiil pyolitii* often txiiits undct-ected during 
life, partly bocauBH it inayot'ciir without proiiounood mdijfctive Kyinptoini^ 
and partly l>et'aufto tlie ohjttt^tivo Myniplonir* arfi <!hi<'fly t" Iw diw-ovcixid by 
ao Qxamiuation of the ui'ine — wliii^h is not alwa\» nmde ; in many ciwies, 
too. the prinniry lesion is of eueb a nature as to ohlitemlc the distiiietive 
feiitiiri^M of pvflitis ; mioJi i» tlio eniw whuii it rcmilts from chronic cj-stitiM, 
pneqieral affpctions. opeintious upon the pi-Ivic visfcni. etc, 

Acuto pvelitia may be ualiercd in with severe chill aiul fever, perhaps 
Tomitinp vim; acuto pain over the kidney and radiating; into the (^oiii 
may be ex[>erieijfcd. Such ciwck nm conijKii'iitively rare, luid mv distinctly 
observed (diitttly during pnigiiaiicy aiid tlie puerperal Htnle, and ax n com- 
plication of Konorrhfea, 

lu chronic cjibbh there may be no diKtinctivfi s}.'ni]itoin8 aside from the 
chaiacti-ra of the tiriiic. When nNitnctalcd, dm it ft'c<|iiriitlr i<t, n-itli cvHtitia, 
frequent and somewhat minfid urinitlion may l>e the snbject of roniptaint, 
the patient voidinjr but little urine at a time. This symptom is also Been 
without inftnmnial ion of the hln4dex, when tlio pvelilis is of cjdculoiu 
on'tnn ; and bt'caurte asnoL-iivt^d witb piw and blootl in th« uriue, it luajr 
misleitd the [)hyiiictan into ii diiL^iOHiH of c^'griitix. 

I'ain ia the loin ia a fi^quent thou;;;h not eoiistaut ^Daptom ; it noAj 
be of a dull achin;; chnrncter aud ncraitiunallv ahani and severe, snmTefitivs 
of renal colic. In the latter caw it ia felt along tne course of the iirctrr, 
in the gouitala. pLirlmps in the thigh. This piitu neeuis to be; cauM-d Lately 
by tmnsient hydronephro«i!i ; it varies in severity wiUi the free<lrtm with 
wluH^b the uiiite is discharged, being greater wheu temporary obstiuction 



DTSRAaiM np THE KinimT, 



237 



and olipum exist It mny bo ffit owr both kiflneye, cren when the in- 
fljiiuiiijiliiiu t^'xisU on one wiio otilv. Tliei-o w (iM|uiiitly eumio tcmlerufi>a 
upon pif ssnra over the fewlneir. 

Vamtlons in tlie qvuintitj^ of pus diBcbarffed with tlie urine tire often 
quite cbarwctcrinlic wf tiiia iiiTctrtiuu. U tlio meter of tho ttftccted xitlu bo 
obstruptoil by pun, murus, cnnprMionis, ftc-, tbo p«8 (limiiix'-im« from Ibe 
uriue evacuateJ, lUDce Uiia is furniBbecl b_v Oie beoltliy ItidMev ; utter ft liinw 
the obHtniction m overcome luitl a Huilden iliHchnr);!) of pu» with tlin urine 
is notit-eil. These ph^tiomeiii aro occompdiiii^il by oorrespondinc fiyinp- 
tomit; (luring tji(t excretion of cJ^Mir urine — while th« opposite ureter i» 
ob«tnictfr(l— conirtantly inoraasing paiu ttml temteniPiw on iho iifTeclcd 8i«l4*, 
perhiipa a chill, ferer, ami ronuUii); nro iiotiopil. The »i(ipi«niii ovniMiitliun 
of tui'biil urind occamoos an iinmediitl e i^iilwiiiitiicfl of thc'ne H^iiiplnma. 

Ill (iLTimiiiiifd avicH the olmtriiptioii to tbo iirpt^r pmiliKrea Hiii-b a tie- 
grwT of Ut ilromtpliniMw n» io crtuxti n perceptible Bwelliiig in tbo region of 
the kiiincv. The ilinidiiHionsof tliin luniorviiry with tlio oilier syinptoni* : 
it incn>a*?s in size when the urine bf^roiurs clear and the pain severe, nod 
diiuiniMhi-H ts-hrtn tbc piiu U n^n iliscbHrgeJ antl the pnin BubHidee. 

The i^hnmcterN of the urine 
Yftry with tlie cause and compli- 
c&tio»» of tbo polric iiiAnmma- 
tioD. If tliore tie no niiuiiouin- 
cal ilocoiiijKMitioii ill the lower 
uriiuin- clmnueK the urina in 
luM, pitle, and in ii pruuoiuie»(.l 
onae luu> » low xpM-ilje gravity. 
<liie to the fuel that the quan- 
tity excreted in twenty- fonr 
lioiirH u( niitrh iurreowMl (rrcii 
to twin» tlie itMiial amount). 
Thin polyuria is oBpeclally great 
in ctuea where chronic inlliiui- 
tnntiou and cirrhosiH of tho kiiU 
iiey buve super n^ned. It loav 
be ao pronounced as to miHleod 
into a dia^oeis of diabetefl in- 

HipiilUK, n iiiiHtako to wliii-b 0}i- pia. n._8viinimi rrmi jtniie t-rt-litl>^ Kpiihrimi r»K 
poller callpd attention. '"" "" ^""' '*'">»r"^ ■"" i"""i™'pi'--i-^ 

Tlio aediraeiit contmna pus anil blood, tlie amount varyinf! at. diffeiY^nt 
timoH even in tho nomo coiw {iPm- 19). 'Riif puM-orfnisclOH arc ttftcn rnaw»e<l 
into pluCT or thromU, iimilnr to thoae proiluced in the urethra during 
pleet. Niiniprous epitlielial eells are seen, ajid it hna been aa«erte<l that 
the lociibty of the HUpmiration mn bo rem>;n'i'«^'l by the appeiirnnce of 
th«8ii aecoinpaDyin^ coIIh Now, it is tnio tkiU in pynlitiK nhnrt eolumnar 
cella with large iim^tei, ailhorviit in rnnitMeH, iint OMpfoiiUly frequent: but 
neither the arrangoiiivnt nor the ftirni of tb« relln is rJiarncteriHtic of pye- 
litis : for thcoe. m wet] an tU« eituilat« and t^polar cella oFten eonsidered 
rJiaracterislio of tliia alTcetion, are also prodncod in tli« bUdiler and 
urethra. It iH unsafe, if not imposKible. to biwen dia^oaiHof pyelitia upon 
tite i-pithcliiLl oella foinid in ibe neilimpnt, 

80 BOOD iw Ihij inflmnmation hrw iixt«nded (o the tubnlea of the kidney 
(and «V0B before, if tiiei-e be deeided feveri hyaline casta appear in the 
sadiment ; the presenre of granular mflta iimy lie regnnWl iw indirnliiig 
the impliuatioD of Uiu kidney, i.e., pyclo-uephritjii. In caws uf cygto- 




-228 DISEASES OF THE UKIXABY OBOANB. 

pye]ili% eaits iwmposed of or thidilj coTered vitb bact«rift irt seen 
(fijr. 14). 

The unnc nlnftjH iWntAiiut nlbumeii, tncu tlioug'h V)ut liltle puH be pres- 
ent; the exUnsioa of tli^ infliuDinstion to the kidiii>y is iniik^IfHl by h 
ntili p-faUrr {M-roentnge n( atbumeti. Tlti^ aicmm of ullmmcii owr tho 
(juaDtitr which can be espcxte<l froio tlie amoant of ptiB preaeot is, there* 
fore, in &t«brile oLsee. &n important it^m in rycfig njgi np the itDplication of 
th« kidnu}' ; jvt it im Icaa decioivu tluui Utc vvidouco fuiuudtoil hj tho loi- 
croscopa 




Tu, II.— SidlnMil from I^1o-a«rliritla ; C4M* >tniMi<l irftri nuiinfi, Itpi<ho1lnm ham tKa IUvIa 

LiuiiJt:;!*^ Hbnal-GutiniKlni iinil h ntlni mt ilsiilnrU ifniliriiiicrrf, 

Tho kidney beeomes the seat either of adiiTiieKi iiiflainninHon eonuitinm 
terminating iu cinhtmiB, or of a Biippunitiw iifphriliH. Thn littter is the 
rule vhciD cystitis slao «xist8 — thfrrfrtro. nftor itijiulieirtiiB iisp n( the«ith«t«r 
or indtniuaeiita — and ia«apef iaJly (reijueiit iji oKl tiion at the vumiiienceDiciit 
of " catheter life.*' This complication is marked by remittent fever, fre- 
(|uent chills, eomnolence. a emull and ntpid piiUo : in short, the features of 
Hubucuto uni;iiiiii or pya'Diin. In old iiil'u Ihu fcicr nntl coiistitutiouaJ dis- 
liirhftiiw may ho Rliaht. iiinl the Roiirco of ihr* diffiiciilty ovcrlookcii. 

The pyelitia of tlie pueriierol utat* in uduMy indiculed hy ]iroti nil need 
ayniptonia whicli cannot Iwt overlooked nor niisintcrprfted. Ito onset ia 
marked by diill, fever, and pain over oue or lioth loina ; t iicro is deride<{ 
tenderness in thin loralitj. The pain is ar-uU: luid iiiiiy Hiiiiiihit<! rcmal 
colic. Th(t uriiit.' is acid and coutaius a decided amouiit of albnmeu And 
Bomct pus. 

Ad acute pyclitiii is ocoasiouaUy seea durinir or iiDiDcdintrlv after flfoti- 
orrhfTfi ; it in wcrondary to cy.ititifi and is marked hy pronounced tiyniptums 
— chill, feter, severe pain in tha loin, occasionally vomitinp and intcinto 
headache. lu the Vcnerwil Clinic at Vienna. Fiupcnaiw this complication 
twelve timM ninonjT fflur himdred and ninpty-five ctmt*. It j« ii«u/)]Ir of 
bri«f duiatioQ ; is favored by bodily exertion and indulgence in alcoholics. 



DISEA^XS OF THIC KIDNET. 



329 



Id n fenr coaes the mbddraoo of t.he pvetiti;^ liii«t lic-ca ftc«(>n)])AQl«d ^3y tl)6 
(lifldppMiraiicA of both pretitis ani I gnniirrlirr-a. In n few mrf caacst ( Vidnl, 
RoMeostem) aev*?!* lij-elo-nepliritis has oripcated duriug the course of 
gtmorrhcBa and has )i(-roLue chruuic. 

DiniinonK — A proiiiniin'(:<l cjiko of uriilc pyelitis i8 oh n rulo oosil^ reo- 
ognizcii by the Hviiiptoiiih alieaiiy meutioueJ. 

CliTOiiir pyelitis, on tlie other hantl, is fit«(iiiPQtly for a Iodk tiinfi over. 
loakeJ ; au<l wbeu pus in tlLHcoverGd in t!ic urinp. (^r:tt euro ix nc^esnu'y 
iu distinguisliinK bftwci'u pyelitis unt] ryHlitia Tbf rfat-liori of th« uhno 
does not serve U> <iiflt>rcntiaU', since it nwy be neid nr HlUulinn in Aitlinr of 
till? two afffi^liouM i tJm fonii of tlin epithohiil cells ami the peivcutage of 
iUtiiiiii«n ftfforxl B. prohnbility but not a rertainty in iliaj^iiui^iii. The fl]:)near- 
aiiCKj of li^iiliuo, emutilar. ami bacterial casts with the pus infikes the diftg- 
uutdit quitu poiativu, lii the- iibBL-u'^'u ■■! I \ii-ii<; t-k-riivuttf tlie cxinlvucc nntl 
lotuittnn of pain arc impoi-tnnt fontiiM ;. rMiitiMiAfrviiiicntly painless; tite 
piiiii if felt is oft«u referred to ili" [•nnx. Cystitis i« mrely piLJidess, anil 
tliD pain in felt behind the Hnnplj'- -ih uud iti Llm periuoum. TI1080 ore, 
Iiowover. hy no means [il'^'lii. r-uIcM. mnce the jxiin of prflitis in i»ia6- 
lini(-M nrforretl to tlie hluJili 1 hm k iiml in occompaoied wiUi fr«i|ueiicy of 
iiiictnrition. 

Wlien eecondaiy to cystitiB. pyHitis can b* rocogaixed with oei-tahitT 
ozily by the |KUti and tc-udfruess in the region of tli6 kidney, and by tho 
iuercimcid fover. (io noon as Uie kidiiey ulso in invoked, nylitidorH will Iw 
found iu tlie Bodimeut : chills. fe<v«r, Tdniiting, etc., may occur. As already 
staled, pyelitit may bu expected ns n itRt{Ucnce of cbrouio cyHtitiH ; ito 
onsi-t in bnMtcneil l)y injudietowt qr^ of inHtnimentti. 

If It denidod tumor exist, tho difficulty of diai^oiosU may ke decreased ; 
fluctuation and a conntnnt rclttliou bi-twccn raniitioiis in the isizc of the 
tumor (ind vuriationH in tlio <iii(mtit7 and wtidition of tlio urinfi indieato, 
whin oljMcTVtil, tlm natiiro of the tumor. Il*;curriuy fever aud chills sug- 
gest the pumlont chaiuctor of tlio conteiitti. 

In evoiy r-asc the possibility of the or4<pn of th« pas outndo of the Uli- 
uary lru<;t hIiouUI \m rcmi.-mbiT(.'d in (uruiiug a diiLguosis. 

When thfi introduction of the cjithfitflr in au old man or the fnibiect of 
paraplegin, or an operation upon the bladder or urethra, is foHowed by the 
uppeai'iuic/T of hloud iiud ])u» in the iiriiie, ]muu iiml tcudi-rnceM uvc-r ihtt 
liidncy, chilln, fowr, fU\, pyclo-ncplirili« u»douht«diy exiuta. In tliP ah- 
Hcucc of auch Hjinptoma, the diagnoaia muat be ltu;goly based upon prol>- 
iibilities. 

Proynoti*. — Tb« Mtirsft and t<srniinfttion of the dinflaiw d(vp*nd« liu^ly 
iiI>ou Itiv cuuiw: niid upon existing complicotious. In genend th« daugftr 
arisea fmrn tho tendency to chronicity. whereby tho proljahihtieM of Horioua 
iinplicAtiun of the kidneys aro in<rrp)iiMtd, WTion ciuised by iiu infcckioua 
diHtusc, ■^ouorrlKto, or prcguaucy, recovery miiy he cnjiected ; whvn pro- 
duced liy tiibinnilofdR, it ut incnrnble. The pyelitis following mechniiiesl 
tinpodiiiients to the evacuation of urine or produced by renal calculi maj 
be improvcil or at least arrcstccl by the nmoval of the c»u«e ; it is qnito 
poeHible thit recovftiy oecasiotially tAke» place in vnch ciwea ; tlumgh the 
UDcerlaiiity of diagnoMa vitiatoa tbo value of auch opinioiu Wben mrcoin- 
pMiiod with or renilting from aminoninrul decoropontion of the urine, 
pyelitis and the oonaecutite nephritis soon produce a fatal re«ult : whea 
doo to oUier cnuMOs, on the other haud, it luiiy Iwt for miuiy ycara without 
mAtcritUly impairing tli« p:eiiem1 health. Cirrhosis of oue kiilney niny re- 
sult ; yet the other underj^oea compensatory hypeitropliy anil performs per- 



330 



OWEAftEB OP THE CRUTABT OB«ASS. 



f*«il,T Um faadioa* of boUk. En A i o ni p <■«» p«noda ol ilMilad uuyim ^ ' 
jnent wkI cosipKBtiTB health alteriMte with interals g( uiutafr dcnsg^ 
tuent uid giBBCiKl nbanKUon. A fatal result tuT be oaund br mar at Um 
{MMMlila eoBfdifstkmii — pcciotatiaa of ptw into the tiiiiiliiwl or thomcso i 
vajity, patDeplihtH ■a p pn ra ti o a. douUe bj-dnwcpJiroaa, niwnua, etc Am ■ 
B rale p}«la«epltritai exMla oo odb Bde aiHr in efannie awes ,- ret lalai- ■ 
tffal iiiflaamattoa (ron oalcali is not nrs. ImTUd degeneratiaa mar fol- 
low saopontiOB ben M dMwbere LQ the bod;: in afewcaaes it ban bmi 
Dot«(] thai tbs iudntfj om the ofptnile sitle «xhiUt> tbiscfegaunrtioB, vbtle 
that oulh« auiie iide reniaiua Dearlj or qaiw fre« from tboHiij'IoiileLaiietL • 
It bu rfpoflUiU; happened that after ooe kidney hss ccaKd to tOMaou. 
tbrou^ffa dia^aMG of its j^Itm, tba othoT kithicT, tbongb &ee fioiu diaBna% 
CMMsd to cua«l<^ aod fatal aonna followed. 

TWHtnwnL — Iritis, bkc eystitiii. iji often tiic dirort nsolt of n«sli;*enca 
on the pari of the aorgeon ; and propbjriaxie is «xtreiudv ixnpurtant both 
in UToiiliiig the inflammation and in prervotiDg its ajit^vation. lu the 
tr«uliii»iil of vewical aod prostatic anMtio&a, («i>«cinlly in old lueu. tbo 
greatml luire tuuKt bv tak«n to ttas ouly clean catheUin auil eouuda as well 
M to BTr>id the Kuddeii emaiation of an habitunlly distftiidcil bluldur. In 
tlis various 'j|M'mlioitii for iiloue and fi>r the relief of Blrioturr iti tlie {loe- 
terioT nrclbm. tb« prwawlions pruviously dij(cii»od (net: L'rethnU Fevnr) 
may nnrt pyclittH nwl cyittitiH. lu tlio tn:«ttii«nt of gODOrrhcM am tibould 
\>n u)n.-u to proviriit Irritatiou of the ktduey, the jielriii, and the bhuldcr bv 
OTcrdoMT'H of rojnilia, cul)eb)i. tim>ciiliiie. and other acrid drugs, and to 
avoid irrilaDt sLd forcible ur«th»tl itijfctiona 

Tl>(r attouipt (o r^'livvu iiidauiitiatiou of tbv j>eh'iM inuHt be baiwd npon 
n knowledge of the rauNe upon whicli it depeudx. If it be pTodtuti.i by 
reniU colctui. tb« attempt to aoften and i-emove tbe§e by free diurrtiiit nod 
thi> lue of alkalies Bbotud be madv. Tbiii effort i» nrcij auocce&ful in re- 
niorjnK the Muiie, but it diiaiiii]*li4« the irritation, wmlics out thf inllam- 
matory prodacbi. and tbua iuiprovea tliB general cooditiou. If pyrlitin aw 
be tmm-tl to the retentiou and dcrampofiition of mine in tiie blmblEY. the 
gradual relief of tbiH r»uditioii by cnrvfitl catboterigiu. dilAtfkticm of etriei- 
nres, diviiiioii of li iturrow ifiuhIuh, et^u, bTtens a giHxl v.iTi^-l ii[m>ii Dii? in* 
flanimntiotj in the [telris ; and tluH (!nn be furthered hy Uie iuteruid um of 
alluiliiie wiitertL 

lu ull cuw.a <,'i'rtaiti ^nurol mettsures luri.' useful iu the endeavor to pre- 
vent a ronliiiuiiuMi of tlio irritation to tlie inueoUK niembiitiic TiiL> pnlient 
alioidd avoid cxc-eHhirc boilily exertion niid nLoiild Leep the i«cuiiibent 
pneturu much of tiit- time ; tlio diet should be »o cbo«en a» to prevent the 
excnttioti of irritating subsl&uoeii by the kithiov ; milk, eggs, and \ege- 
bildi-H iim es)>Qc.-iulIy needful ; fitio diuretux k1ioii1<1 Im narannX by tlio ad- 
iniaiHtrnticn of alkaline mineral waters or nrtificinl HUbHtituteK Bysecur* 
iiig n fi-ee excrbtion of alknhne or neutral urine tlio deposit of urates and 
p)io«j>ltiiteH ill luid upon t)ie inHiuiiO'I <>i' nloernted tiiucoiiH mi^inlirnuo ean 
Im nvnided, I3y oiiBorviug tin* iM'diiticat it witi b« nRcertained wlictJicr the 
reoclioii of the urine riH|uirt'jt itnxUfii--atiou : detrided ncidity mid the de- 
jMMil of uric; arid calU for the aitmtniiitrulion of thi< bii-Arbnnnto, the ace- 
tnto or tortmte of potjuMiim <n'/ori; itimli^. If, on tlip otbti' liiuid. tho urine 
bi! decuiledly iilliivlirK' brforu nutin-iug the bhu.ld<-r, beii^oic nciil alioiihl bu 
utTmi na cdiiipn'i'Hed t»bleLaor pilUof live (grains each ; three or four of 
iboM daily usually sudice to reoiler tlie urine in tlie pclris neutrul or 
alightly noid. 

Uauy att«iupl« Lave been Jiiiide to diuiiniHli the formation of pus by 




DISEASES or XUE KiDXlCT. 



fiSt 



t}io lulminUirntioa of ilriigH; iMiiiilit M'tiinH U> liav« Um^u ilcrhneil in iudi- 
Tiiitiitl caauti fiom the use nt gallic acid, the ncetate of leiu), (>iicalyi>t*»l ; 
wlifu tlift disoasfe is chrimip, turp«ntiu«. copaibii, aindELl-wiKKl oil. or Uie 
fluiil extract o( ciuniU'ptnK tiuiy bii niiiiiiuwtorcil in umiill (Iomi-s* only, for 
tliej nLiy otlierwwu hiive a ibciiUxUv irrimtiiiy effect, uimii tliti sfi-rttiiiy 
Hti'U(.'tur<?» (.if iliv kiiltiu^. Tlio tiiiuiui'e of iliu cLloi'iiIi! uf iron in u«'(ul iu 
c-atiLtrli ul tlii» IU ol other iuiicou» iiicuibniti«tt, jnobably (or ita couetitu- 
ti'iti:il nthnr tlinii ilH locnl efFetrt Iji i<])i*oiiiR cam^a inm niul nuiuiue lUiuuld 
be lulmin bite 1*0(1 foi- the luaiuteDanccj of the palieut's etrenp^lt. 

A few wt'fks' WLijourn iit n. miiitind spriiif' hua H<iiiiL'Liun.-» ijroduetd rfr- 
ruEirkablv ftkV(tnd>!<^ rcxiiltx; tlinwittiT ivWt^til ttlntulil bo ofiuiKUy nlkuluio 
rviiL'tiiiii, cojiUiiiiii}; only a small iiuautity of juiueral iiigrediente. 

If tlie atta(;k be anito uud uccoinpniiicd mill puiii. ttnderncaBia tlio 
lom, ft.nd reiiicid irri|jil>ilit,y, hot ui)i>Ue:utiuu.-» uvcr llio luiu uud grtmi and 
morpLiiuu uUould be «iuploifed. 



Concretions vootaininrr minernl Balto lire found at vnriou>j pcnnta in the 
uriniii-j' cliODtK.']. most (rf((iHiiil]y in tiit- («.-lvi» uf t.ii« iidiicy. The mltii of 
which tlii^y arc ooiupntted oi'g doubtJc^i uiuinllj,' thrown out of sohition in 
the iiriiKiry tiil>ule» tlieoiBebcB ; indeed, ooQcretious mnv bo formed iviro. 
1}iii it in an 11 ruli) ouljr sftur thi'Dtt m!it.Eri»lit lure rrachvil tlw pelvis of the 
kiilnoythni ihc nnnt»iui(uil<fm<1iti(>nM pnrniit thoir a^rgrogittiDii inUi nduuli. 
Sumciiiui.-it th«de cuiior«tioijei involve both luditey oud iielvut ; iu a voae re* 
portod by Maring, the Htunu extcudtid from the pelvis to the oapsule of 
the kidney. 

But few uf the many cmiditiouB wkirU favor the deposit of suite from 
the iirino in th^ |M-lviit of tlio kidney baxo been dettnit^ly aaoertainod. It 
in kjioun that anvh dcfiosit occui'a more fro<{iiently iu childhood and in o1(] 
HUe than iu mithlle hfe, and Car uiorv frequcully ia malt^H than in ft'iualeii. 
Climnlc »«>il. wid probably <h-iiiking-wat<T influ^Mico Uw foi-inntion of rul- 
culi ; tlte relatire trL-<|ueuc>' of I'eunl au<.l vt-fucol atoiic&ou tli« i-iwtirni cuLUst 
of Kii};hiiKl in fiiniiliar. Kveu neif^hlwrin^ dintncts iu the Enino oftuiitry, 
where hiibjifi of lifo two pnicttciUly idi-nliciil. oshihit greaLdifterences in the 
fi'uqiictii^ of hIouu fiiiiiiatLuii — n fi\(Tl whi<;1i tua boeo vmphusiiwd from por- 
ftonal ohservatioit by Bc-vend (Jorumti ubaiGrrera, espeetally Oututatt aiul 
GeibardL 

HabiUt of life Aro cCTtainly of iroportuixMi in iK-c>ouutiiig for the forma- 
tion of n>nid hI'iuciv A j>rL-jH)iid(!r(Lut!a uf ainniul ili<:t aiul t)t« vxcumnvo uao 
of wiiiea and beer favx>r the formation of uric ncid ruQi-retionB ; aedentaiy 
ImhiK wbiob no often aocompaoy im excewtirt-ly nitrot^onuiuidiet iu weU-to- 
do poopto, nro Miotbor favuriiig circuiuslantrn : htrtif.i: ii liap^ionH tJiat thoae 
will) live iu luxury axa iu all oouutnes especially proni- to the devdopmcut 
of uhnorj' Htones ; while it i» mid that tlioHB ooDHtantly eiif^^d in iu!liro 
(.■Kerciso, «speoiaJly eoldiera and sailoi-s, enjoy almost pcrfi.^ immunity 
from this aJTi.-(!(ion (KichliorBt). Thi< production of likcliu and butyric nciihi 
in oxi^tu in thi^ jiliinonliuy canal, cithfir from ovenndul^'fnce in Njuvhanno 
naA Btarcliy foo<ls, or from imperfect pancreatic digetitiou, seema to favor 
stoue-fortnntion. 

In corluin ciukm it would mom that thrro iw an liorcditiuy prc>lii^x»tioD 
to the funaation of rcoa) calculi. This has he«n setiu espuuioUy Ju owes of 
oystino KtoueH ; though ihetw lu-u so rare, thuy have beea observed iu tlif> 




23S 



DISEASES OF TIIE tTRIHART OSGAH& 



ferent tneniben of the hiudo family. Id vtm« iodinduals Uu>ro m«ran to 
be a t?^oeral teadeacy to the foniLatioii of concretions oa tatioub macous i 
mvniltrMHM — tbu irUivait n&d biliftry ducU u wcU as the Qhncrj ctumod 
exliibttii)^ tti^iu. Eidiliont n-iiuris s etngalar example in which bd io- 
diriduiil in able to jHxxluve reiml c<>iiet«tioiu oi will by tamp\y tliinldiig a 
Hiuall quimtitj' of white vrin«, a quarter ot a gUas of wtucb is suScdeilt to 
pnxluue, after the Upm of a few hours, intense jMtn in the reifion of tbo 
ndnejr, foUowcd by tlio uspahatm of minute roncretioiiB up to ibe size of 
n pen. Tli« e«mll«miui, a proiuitii-nl (oir^eoQ, i^ves the aiwunince Uiat be 
IK U4!Ter troubled in tliix way (!Xi'n)>t uftcr dritikin^ nhit^ wine. 

Certain tranaieut coustilutioual coDdiltons doubtless aerre to origiiuite 
teuol cali^uli whuae esifilence beconiea apparent oiily after the lapse of a 
long inlcu-vnl : tlitis the pn^cipitation of amlf« nnd uric ncid. UEual in febiile 
eonditioDS, cttpcciully iu chil Jrt-n, miir result in thu foniintina of concrfr- 
liuDH ; IheHo are doiibtlctn tiKuiillv rttuiort^I by Ibft BubtieqacDt incrcaaMl 
jluw nf urine, but uuy rcutaiii auu iuctfrase ia aia;. 

Load disturluincnt of uutiition in the reual pelvis favor the driKHil of 
aolta from thf; uritio ; a catarrhal or pund<-ut pycliliit iiulv fumixli ina«sci* 
of pua or iimctia aiid blood-clotit upou which the uritiari' salts are precip- 
itated That this ia actually the origin of calcuU kai been beautifully 
di-moDHtrnleil by intznumii'fl reoeut microscopic reaeorcbes into the com- 
pofiitioii of Ycsiuiil atouca. Thitt olmcrver mado aootionB of cidculi eufficientJy 
thin fur minoitcopic iiup<!(>ti()n by teawin^ and mbaequentJy griii<ling tlio 
atones ; lie wat) ttiiis enabled to dintln^'ui^ and even to photograph with 
ttie microBcupo puB-L-oi-pnadca, hlood-clota, and hipmatoidin cryirtalit con- 
fllifiitin^ th« nuclei of tho stAnec Otli^r foroi^ boili(A in the rtnal Mlvis 
also favor the precipitation of sslta from the urine ; thus Qrieainger fouD(l 
that th« uudei of cerlain renal Btoues in Kg;>'pUa)iH were the e|^ of Ibe 
bilhiintia. 

Ulumnun dislitiguialiefi between primary and sevondai^ b-tone formation 
— a distiiH'tion of much cliuiGuI iniportanee. The calculi of primary foi-ma- 
lion arct c<ini|HiM)d ol MulNitJU)rc>s which may be dvpoeited from urine wboai 
only abitoriiialiiy ia a relative excess of tiulid iugredieDta; Buch arc thf t-ou- 
cretiouH of wia add and uratas, oxalnt« of calcitini. cvHlitio and phoRplinto 
ofvalcitini. Overt ndul^nce inn diet which fumioLee these ingredients, 
0tni8titiiti(iu»l cuiiditioiis which pruducc tliciii iu (.-xcenu, or iieg)i;et to uM 
the ordinary ntiioutit of drinking- water, may givp tlio inijintiiK to taich for- 
mntioii. Kecandary Htoiie foiTuntiou results from a previous alkaline fer- 
nieutaliun u[ the uriiic, coni^equeut ujxjii diseaseH (if the blnddiT ur pehia, 
whcrnby Bcvcml other tiuhsLiiicea— rlti<Hy partliy plmi^IiiitcH. the umtc of 
ammonium and tlie tnple phosphate — lU" produced and pn-cipilatcd. 

Nurslings are espoclalu' prone to Uio formation of renal HtxineH ; many 
of ilicMc aro doubtlc^iw of intrauterine oiipfiu and cou&Ist of uric acid ana 
iiml^H. Much »t«[ies hiivi^ been fiiund iu childrtii lesn than a wock old imd 
even in the fa'tiin. In nnrsing: children calculi comiKtaed of the urate of 
ammonium are not inh'equent ; and during tlie &nt years of hfe the urates 
attt fraquentlv prwipitalisd witljin tiie urinary fhajinela during alight *Ii»- 
turbaiicoa of health, imrliciihirly during Ixiwd cotnplainta. I'oKHihly these 
infarcts in th« child itcrve as nuclei for caloulu^t forniatiou in the adult 

Yet the presence nf precipitated urinary constituents in the renal jielviii 
ia by no means hulGeicnt. to pi-odiicc their aggregation into tltc ahnpo ol ' 
calculi ; nor in such iiggregatiuu effected by the preaenco of foi-eign bodies 
— blooil-i'lots. parnHitca, catnjrhid products, etc. Many patients ore con- 
Htjuitly troubled with "gravel" oud yet have no cidcuU ; and Litten boa 



Eases of the ridnbt. 



S33 



Bbon-Q tlint nocrotic c^iitlicUitm miiy l^o contod witli pitosplmion front Uio 
rL-uuI cujtsiilt! to the jKilvi^ witliniit inciiiciug stone fonimtioii. Tiic. (actx>r 
necessary Ui sociiro tlie ttiigreffation of the uiinai-r aalta, niter prempitalion, 
into culculi in «lill uiiknowii. It in eTidoDtly eomutliiri^; funii«liod by tlio 
epitli(!li[il (X-lIti uf ttm ]iflvii: iiiucuii!i tn«mbmni> or of the rcuul ttihulca ; 
for Ijio Kidtn whioli couKUUilf' tlii! iiuclr'iw of » stonn ilo not vxiiit in tlioir 
onliiiiu'y ^rysUilliue forius ; Uiey are citlier in aii amoqibous vou<UlioD, oi' 
are (.-rjstiUlizril in uim>uttii (TJIttmaiui, Kraiiclie), Now it is cstabliiibed ex- 
pcrimnBt.'ill V (but tliB praHoni'oof n colloid mnterinl causcH (be precipitation 
uf a tsitlt, uliiL-rwiso crytttalliiie. iii Kjibcruitlul iuiihscs (Il^iiiivy) ; umi it is in 
jiint tiuH form that tlio uric iu>i(l nimbi of Ktnnt'ft, and Ibo iiiii' fu<i<l infiuvtH 
of iufants, are faUji<l. Wbniever bo tlie nature of the colloid luatei-m) en- 
terinf; iut« tbo fomiutiou uf reiiul stoma, its preaenco in ccrtHinly iicffissary 
for their piiKluctioii ; wilhout it tbo individiinl oirvy for ynm ]ui«h <tutui- 
titiee of precipitated uric acid, umt«it, and phoHplulca, »uU yet cot HufTer 
from calculi. Tbure in certainly a protliHpositimi, either of tho individual 
or of ccrtiunconditioiiD of ibo ui<liTi(niid, to Ibo production of this mnterial ; , 
aiul tliiH prtiiliaponiUuii euuiuu to bu iDiuiifuHtt-d by tlic pruducliou of coUoid 
matiiKal by the *'pith(Jiura of tbo kidnity or jwdviK, or both. 

As a riilo cnlculi me found and formed in one pelvia only, tbouyb tlieir 
occurrcciru on boUi ttiduK ittiiob rare. Tbe number of HtuuiM ^-nriea iu- 
dfifinitoly, Oof> having roportc<l a com Id wliicb uoorly ono tlioiiMutd wcro 
fouad on oae hide, and uumerous wucretious iti thw olbt-r pflvii*. Tiio 
nxe, too, may vary from tbut of Hand particles to tiie vnhime of a gooso- 
•^ ; in tlip ciuo of Oco nlrcndy iiiPtitioDcd one of tho tliouennd etoDoa 
i^iuglicJ about tbirty-live ouncL-it. Tlio form tuny bu ijuitv LrrcgiiUr ! 
BOtnetimoii tho concretion liait taken the xhajm of tho peKin nitli n pro- 
jection into tho ureter, tnakicig the so-called pijte-sli&peil stone ; in other in- 
stancea ibo ooucrutiou fiUs Ibo pdviti und eidiibils piujectiouB into the 
ealjrooB of tho kidney. 

Tbe couipositioa of ttiese concretions variea ; aome consist throu^^-bout 
of a iiinglu HiibHtauce. while in ot liem concentric layers are found differing 
in compoHiti'in and giitliorud arouml a cviitriil iiuclnus — im iirrniigemeat 
oominon in bhuldor-aloues. Tho vanouti subittiuii«s coutaiiied is the 
oiine insy contribute Lo these concretionH ; lunoiig the nutxt frequent are 
uric acid nnd iintleo. oxalate of cnlcium, phoHpluitcK c.%rbonalet», and 
cystiuu ; cuucri;! ttius ctMiijiuMcsd uf iiidj^ uud uf xunlhiii hitvu rihto bc-vti 
found. In ui.'iiiy cjim^k tbi^ Ktoni* in cohipa«ed piu^ly of nnatoniicuU elciiK^nts 
derived from the potvia, such aa pun, blood, and libriue. 

In u Ivw uucfl then) huve bcon found in the polvb of tba kidney coa- 
crfttioRK coRjpuwid of biUnry HnltH — in short, ^ll-Ntoncn. In Hucb inirtaiices 
careful Hearoli h&a discorored a ovuiiuujueuljou betwinui tho bil»-duota or 
the iutastiiuil canal and tlie urinoiy pMsace. 

Tbv proiiotieo of stones in the petm oi the kidney cAuse« an inftamma- 
lion of the nmouiin iuuuibrunL\ ^vLicb in tba must fuvoniblu camm in 
aimply cntarrliid, but in umuolly suppiimtive and mny bo oven of Bo-coUed 
dipblboritii? chantcler. Uloeration ia a common ucourreooe, and may lead 
to pcrforntion of the pelvin with pamQephritic inflammation and HbHccw. 
Tbo kidni^y itiutlf nu-ely Monpts morbid cb«if*e9: the most. fri>(|iicnt and 
leMst »evore ifl » ciititrrb of tbe mvduUary portion; int«nttitinl u<.'plintia 
and the form.tlion of abaoeneH iK a not infreijuent ivsult ; indeed, tlit* 
entire renal tissue is sometimM deBtroyc-d, the orfi^ii being rrpkccl by a 
uewbraiiutu aac ooutuinin^ pun, rcnid Htution, and frogmuuts of tisKUo. 
In rare casea a goiiuiiio vUrouics nephritis is the 8e(|Uol. 



334 



D1SE\SIC3 OP THE URINARY 0RGAN3. 



It BomctimcB linp^eus that the xtouc piuses into nml lodgea in tlis 
tiret«r. eiU»ir ocdmliug its cbannel or penuiittug tlie uriuc fco pnsa 
through a iiunxm' ^n'oovc ouooe sidvof llicKtuiir. In hu<-1i cases nUrcinilioa 
tak^s plitcci ill llir mucous iiioiikhrano. whicli may r^tiilt in pf^rfomtion or 
vvcii ritpLuru iif tlio uruter. Ujk'ilruiitTphrosiii n]tui naiultM wbua tbs racape 
of urioe is ouljr imptHlcil and !iot oiieHtciL 

Iti Boiue lew canen tatori'li of tlie bladder is ohtierTDd w* n rcRull oF 
roD»l calculi TWn miiy incur uot only wbcm concrctiuufi hsve escnped 
iutour fui'irird in Uio biuMor, but alitu u-ilLout auy upptuvot exc-itiuj^ 
ctiUM'. oilj(.-r iliiiii tliu catturl) iu ilio jmlvU. 
^L lf;/mpltiiiii^.—l{eual calculi mo snmetiiuui fouml quite u uexiiectetlly 
f^KX, iQorlcru, or tLi>y iiro ptuMcd vrilh tli« iiriiiB wilbout |>revioiis tntnp- 
tnniN iiidiiiitiii)^ tlivit' t:xUtlcu<!u. In hiiiiiu Mt-it-H nIiHciim eyinpUiinB indJcat- 
iug riitlicran oflection of the stoiiinWi omf tlie blndder tUiui of tlic kidneys 
are produced l>y rcual stoneH. In most instjiiiofs. hi>wev<tr, tlie jitcwwt-e 
of rvaal i\»lculi is iiidicsited by distinct syiuploms wlilcb may occur at iiitei> 
_VHl8[oL'yt<)ir>(be(oreaix*«itivL)(liii;:iiOKi8 is]K>«sible. Foremost iimou^; tlie«e 
in liwiiiiitui'iiii. (iiccmrriiig pi^riodiciilly and itc'i'uru|iiirii(!<l with kciiuit fcmr uiitl 
paiti in tlio loin and groin ; Id cliildrtn tlie coiiicidiiiit ikiIu ntid fever are 
ottou biukiti;,', aud u stiHpit-tuti of nauA catmer ia puti-rtauied. Tlie pasan^ 
of "griLvcl" oriitt' preripitutjoti nf it bc<i\y ecdinu^Tit while tlm urioc is 
still warm, in anolber svmpUiui. The Ijiceilitif: is ffipwidlly pn>fiine wheu 
tbe fttouec-ouRists of culciuiu oxalate ; iii such casea tbeiL' i.i sometimes u. 
dbcidcil impnirineut of tlic ^ii-ncml lioiilth. 

The pr«8euce of ri'iinl ra1<'iili luiiy. oil the otlior hiuid, be indicated 
<!:uly ill th« iitTt^RtiDii liy altackiiof rouiJ t-olif. Tbt-Hi* art! i-HjMii-iiUly opt 
to occur after sevei-e bodily or nioutal excrtign, or after a blow in tb9 
region of llm Icidnuy: ihey have Iwdi imtod iilwj iii; a H('(|uel tu cutifiue- 
luciit ami tiglit-liu'injr, Oti tbn nUtcr hiind, tlivy oi'ciii' without nppuruiit 
provnmtjoii, Aoin<!l lines awnkcming the indiviilunl fiiini fiufi). 

The luost proiuitiont Bj-mplom in renal eobc ia osti'^iue pain, aome- 
Uniru4 no aciito u» tn ckuhr i-ollapw of tlio putimil ; tlit^ itliin bpcomcK cold 
and moist, tiie. pui»c is wiinJl Aiid rapid. th<'n> in nniiaeft and vniiiitiuK. peiv 
Imps even faiuttifHrt, and in children convulsiona The jmin is ubuaIIv fell 
on one sido only, tiriit in the rc^nou of the kidney nnd then ^tm<lixi(c 
down tl]« counu* uf tlit> ur»t«r tu Ibt' blidder. acrotun), and ptfaia ; it mnj 
nisi) nuliiito ih>wn the thi;<ii its well rut acniNH lh(? jdidouivn, mid oven up< 
waiil t*) tbe 8bnidd»r-blaile. Tbrre ncrrim snotiuiodir contnxrtiou of toe 
<TE<niiMter, aud tbo testiclci is dniwn u|>vviir(l ton-aril tb(.> iu>^iual riii^. 
Uriimtion in wry frcfpitnt ajid painfid, only a f<^w Hhi)]w Inking %'oidijd at 
carli (tttctnpt. 

Tbiiiattafk may ucnse in nf^vr minutes or tnaylast for eevernlday«; its 
duratiQu ]» liiuitoiluierely by tbe lenRtli of tirao diiriii}; wliiili th(t KliuKiro- 
tuaiiiH ill the ureter. Samf-'tiiuus tbe cidculus ix forced bm^lcward itit^i tlie 
pdlvi.i, wbilit in oibi;r caKeait is gnwiually piiHliriltUix>ugb tbe ureter aud es- 
capes into the bliu]<)er ; its pas»ai;e tliroup;h the vesical end of tUc urotor 
ift apt to 1» eapceiidly painful. The escape of the Boncretioii m followod 
i lit mediately by complete relief frnm tlic (iicriidntiitg pain, oidy a snense of 
sorencsH remaining. Souietinies tlie piiin ifi rcnttwfid after n short interval, 
indicating cithfr tlie paitaage of atiutiier caleuhis or the uiovtiment of tbo 
Hnme one farther down the iiret<rr, Tltc piiiii is iwmdly ac<-nti>iiiinli?d with 
some fever and uiiiy be u»bi>red in with ii dmdwl chill, The patient 
camftdly nvoidx uiovemeiit, whic-h ajik'tii'i'att.'S tb<' piiiu. and nflt^n assumes 
a positiou ou tbe iliaeased side, tUo lower cxti'emitiee iu oxtreuie doxioa 




DISEASES OF THE KIDNXT. 



235 



I>uriD? Hudi an nttark the urines cxliibitH impurtotit iodicatioiu. Tbo 
pnti<!nt in tAi-inAiil4;i] with a oonittAnt tU-ttiro tu (ivncunU'tliR bliulrlcr, bnt mic- 
ceeda iu passiny oulv a few drupa ; imleeJ, this Jesiro luaj esiat when llio 
blaJtlor in really empty, m sihown by the iatroducliou u{ the catheter. TUo 
qiianlily o( unim i" tciiiiioiarily ilecifased, auii it vmy Ixi iitixod with hlood 
iu i:uiiHi.'<|iit;iicii vi th« lujurj' to tlii.* iuuuouh Riuiiilinuiti of lliu iiriiian' {klk- 
muPS: by thn noiim'etiuiL It often ljiipp<-tiiiUiat iihno wliinh had {irr-vjonsly 
coutaiiieil \>un bt-conics during i-vaal i^oliu iiuite dear in conne^uence of 
tlic ubHtructiuQ tci Iho iirutur on the offtctod aitlc, whereby tho uscape of 
pui* irom the intinanid pclviH ja prevented. 

Iu severe (■iisfH t'>t;t) iiiiiirin (it.'Rtint, uitbt^r Ixicuutie both un^ti'ra Arv siiu- 
ultaiieotiHty obatructed hycalinili or becaitsa the nl>stni<rl.i<)n on one tdd© i» 
followed by syiupathotic Hupprea8ion iu the oppoKito kidney. Tliis condi> 
tiou uf u.iiui'iii, uiiU-tu isuuii n:U(jvt'd, U fulluwvil by Ihv uvinptoius ot mre- 
miii ; dentb his occurred within twonty-fniir hoiii-«. Yet the niturin whlfli 
fr>Uovre and depeiula ujxin tho loiIj,'m<'iit ot calcnU in tlie in-iiiary chaunds 
is uvrbuuly I«si ibintteroiia tbnii tliat whiuli rt'siiltfi from diii'tit iutcrltTPiire 
ith tho renal tiotivity ; fit ikiiy ratf, tlid diwwtn>u8 ro>inll)t oovw tcK» ir^ 
leatly nnd at u greuti-r ititirviil ficim the liegiiimitg of Hm uuuriu thiiii in 
ihc otht'r (XMi.Ution. Thns inHtiinrpH nre rewinled in whidi nnnria from 
CiLl(^idii8 iiupictJoQ Ua>i «siiit«il twelve, fifteen, soveuleeii. tweuly-tive, and 
even twoaty-uigbt diiya with ultiiaato recovciy. Ou the uthur UwjJ it 
muHt bn aihiiitted that cntu-n bnvo t«rniiimtod tatrtlly nithiu one or two 
days lifter the establinhiueut o( tlie anuria ; llie varwilifn between these 
])QriodM i« duublltiss to be cxplnincd by the wtudition uf tbw Uidnej-s at t]io 
tiiDu tho ohitnii'tion occiinud. In tliimtj vnwx in wTjiwh exl«ii«ivD di#ir- 
gAniiatioii bad tdremly resulted from tlio proaeuce uf the culctJus tho tiitnl 
tcrminatian luipp^ned cnrly. 

In miny eisns rpnnt caIciiU orist wthout ginng rise to nttaebs of i^nal 
oulic. Tliu HytiiploinM uiiiy Im Kiiirh ii^ U> iitlvui't attenlJon to the kidui'Y> 
cuuHiHtinj; nf h»tiii«tiiriii and dull juiu in tho loin ; tlie latter inirejiwiil by 
ittraig'htcuin;' of the spinal oohimn. which is ilic-r«fore avoided by the 
P'ttivtit ; he hcu'ht Hli^iitly forwujd ; the ipiautity of hluod may bo no cou- 
aidorable as to nttmot thn patieiitH nttentimi, <>veii Hntx nf <wiit(idomblo 
size betn^ riaible. or it may be bo alight as to be detected only by nieana 
of the luici-ostMpe. Tlum in one case whit!h cauie under my tdwei-vation 
thcri> VTAB nothing t'> indiojit) r«nal du»i<«MO, nnd th« esitiuiniition of tlif 
urine waa mnHd merely for th« aako of completeueMt ; n few Llood-contufl- 
clea flonstituted t)ie only abnoniL-Uity detecteiL During tho year follow- 
ing, liowevor, uninititnkAble Hi<;ii8 of rennl oaIouIus — pui), prtiu in tbo loin*, 
uad pointed lu-io iicid crystiilx, t<^i{i:tbi-r with a dvvidud iucreoBe in the 
iimoiintof blunil piTownt — heranio nji^Mrcnt 

The [uo8t pmuuiient Hyiu)>toiuH may be tkoM usually referred to veaicf^ 
irritrttion or c;ilarrb ; frcijuent luid painful urinatioa and n buniiuK iiiuii 
around ttii^ iit>i'j{ uf the bluddc<r mny de«6ive the pliyncian ioto a diagiionii 
ot oyatiti^ uideaa he mnkes m cari'fnl fxuiuination of the urine. SometiineH 
Uw Hyuipt(][u:i nain^ent irritatinti of the atomadi ; pain in tho epigastrium, 
tROMA and Toiuitiiii; vrith or without dinn'h<»a dir«ot att«ution to the di- 
qmUto tnuil. No oxnniinatiou of tho uriuu is uiadv ; tiie ctaio ia regardud 
tts one of biliary or iute8tinnl colio. 

Tbe Hyiaploniii produced bv renal c-alcnU are frequently Ihose of the 
OOUfwcutiro pyelitiH ; the calculoiiit urit;in uf thu iutl:uunuiliou mu bo de- 
tonoined only by the eichision of othi<r musei^ and by tlio prettoiico of 
cryatala io the sediment. Vet the aboeuce of sucb «i}-»tiillitie dt^poait does 



H wtrnune 
■ crjratala 



936 



DISBASES or TEIK URINAttf 0R0AK3. 



not of eouTM dtqirove the oxutenoe of calniU in the pelvic of tlw kidne7. 
Sometimes the irmptoioB of ro&al cirrhowiB rt* (Ip-T(:l<i|ml before erwlaaoes 
of nual calculi becom« manifcat. Uydroneplirositi, periDeplintic sbaoeai^ 
diadiu-gs of pus c<xt4;nially or into an abdominal organ may be the fint 
dccmvc iotUcatioii (unii»lj«<l hy rcual «toii«ii ; tbe cause of thrae c<«a|dics- 
tiout) tuny roinsiu uudiHfovprcil until r pnirt-mortem examination is made. 

Women nni vnpecially lialile to JiflifulUes otuis>.-ct by r<?iial caleoli dur- 
ing pre^roancy and after d»liFcry ; nttocka of rcnal culic rue not ialn.^ 
qu«ntly productive of abortion. iVoja mentions a ouw in vhicli this fte> 
viilbiit (>c(nirrt-d fourtiM^ii tiiuoH in tbu lutUir. monlliB of pr^naaqr, e»tii 
time ds Uie remit of rcaal colic 




n«. IB.— H*dlJ9«it (rgol Calcnlnat PttIIUi; Urc^ ixlnin) Crj*ti>,U at tirto Add, ICtHthdlil OaOa, Lm- 

oocf um Mild Itkjoil 4»rpii*cilf« ^UlunuLiirt). 

jyiagnonia. — There are no conttliuit antl t!lianic1«ritttte aymptomfl which 
indicate the prewence of i-enal caluli ; luui thftse often exist for yeare with- 
out exciting a tiiiBi>iciou of their preseuce. The poaaibility of tho (^xiMl«nco 
of coacretiona in the ]>dvi» usiittlly hfconifu tljo subject of inquiry only 
after one of tvro conuoautivo oouditions in discovereil — pyelitis and renal 
colic 

Pychtis, while frequently induced by renal rrtonce, may also he excited 
hy other eniinc« ; hfnco n careful examinatiou of tbft history, mode of life, 
and Kyiuptoms of thr- ptklii-nt. im wrll iw n1 t)i(t iiHek' iniiHt l>u iimde in ortler 
to axcUide the olhpr jmHsiMe causex of iiflvic inllamiiiation. An habitual 
deposit of crystfiLline forms, atnl t-sjieciallv the jfresence of pointed flryatals 
of uric acid in conradcralilc quantity in tho sediment (Fig. 15), iiidicnte the 
oalculoiia oriffin of an f xititin^; pyt'litiw. 

Attacks of reniil colic are in mont eaaei* caused by renal stones : yet it 
is jioHHihlu to make a mistaken diagnusia of renul colic which cod be cod- 





DISEASES 07 THE KIOKEr. 



237 



fnundoil uilli prryiiicplirit.ic iiiflitunmlioD, renal enilmliBm, npinnl cariea, 
Uiltaiy cnlir, gaHtralgia, and evf^n luttihago. (>a the otker hand, a renal 
colic may bd fe-^nnlecl as biliary oF iDt«»tiQfil colic, DPUnJfnH of tb« stom- 
iicU, u " ({"'itric crisuf " of tiibi-a (lut luippuDod iu ii pergonal cuse), etc. 

Ill r-liildwii Incurring lia'innlurift lutiy bo tho only jij-niphim, in which 
Oftse a ilistiiir:lji(n 1iet\veeit i-eiial calnjlutt ami canner is ilifliciiU. Yet if tlie 
blcciiinf; bo (-^luaoil by n calniliifi, tho gcneml bt^nlth is uiiimiKiircil. and the 
urine pri'dpitnU'S mpiklly, ptrluips tvGU wkili.' Htill wiirm, u wvliuioiit. <'0u- 
taiiiiii^ iiru- JK'iil unci tuiitrH. If miinl onnn'r fviKt^ nn ihr. ntiuT liimil, 
eiDaoifition and cat^iiexiu lire ol)seiTcd, while tlie urine iimj funiiiili positive 
information, 

Oc4.-a«it>tmIIy RFnuine roiial colic romilt* from cnuaos other thnii cnlcali, 
thB poHi«ibilitv of nliofie exiHt«ni.^ ttboiiKI tbeTOfore bo loiule the subjft^t of 
in(|iiiry. ylfocdi-vieniiliiolic, coiifltating of one or more of the usual Bymj^- 
tum!i uiiuiifcst«d in a »liRbt degree, U a not infrequent oocurrcnco whicU 
wotil'l he i>iteti9r recogaioi^i if tLo uviim wcro eKaiuiucd 

Afti-r tJiu (.•xi»<4jD0C of riMial xtoncHbiiH Ihicii d^teruiiiKfd, It ih iinjinrtftiit 
for Ijoth prognosiH and therapy {surpical interference) to ascertain whetbei- 
only one IdHncy m involv«d, and if eo, whioh one. If paiu and tondemeaa 
oust only on onu sidt', and i-'apcfiidly if iluring nn iittnclj "f retial coUc pUH 
and bloitd disappenr U-ntn the urine, it is pirjbablo that only t!i« ona SJdo 
iaaSectad. Wt tlieae farttKitloid only a prubabilily Unit tliL-neooiid kidney 
ia heollliy ; for luany cmcs, butli of post-mortem i?x»miii3,tion iind of HUi^i- 
(?a1 operation, havo mIiuwu that »K<rii>u)i disuiwo uf thu Humnd Iftducy. reu- 
d<irinf{ it inc»pablo of [terfoniiiiig t.bi? fiitKrtioiin of both, Liitt eacupod ilc- 
tertioii in tliiti way. Powtivo knowledge of the condition of the second 
Iciiliiey — which ahuuld be considered an eaaontial ppeliminaiy to any Biu^ji- 
caI intjirfcroncp — can bn MOiiiirod <inly by oblAiriiii^ fhc iirino dircetly fiom 
IbiH organ. TiiiN iitM iKen done in fftinalei* by inserting a catheter i nto the 
correspond in}{ ureter ; and has been attempted in males by occlusion of 
I ho opposite ureter- 

A(t«r n dia<^uo!Ki)iof ronal tttoiie» has hem\ mnde, it remains to dvt«ntiine 
HO far aspo-tMible Ui» chumiuat ciimpoMtioii of the eali-utus. ItH nature cna 
bo predicted with some probability from tlie liabitunl reartion of the urine 
and fruni the clmnurter of ths iMHiinicut. If tb(! uriuo I>l< coimtantly lu-id. 
and tint M^dinK'iiLc'ontjun (!i>|ii[)u>t unites and uri» lU'Jd vryHtjiln, ilic cidcidun 
is probably composed of uric arid or oxabite of ealriiini, or both. If, oo 
the other band, the urine be allfaline from the preaenoe of a fixed alkali, 
thu mIuuc in probably coinpouc"! of pbngpliatcs or carbonates — » rare for- 
nmtioti. If tlif urine t>o amnion iiuvU, it i» ])robably ho ri'iidei-od in tlie 
blaililer. and tio dt-duction oh to itn reiutiou in tbc rimul ptlvitt cuii be drawn. 
Them inforencea are of course mere prubabilitiea ; for the character of the 
nriue luuy havo radically changed since the uut-ltiUHOf tbi^ renal coucrotioa 
wax fiirinod ; yet ili<! coiiijxttiltioti i>f thd onlvr luyent at l^iruit in prutt^' cero 
lAinly rcvealiHl by the <-oni]ition of the uriiia 

ProijiiMiw, — The teiTuination of the diiticidfioacatifled by ren^d mImiU 
may rary fi-dni rnc'ow'ry to ili-iitli ; and Hincd both kidnnyi* tnny Im or Ije- 
oooie dL>»en«6d, anrl w^riuiis cottiplicntionM are aliViiyB iioMibl«, the prog- 
nosiii rIiouM idwayn be recterred. Iti (lie uiont favorablit ciute« the diflttaM 
ia Dnilaterul, tlio concrotinns escq» into the bUdder, tlie conseoutive pye- 
litis subftidcv), and compleLo recovery followa Iu otb«r icistancea tlie 
p«lvi« and ural«r w* obliterated h^ inftananiatory uoUon, Uio kidney 
atrophies and oeasefl to secrete^ one) tlio patient experienoee no fiirlhi^r 
di63culty, the excretion of urine being uuiDtained by the remaining 



3S8 



DISEASES OF THE URIXART OROAN5, 



(bjp<>rtn>p1ued) kidney. la othCT instanws some one of Lbe nmncivufl 
poanblc cuinplicalioiiK twcnns inducinfj ilircclly or indiircHy « fntnl irsnll. 

Indn-i'liinlii who hftvB onp« duffcrwl from renaJ ftalinili ore Kpt to T>o <or- 
jumtotl by tlieix i-eciirrence for vesrs or erea during' u Hfeliaet In ibo 
inforvak iN^tween the pasaaf^ of concmtionti, the patient nmy »njnT itoricct 
li4?alth. though a Kiiiiirlitig' paiu upon uriii.itiun is not infrequetit «vea when 
the unnv in free from cnHtitllitie itcduueut. 

'JW/am«iil. —Tha innHt important itoni in tTMitntfnt is {imphTlaxiSL 
Oneottat'lc of renal colic hIiouIJ be an inilicatiou for the iKlo])lio)i of suck 
inetunuvii fLs Itml to proveiil tliL' dcpusit of uritiarr tiiprpdieiiiH wilhiu the 
lK>dy ; indeed, before i)o«itiv<» oxidcDCO of th« esist*iici> of renal cnlmli is 
pru<f ut(!(l, rni-iouH sriujitoitm may wariujit a Aiutpii-ion ihfti Mtich it c-undi- 
tioii limy Ix) expected. A jmlient may mmplain of oraiirianHl M'al<lintt dar* 
ing iirinoliou, oft«Q acoonipauied with a burning pnin at the neck of II16 
hladdcr. la ono case which ciimc uodcr my ^>^«^cr^*tltion this sriDploDJ w»s 
fiitit uoticod uoder circumHt-aix-os which a]x))iM)d a 8tiii))i(-ion in th« 
patient's mind of gonorrho-a; the mtuirting and pain fntlmded, Imt re- 
curred again after «>veml ilays and siibwquently Itrcaino almost hiibitanL 
When ho came iuto my haiidtt, the pfititnt Wl calotil'nis pyditis. In these 
OOWt the iin:i<! 1.4 iii>iiidlv hij^hlv ni*id iitid nipitllv di-puHits n riyntnUino 
sediment ; this preripitntioii niny orriir witJiin a few niiniitfa after ernctw- 
tion or even before tJie ui-iiie is voided. The addition of nitric acid causes 
the- iipiK-unwce of a cloud ulri-ady described na iudi'cutiug on oxoew of 

It ia not nimmiftl to detect in auch pntienta a nlight lUbuminuria. nbicli 
cinuot be nttributci) lo any leaiuu of Iho kidncya ; indeed, the lObumeii 
diaip]iParH whttn (me diitmitia isKoeiircd or whcii tlio iiriiio i» ri<iidc-rad 
ftlliftlini'. Tlietie phenomena are onp<tcially i>roniiiieut after free iitdutgenco 
in alcolidlicH and hcaily menla. 

The presence of blood in thft urin«. even tlioni^li in etich small quan- 
tity H" to bi; ilt.ii;i.iv4-nd)h) only with the niioniiicoiK', iaespeci(dly in <'hiIdpeH 
a frpfnienl indit'iition of renal nomu-etiona, mid may be preaent before other 
symptoms have become a|>pn]'ent. Thia «J^np^^Jnl may bo transient and 
occur ut iuIcrvniM of wccku or moutha. If it Ixi acconiiHUi iol with dmtied 
acidity of the urine and pcrliaiw slight teiidemeiw upon timi pi-csiHnre over 
the kiiliiey. trt-'atmeutadiipted to the prevention of I'eiinl concretions should 
be instituted. 

Persistent irritability of tlie blftd<1er without diHrovenihle cjinm ig 
■tonietinu-H rtliercd by thone meaaurea which tend to prevent the preci[H> 
tation of iirinm-T injrredients within the body. 

the i-reM-nUce treatmeot iDclud«s n careful rogid/diim of thn ilifl and 
the tnt^L-Hliou of pure water ui large quantity. The food prescribed must 
l)p detprininixl aoni«what by the eotnpusitiou of the utoiie. The inoBt fre- 
quent calcidi are composed of uric acid anil nre fiirm<il from vcri' acid 
mino. Tho diet sbauld tbervfurv bv hiicIi as fiiniittlieH a conipiu'atively 
i<rmnll quantity of uric and othor ncida; lean moat and alcoholics should be 
taken in only rncHliTiiti! quantity. It ia a mistrvke to excluile these and 
other nitrogenniis articles from the diet entirely : Much a course results in 
an over-pruductiou of uric add. Sugar and fat nrp unually regai-ded a,-! 
prodiictiro of acitis in cxcc»» ; yet they can he allowed in mclerate quan- 
titiea. Tlio roeont ejiroful inwatidationa of Oantani as to the relations of 
food to the reaction of urine have shown that milk iind cfrcidK ]n-(idiic^ lbs 
grbatvst nddity, gelatinoua and k-(^iitiin«ufl duhstances the least, while 
meat, BUgnr, oud eggs aro intermodiato in Uiia rei>pe(il. 




DIBEASE9 OP THE KIDNBr. 



S39 



Til© regMliition of tbo liipt, whilo taVins: thfWi (tonionrtratfiil facts into 
coiixiilcratioii, mIiouUI I»- Iidm-lI lewsiijjnu j)b_v Biological riiles tlian ii|M>n tho 
rpftiilla nbtaiiiPtl in each iinlividufil nisp ; foi' ii " rational" diet wjcallpel 
will in many instances piodiice (lyspepxiA iinfl constipfitioii ; (iiid it ia c^v- 
tnin tlint iii(li{.'<^ti(iii — [iiLiiiciilpirlv n (iiiliirti in pnii<.'ii.'>itir (H^cid.ion — ci>ii- 
ti-ibutL<)« largely to th(i fxreaxive anility of th« uiine. H^-ncf the liitt 
nhould bf. (K) lefftilntetl »a to ftepiire a [*rfect performiujfe iif tlio aljnieii* 
tar; function, even if munt imU Dlarcliy HubHtnnccH must be included. Kx* 
cemiTu indulyencB iit food nf any sort, ^lioul'] bo forlndden. 

MiiKi-iiltir csert'iK' is Imtli tlnti>M-ti cully itii'i pmnticvilly of tliv (»rpjvtp«fc 
motiifiitr in (trevpiiliiiy litliiiisis, Thn tendency nf itinuy iiattetLtit ikfflicted 
in this w«y ih to Bodentary oet-npalioiis or to abmlute pbi-sirnl lazin^Ra. 
Miicli *ffr>rfc mity Ijf rociiiiri-d to piTHWulo the in<liviilnnl to tnke tlin nccps- 
sary (•x«rc)80 ; buL mich ofTurt inimt be tiiiuk-. A.ti iiicri^AHv in nniHcular 
aclaTitynmy i-eqiiire a (frciitor ftmoiintof nulritiouafood, whiirh L'tiiinbir tbe 
circumstances not likely to do harm. 

Tli« r(>;^lar use of wnna bntliK in un important itt?m of troatraeiit. 

Tho iiigv»tion of jiiirt! wati^r in larp^o <|uittitity Iiiik I'vidctit, vnhtc in ibo 
attempt to prfiteiit tli« formation of renal concretions of nil kitids, siii^-o l>y 
im-n-'fiHinj* the wster excreted by tlie kidneys the tendenoy to precipitation 
of the Holid uriniiry inj^divnts in i1imiiiii>liR<). Kini-n tho larino istma i-ule 
most onncpnti'Hteii in tiie iiitermbt between the ppriotU of dit;p«tit«i. W(it*r 
hIiohM W taken at tliese tinien es{M«ciAlly na welt a« upon retiring at ni^lit. 
Tbo inornin;; tiriuc in particularly acid and dcnw ; Lonco the intfeHlion of 
water kIiouM takt- pbicu fn-cly Wtweon llic CvctiinH; and tlic nioroin^ int-al ; 
if the |ialii'Tit dniiL fn-idy rluriii^ the ort-nin^ npi>ii n*tiri»jj, and tit jioBsi- 
blc int«rvalH nf wakrfulnefH during the nij^ht^ thin concentration of tlia 
urine, nntiiral nnd usual during' i^b'tp, cim be avoided. 

Thi' wnt^^r c.lnwii fcir ihv dihit.ion of tlic ui-iur Khmild Iw cdnjpiim lively 
free froni niiiicral ii i;^fid ienta (eHp<'rially soda and lime saltst, lint mildly 
alkaline. Good reatilta haye been obtained Ivy tbe in^r^tifin of noft ivatev ; 
bnt winre thin wimiot nlwayB bn procured nti<l in nmrcovcr impnbitable, n 
more efitcient coinpliniiw on the (mrt of the [mtient cftii bo wnnired by 
preMcribiii;; ii iiiUiUy alkaline iniuerul ajiriiin watei-. Tli« «prinK« at Vic-liy, 
Ou-Ubad, King, and IJodcn, have CfpcciaJ repute for this purpose ; o( 
Amerieau itpriiigit Lbe BiilTalo Lithia. Atcadiim. nud Poland itre ^'alnable. 
Tlicy itliduld l)(i bdcen iii hucIi ijiiiuitity that the Hpecilid graritynf the urina 
avemiJciH not more than 1.015 in Hummer and 1.010 in wntei*. If auch 
waters bc> not Hv.iilable. diurt'uisand alLidiuity of the unne> ran be aeciired 

thtt admiiiiHtnitiiiii of ludtx ; nniong tbow tht' most >'alurib]c an- the nl- 
liae oarl)onat«i4, ao^tatca, and citmtes; the tribnsii': pho«pli!ite of Kodinm ; 
the beniKiiate and carbonate of lithia — since lithium salu have been bIiowu 
by Oamxl and other* to poswss {^cater Holvcnt power» for uric iici<l than 
mow of sodium nml jKttiutiium. Ciintaiii advii«eK that in onler to prevent 
deraitjifLniftntM nriiting from a diiipropnH.ioii Ixitn'ti-n th*' Hodiuin and jiaLiiif 
Hinni incredienta nf the blood, tlie tuilta of Ihew Itatten ahould be niixrd. 
The borofitmte of DDHfrnestum baa been espcoially recommended by )lad- 
Hfln and mny ha adminiHtcrpd as follou-s : C»rboDat« of raa^eaium, ono 
dmcfaoi ; cilriv ikcid, tvu tlnuiirRs : bornx. two dmclimfi: buUin;,' water, 
eif;ht ouncDH. Take a tablfl^XMcful four or ftm tini«i« daily. Ilartholow 
recotomcnds the tartrnborate of potassium, a scruple of irliich may be ei^'^a 
three or four liineH a day diiMOlvod in plenty of water, lliese and the 
tilliiiini HidtH may bo aubiitilutiKl if tlio j^wttuwium solla provoke gaatne or 
iutetttiuiU irritation. 




340 



DISEASES OP TUK riUNABT OHOAHS. 



^-^ 

4 



U 



Veg«tAl)lc ooidii aikI lk«ir compouuda a» quite eflflrient in diminisliuig 
Uie acidity of ttie urine and ttioa proven tin;; or nrrcstint; the fonuatiuu <rf 
ooQcrotiuim ronHixtiii<; of uric arid, itnitCM, luid oxnliite of calciutu; for 
UiesB Gom]M>iiiii)i« ar<: ciinrrrleil into biearbuiiiiU-M in Ui« lilorxl. Od lUis 
]ffinci]ile tJio (icmitinii lu^ily recommend uici nreecribe a dt«t of grapes < 
ftiMl ottKT RiiLolI fruits — tlie 8o-callw] "jtrape or " fniit oure." Tliis^ 
metluxl of treatm*at Moircn tlio luIvanbifiDS of n country vacation us wdl 
an the iniinediBtC effeets of th<^ tct^etable acida. 

In order tn Mtrurn th« nlliaUne effect of tliiX^ mnorHt)*, rit]i«r TOf^aUe 
acid* or tliL'ir c'oiiii)ouud8, upon tlie urine, tht^y 8Ik>iiIi1 Ije ndmiuiawrcd 
upon an Pinnty Rlomach ; for if Rivpii wliile Ibe Htomnch containH n supplv 
of gastric mice, dccom position occur» bfiforp fhpv pnt*i- tlip blooil. procUic- 
ing neutnu salta and arbonic acid, iw tliat tlie urine uiur be rt-nduitl acid 
iB8t«a<l of a)kiilin(\ Moroover, tliA noiility of the urine ia nnnujdly mticli 
dimiuifllieJ or even neutralised during digestion ; artitici^l ud to orerroine 
the ociditj' is especially roqiuied during the inten'als between Ibo acta of 
tligefltiou. 

Tlie quiuitity of thcw substancea required to produce and maiutaio ft 
neutral action of tJio urine Tories in different .caseii. amlnmntbe deter- 
mined br obsorvnlion iti etich infiiance. Aji nlknline reaction cnn almoafe 
invariubly bu si)i-cdity Mtiiind br taking forty U> fifty gnunii of tUc acctota 
or cilmlc of jiotatsiiint dinnolvea iu a i;Ia.t.4 of water evorr three or four 
houi-§, ao thiii six or bovcq drachma of ibe salt and aa many f^lasttes of 
water are tnktn dnily. 

In ailtnini>>ti?rii)^ (ilkabrrji lo ctt'aet the refuttion of ihti nrine, it is denr- 
able lo avoiit mii-h an eicena of alkuliuity aa will occaaion a preeipitation 
of tlie pliosphntes and rotbonutes ; altlioufjh thfiif) Holfa rarely conHtitoto 
the nucleua of a calculus, yet thny rapidly wv-unmlnto upon a pre-existioff 
concrvtton a» wt-lL as up«>n a catarrhal or ukeniluJ uiucoua mombnne. 
Hence ao noon aa the urine is found to be turbid from pkombiltea nl the 
time of evacuation, tbe quantity of alkali ndministerod should be decreased 
or tho amount of wiit<-r infjtmtfd iucrt'iiaod. to pruveut {Kitwiblc precipita- 
tion in tho rrnnl jicIvir. The oflnurrenee of niniiioiiiai'al fermentAlioD 
ahould be the siffnal for immediate ceaatition of tJie alknline treatment, 
mace the pliuHpUutea arc rapidly deposited uini nsKrenated into rnnrretionn 
from ftmmoniftcal unne ; indeed. a<1vantj\);e uill usmdly bo derived, under 
such circLiinstances, team tlio ndiaiiib^tralioii of Ix-nzuio ai^id, five f^raina 
three to live times a day, until tlie reaction beeotnes neutral or faintly ncid. 

If the adminintralioQ of alliftlieH f^il to relieve tlie ayiuploiiia jiroduced 
by renal (^nivul and couoiiitioiis, a cloavr iimpi-otion of the iirinc may abow 
an exccaaivo cxer^^tion of tho oxalate of eideium. C^nerotione of thiii; nit 
are far leaa frequent than thoae cotnpoaed of uric acid and the umtcs ; yet 
they occur in acid urine, and since their effects are lew* readily controlled 
by alkaliM, thoir prcaeuoe may be euKpected if the alkaline treatment fail. 
Iu thia «aae milMdamwii cont^iiiiin^f an rxcOMt of oxalic add — rhubarb, apin- 
acb, blaek lea, cocoa, fwrrol. etc. — should t>e escludeil Ti-om the diet ; bSm^ 
geudie thought he conld trace tlie formation of oxalic acid coucTetiims in 
two cnaes to the coiiHumptioti of Horrcl. 

The moiliciiial tnalm'nt of oxalate enloiili \s na y«t mt>r«<ly ]mlUnlive : 
the coiicriTtiiiiis an- not dwnolvi-d oor ia their fornuilion i-rfrn umMitecl with 
certainty by the use of alkalips. (ialloia and I'lirhrinyer have recently 
demonstrated that the excretion of calcium oxalate in the urina is de- 
cidedly ilimini^iho'l by the HimultuiK-unx adniitiistnitioii of the alkaline 
carbonates ; and K^bach has libo^nl that the preaence of such carbonates 



i 



DISEASED OP TITE KIDKET. 



Ul 



in the tttrnnacli rondei-s oxalate of colciutu insoluble. Henoo nmler tbeso 
oircumstaDcee tb<f oxalato 19 uul iibtorlxMl, but ui oxiKrllod with ttio fwoea 
The atteiupU U> •pnteut tlie precipitation of tlie oxaliite iu tlie r»uiil pulvii 
b; Icurpiiig it iu tiululitii) tUi-uiigli the admiiiistratiou of imui^rol uciiJ« fans 
Ih^-u a fniliue. It wouUl set^iu that the free use of tiio acid plio^phato of 
Radium luijfht at'fuiupliBli tliis rt^i^iill, aiiice it is Ibn pwneuKe of this Halt 
wbiob IkGoin tho oxolato iu xulutioii iti tlic urino (Xoii)iimici-), Xo oiten- 
Bivo cliDiciil trials of audi treatiiiciit. have yx U'cu n-ixirU'd. At presc'iit, 
tlu'r('fcir(\ wu 1:1111 do uothin^ iKttlcr lutiiliciiially than lo |irum!ril>c cnrboD- 
at«i.l wntem ami alkii^liuo cm'boiiAt«& 

It in iu)iaetim(>(i necewuiry to MK^ure an acid lEsat^tioii of tlie uriiio in tha 
attempt to rtircjtt or di«solvo ruanl com- n- tin i in. Fur nltitmigli cidi^uli aro 
raitiy vumjuj.ted of j)ljOB.pbmtes tiii-uuj^Loul, jvl mii* acid uu J calciii lu oxu- 
ktB eottcrrtioiiR are aotnelimoH iiic!ru)«tL<d oven iii tbe renal pelvuiwitli phos- 
phates and cnrbonntcH ; kupIi n. cuudition may be sUHjiocteu if the urine bs 
purai»k-utl>' idkaliuu fiuiu tbi.- tixed ulkAlit-s. ll in lubt; roiucmbvrL-d. tiow- 
cvcr, that white cxoosttlvo aoiility of tlic urinn n^milta from abnormality of 
ftsBiuiUntiou, oxcessive alkalinity arisi^A in noiuly oil cAnca in the blatlder 
from ainmoniacal fenuentatioii. Before attotiiplitii^ to remedy au alkalinity 
of tbo uriiH', Uicroforr, by tlm aiini in int ration of drugK, tbc phyaioiau should 
liare i>oaitive eviduune thnt tbe urine is aJkalitie bL'fori! rcaoJiiug tbu bUul- 
dcr. Ill aomo cntieH, it ia true, amiuoniacul fermentation takes place in tiio 
pelvis of tbo kiihiey as well ax 111 ttic bladder; yet aK a rule, it may be 
atated that iiu cxciss of thti Qxtd alkaliutt only awl nut of aiumonia culls fur 
the intonial nilmiuiittratioii of (u-idn. 

Ti> noutRdi»i alkalinily of tlie urine froiii tbe lixcd alkalies, beuKoio 
BCid oud ita coiii[iomKla hIiouU hu niimiiiialvred ; tivc to ion grmtn of the 
acid or of tlio bunxixitA of aiuiuoiiiuut may 1>o givitii lut <H>iiipnti(Hcd tableta 
four or live tliiieu diiily. Laetic, pboephorii.-, and i-arbouiu iK'i^l, tlie latter 
iu tbe tilmpe of carbonated waters, have bIhu beeu recommended, [f theBO 
reiHRiUca fail to oflV-t the roactioo, it ut probable that ammouiacal fermeo- 
tatioLi exiats 1 lliia can eotuetimea be anbdiK-d by tliu frL-u odiuiuiHtmtiou 
of salioylie nciii as peoonimended by Filrbriiiper. After tlift ooaling o( 
pliospbaton ia di^^solved, the nlkaliuo trr-atmeDt laay be reijuirod. Tbtt 
pi\>pi;r tirtii; for laakiu^ this ihauf^u of tn-iituiL-nt ciin Homeliuica be ascer- 
tnined by ropnnloi exniniiintioua of the urint) acvenU dayit after all ronio- 
dies have been diacontinued. 

It mUouI;) be atHteil that several phj-aimna, unions thera Dr. Italfe, 
have in<|orH4-<l fnim p'MJwaal obwrmtiiiii lii« plnn omploycd by Dr. iklur- 
r»y, Qiuacly, the uae of &oft or diatilled water iu tbe trcAtiueut of uriuaiy 
fiouciretiuns : tbe a<lvantjiReH claiuiLMl are that more perfect solution in olt- 
tttiiicd ami the tcodoiicy to ciitnrrli of the tirinari.' pnmn^a avoided. Itob* 
ertM is incliueil to frivor tbe a>liiuiiiatrAti»n of iilkaliue Milt«, while Sir 
Uennr Thoiiiiunn coDsiders the natural wnlf^ia fiu- laon titHauioat tlioa 
any artiti(.'Lal compouuda. A judieioUHly aelected 8]iniig water — free ftoia 
or^iuit? niatvri:il, iiiiidly ulkidiiie, utid <'untaiiiiii}; but little mineral matt«r 
— mil aM a rutu l>" moxt palatable, court- iii<tiit, aixl cfTvcfive. 

Iu order to aecure luatiug beo^tits from tlio atu-iupt to n:Iieve tlio ilia 
produoed by renal ooacwtionn. a loufi oourae of frratraeut ia r(-<Hiired. 
The regutntion of the diet, the iiigMtioD of water iu exceaa, and the ad- 
iniuiBtratJou of Uic variuiut ivnicdios meutiooed iniiat he niaiuliuuLil for 
atimy mootha; tvea after tlio djl!iculty lias upimreiitiy aiilHiidod, caro iniut 
Ira lakeu to prevcDt a ri^iap^e, whidi may ot.herwixe be eipecl»d. 

Ill many casM all thc«e lucuaurvu fml to oOix't a cure : tlio patient i« 
IU 



242 



WSEARES OP THTI mnTART OROANS. 



partly, or for a time eveii oompletely r^liered ; but ikftw e&eh relnp&e liis 
condition bocomos worw, ntid tiimlly siipiinrutioii in or iut)uii(1 the kittiiu; 
bocoiiK<8 «vi(]itiiL UiKlpr t.|ic«e ciiTiiiiitiliiJir.es, if not before, KiirgioiU ititer- 
foroiicc in nicjuinHl ; UL'[>liri--eUiro_v luiil uejiUrolomy are now Tbca^aixnd and 
BUOoessJul o^i^ratiDDa. It ebuuld Qoror be foigottco, bQWcvcr, that a ceo 
esBOTf prDlimitiiu';' lu hilHi upcriLtjoii it) to iwct^rtiiiu tluit llt« oilier kidney 
is not only jjivsent but in cnpnblc of pirfni-mitip its ftinclions noniinlly. 

'llKt treNtiumtof i-eiial coIinonnsisW in liie niliTiinittlrtilion of niircolios ; 
mnrjihiiio dlioiilil Ixi ^veii frirnlj hy Ktilx'iitiULi'oiiK inji'ctinnH, Kiiir<; thr> 
stotijJifb ia t<H> iiTitabie to retain or nbaorb itifdiciuee. Tlio itibalulion of 
oUior or cUloroform may be required temporarily. Inimention in a warm 
bath for nn liour or two oft*n expi-l« n markoil itiflHcnrn in subcbiiTig tho 

iiiiiiidil CO II tract ion » ; bol fomtMitHtioiis over the gn>in titnl loin may pro- 
onji tliis cflfcfflt innt^riallv. Vim'oim mpclmniffii licTirrs liavc been em- 
ployed in speciiil cases ; tuns Sinipeou BUicc«e(Ied in. forcing & cnlculiifi back 
into llic rcnul pdvia by slaudini; the patient on bia bcud wid riibbiiiy the 
ftlTdctoil sidft ovor tJio tir<1*r : 8iraoii propooftd to introduoft ft noiind into 
tlie ureter (in tbe f«iual<;) mid thus force the concretion into the pehis. 
Iteliqiiet BUKR<'«'« that the lower pxtremitiett be eiiveloiied in elastic blind- 
ages, wbrn-by nn increase of blood in thfilcidnpy luid ofthc uiiiinry prvMniro 
oiuv bii oiToclcd. 

<Jiiilo ret'pntly i-idsoii biia recomniDnded tlie JiydranpcaarborDSoenn and 
DuL^ne^e tho idi^'ma of nmi/e ns vaUiablo nr^-iitit Ifotli for tho pro^-eIltioD of 
renitl cjilctili and fur ukc. during itn iittnck of coVk. 

TJiiit tii(v nsn of aJkalioB or of noft i\-atfr i« «dvanla.«eoii8 in preventinjf 
or iirrcntiiij^ tbo (oriikatioii of cnl<ridi in the uiiiiary jtwwnfea there can be 
no doubt ; tliat they arc cffcctiin I in I'cdissolnug una removiuu cnlctdi a1- 
reatly formed. i« not bo rcrbiin. Tii fiwrt, it may be saft-ly luaninirid tliat 
vul<nili. »o louj{ tm Uii-y iire retained in Ibe pelvis of the kidney, onunot bs 
diH»ohed by any niedieinal remedy, BincB Ibe quantity of urine with wbid] 
tiiey are brought in contact is loo Hligbt to infliirni^e them, no mutter vrhnt 
itn roudion or oouipouiliou mny be. It ia, howcYfr, deiiioiiHlmted tiiat 
calculi in thn bladder, RUiToimdcd by a i-onsidembla quantity of tirine, can 
bo softened and oven ilisinte-^ratcd by nrlilicial conditions of the mine. 

It is well known thnt remcdii* of all soits bitve bi-fu pri>i(ustd mid tin- 
ployftd by lay fis wHi aa by professional ndviw-r.i in thn hope of iliBsolnng 
and removing calculi in the bladder. Tliat tho B\-mplonis caused by tbeir 
pres4>nca bave been nmelioraled even fur yeimt in undoubted. lu most 
ciMot tho improT(;meiit in the ttymivtonm w/m doubthn!* dno not to any 
duorcone in the wao of tbe stone itwK, but iiit.Ti.-ly to tbo Itw Irrilatiug 
<>hamcter of tlie urine ; at any rate the poBt-niDrtem examination of innny 
audi patienis, who bad been relieved of the timst troublcsoiiie aynip- 
tumH by the nao of iilkidinc romcdifs, baa dcinonstiral'Cd tb« prctw-nro of 
«i\louli in Ihfi bUddor. Kir H^finry niompaon aitya ( 1H82) : "I (uinnot find 
tliat any patient, cerlifted to have atone after sounding by n competent 
Burgeon, baa. after a course of any nolvent, been aRain Bounded or sii't* 
milled to autopMv. ami dcmonstnitcd to bo fro© from Htoiic," There arc, 
howovi-r, eevcnd cticin on rcconl in which einin{riit English siir;:^ou9 testi- 
fiind to tho diaappeni-anoe of all symptoms indicjitinj; stone oven upon 
sounding, niter the uBe of alkabes. An examination ioatittitt^l under (lis 
observation of the R<iyttl Oollcgo of I'hjTiicianM for the purpose of deter* 
TTiininjj tho merit of tliisi plan of Ireatrnpnt, iucLudcd among othern tlte fol- 
lowing four cases : 

F. Applcton, Htity-fteven yearn old, was examined at Ouy'ii UoHpital in 



DISEASE OP TttE KIDNET. 



S13 



i 



Jul;, 17:10, hy Mr. ShftTp, aurf^oon to the bonpitAl, in t.hA prcaeuce of the 
President and a Censor of the livyni Colleso of rb,v>nci!Ui«. A Iiirso stono 
vnm iivU:v\&d. Ttm piitii>nt tuok alkiiliti« ivui<'L)i«8 fur fivu inoiithH, duriiig 
wliicii ["-riuil a liirj^o uiiiotiiit uf " gmv«l " tei'itpi'i) witli Uitt uriav. Al tlio 
eml of thla time lie ynis t^tiin soiindeil by the name sur^eou iu tlie prei>- 
enee of summ-uua medical lueu, >Ju etone could be detscled; the Byiup- 
ioins hiwl nil iU&ippcdirE<<l. 

Tlii^ thrfc utiicr caiwii vtcrc i-saoiitiiiUy siuiilnr, \ht csaiiiiiiiiig siirg^oDfl 
lioiufc Mr. Cliospldpii, Mr. Sliar|), iiml Mr. Nourac. The jkuliitiils took the 
soUent remwdivs for pi,'riod(» of four, eight, and (oar iiioiitim respect ivilr. 
la every curb consiilerable sand was pftesed duriiiK the treatnii^Dt iiiul i*- 
licl from all symiitoiiiH wa>i cibtAiuod. At tliw end of the respcctirc iit-ri<)J»i 
specillod, vuimii lit lion by the wm« surgeons fulled to <Iclt:<;t a atou«. IIkbc, 
it muot hfi odinitted, ore the rare eases of succesB, called from a largo uuin- 
b«r of foUuioa. 




na> l&— CTlliukTii nf Amirciiiliiin Vivie; Itritintr tMlmnnt hnm a Nnnllni; wfth Udo A«U InbNl 

I Ul luulou ), 

So far iiH rMti(^Al cnlmli nit* nonnftmfd, thn mivtlicinal tmalmont in now 
K mutter of little (wuseijiietice, aiiice the operation of lithotrily nffordH a 
fi(H-eily and Kifv nilitif from the AfTediuu. An for calouli in lliv iwlvia of 
Ihi- kidney, then: i.t no yvt nu I'cc-ordcd ciik! in whiiOi Hulutiun Iiiih bt-cn ai-- 
com |ili)the(l by medical treatuiMit ; yet tlieiv can be do doubt of iLe value 
of Huch EjfeniK in i-clinvint; the piunful nnd uiiplea^iant nyiuptunM cautied 
by tliitir im-sonceb 

Cftlniili (ire BooicUmes found in thw kidney itwlf. mi oceuiTtncc of 
p»llnilo;{i«d miller tliiin of elinicnl iiiten-st. Thoiic concrcitioiiJ* lu-e lopjiteii 
in the tiibiili mid ore caniinoidy teniied iufoj-cta. Those m^ntt froqueiitly 
olMcrved ore lufarctH of niiu ucid, lituc italtit, bilinibiu, oud ba-uiutoidiu. 



244 



or THi umicAsr obqass. 



Urie acid wtMniM ate fotad kfanaal msdamnij dariOK tfe fast 
mdnaftar b«tii ; tlMjr Wt» bws oUwt^ id about om^mU irfaD lfcs| 
bilMrtA nMHiad p(Ml-nnrtBvi daripg tids pwiml ]l it ft Bngda 
tlal ■iiU-faon cUuna,«wi tfaoM bon ii tafl IvmdDiwc nlibit mdi 
infuKU. Virdxiv, aftar a kioy aema irf atment^omm Ut tUs cAct, was 
t'H^'pf^ to RKvd lbs | i iMmu) od wte acid Ukicila is the ocwborn aa » ' 
BMt imtiortafit aid poaitin [«ouf iLiI Ui* child had brtalbtd, tati betM* ', 
Mttmebt^l Uj Ham fM4 nrairfa ralu* frtna a legal •tatK^nntL In t«MBt nmm 
il hH, bcnramr, ban detuonaUated in mMalad in^anpra thai >a^iafiui!l»j 

Mutin, EtMtiiw. Uoogvwcg, dm) Btn-b-HinclafcU baiv obaerred aatt n- 
poftod MieheaMa. 

Hw uriii<! ilanit^ tine fini b« weelu of UCe ficqiMally « art « i n a reddkli 
powder wbicli i» ddpodted cm tba luqildn ; niicraMopie ciannarioB often 
■bowa cjrUBdani ompoaed of nddub-brown *pbe««a (Fie. 18) oC wMp of 
anuDonuun. Sucb iu&rcU ara oormiimmWj {imumI in Uw kidiit7« of mluh*, 
u in onR ioflbuica which 1 claniinecl in tb« ItudoUipita] in Vieoua. They ■ 
apiMmr Ui liav* no caip*cia) Mg&tficaticA. 

luIUTtH of liow wlla an /ouad in Uw du^w o( outdw wliite Unm pi»- 
caadins frr>ia Iba pelna of tha tddrx!; tominl the cortinU portioa. Cpan 
niiciwioiiic epun I nation tbcse lioMi are found to ooo^ist of nuiorpboua 
loaMM UI tiui uu-ltunato utd ybatpbmtm ot calciuin which he in the Elnut^bt ] 
tubnloa uid tiif ^>upt of BAmm 

Hiliniliiii iiifarctM arv rmiml ia Ota lutlncTA of jniiiidioeil n«wlM>ni diil> 
drvti. i'iui Ifilirubiii iM pn-Hent in tbo •faape of (•niuukft or uf needlM and 
Hi'iirilMii'litl <;rviil»lH; it liro fttlicr in tli« luntrn of tlio tiil>iilp«. in the 
Dpilltf-liiil r^-llit, or in tin; inti-rlubitlur tiBHoc bucL iufitrcttt urv otU^i ojimo- 
cuUwl with liunu} of uric fii>iil. 

Hiifitisliiiiliu infutvtH lU'e fouud as brovn miripea in Uie tubuUa of the 
mini fnpillK'. 1'he lia-iiiatoidin is fouud ncldoin iij crnrtaUinB torat, bat 
itxtiAlly lu ruuoil. rudilifih-bi-own tiumRM. Stieli iiifurvtM may h» w«n after 
Mty (if UioM' cciriilitiouH wlu>-4i cauw a HcjiBratiou uf bmooglnlitu from the 
oarpOBolui— (titfiiMive buruit, cxc-cicsyx: adiuiuiatrntian uf chloroforui or 
•Uior, bnoafuiioua, cte. 



HvDIIOXZPHBOSn 

Dilntatinn of Iho iw-lnii nf the kidney by the Bocainiilntinn nf iirino is a 
uot iufrc^iivnt comlitiun, which luny be «itlieroon(fOTiitHl or nci|ub-<>d. The 
funiit-r i-loMi ia umially tht- R-HuUof coui^tnitul ninUurmiituuiMat sniiii; point 
in Iliti iiriiiarv olmuiii^l. Sucli iiiiilformatidn inny ooiimhI in jibinKB^ift, «>»- 
pfDiiitiil ntriclun? of tb« utetUra. but uiont (i-e<iu«ut]y of an aboonuol iueer- 
iioM of Uit iireU'r inlo the jH-lTiK. I-'or thoite two portioim o( tbv urinaij- 
l^hlUllK4 ATv tlovolopix] iiidupciiclotilly. and tb« iiisorlion of t)i« nretiti' itt 
•oniotiiu^'H ctYct'Urd, uut at ibii Ivwvsl ])oiiit of the pvlvia, but ut boiiiv lij[^i<ir 
point, or it [M-rfonitftH tho pi'lviii obliiiuidy. nifikiii); a vidvnkr tttiifniiro. As 
a ramill, Ui« pitlvJH iH<'inptii«l ot \mtn^ only nlioii ib<? patient nssiiiues aotiio 
Other than the fn-it )iuHtiin> : the nrruiuiibitiun of iiririi' tUirint; tha 
wokinc houra reHiilta in conipi-ession of the pelvic n]v-uinff of 'bo iiiY'l<^r, 
whwalty n di>iltititii>n of llic tH4vin rcwulle. Sucb cnawt aft'uil ii mosl fiivor- 
ablfl eoridilioii (or by<innH'(diri»iH, «iiw the obatriiclioii to Iho free eviicu* 
atioti of viriiii' ik iiiU-niiillt-nt. For il ih well >'Hl(il)li»bfd ex perimpn tally 
Ihikl bj'tlronvphrouiii in not pi-oduoeU by iwtnj>lete aud penuauout obHtxtic- 



^^^^^^^^r DISEASES OF TUE KIDNEY. 34S 

tian, 1>ut oalv bv incomplete or interniitt^iit ini])C(lmieDt ; a complete and 
]iLTniai]«nt o\*stacle to tbe ei,iu.'untian of urine reautls first in slisut lUsUn- 
tioii of ttip prlvi^ but Hiihtu'ijiKiiiily ill alropby nf thn kidiiey ami ilin sui-pift 
of tbe iiriiiaiy aecr^tinTi. Tiie ilevelopinent of hyiiroiifljtliroKin rfqiiiiiiS the 
continiud iie<n«tJoti of urine ; tienoe it ocrura only when tlin obstoclc-ct to 
micli secretion nro not complete nor jM'rmn.D^nt. 

IttSODie ciiMCK i)f corj^cuitul ImlrLmeiilifuniM, the affuc tioii bus uttuiui^d 

aaeh (twdobftforp birth ns tn intf i-f^'ro HiinoiiBly with <Ii>iiv*'ry, und lo piy- 

vent tlie resjiiratory inovementa of tlie child, ami therefore c.-iiisif <li?alb. In 

, .otiier fnMeM tliero may be at birllj no evidence nf hydronephi'osiB, which 

UiOT«i-tlKd<'fM (I<'\i>1mi>s ill thu courts of tlic enrly yctiTH of lifu. 

' ADatoiiiiciiUy n ititttiiiutioii ia umdu between jiortiol and complete hj- 

droneplii-osia. accoriUujf as a ]H)rtion op tbo entire pcKiR is involved in the 

dintentiou. Tlio pnrtinl liyilrouephrosis is especially coiaitiou in canea of 

cuti<;«nitiil lualforiuittiou ili wtiich tlii: pclrtK uud urt-'tcrs uro doublo ! in 

•ome cfUMi«, cvrn -wilb iiinj;lA pfihnH (ind urrt*!-, oiks or mora oalyfis Ixtcatnn 

M>bati'tictcil either by a vnlve-like (old of tbe mucous lucmbrniie, or by a 

CttlciduH or hltjod-dot 

Aciiiiircd liydronnphrouH can wnunlly bo tnicci] to soma obntrnotion in 

the uriunry cbautiel ; euoh obetniotaous may b«of very diverse nature, Botui- 

of which it liAS been impossible to uitcertain ur even imufnne prior to tbe 

|liutnp«y. Tlie most cominnii of tlioM arc Triutl ralritH in tlic jx^lvis or 

uiretcr; ulnrlnrv of Hie ureter iu couseiiueuce of iujury fruui cftlculi; (/<<<- 

upliuymunt r^ Ihf juific urijuvv/tiie urcler by tutnm'sof the kidney or byibt- 

ltid)i of tbo ]Kilvi« ; dii^afvnrnl o/" the van<if^ring kidnaj ; obstruction at the 

IvxtTii/ orijke of the ureter by cak-iili, or inflnmnuiUous iii<luci>d Ihn'Dby or 

'l>y tUTnom ; pr^titunt upon lhr> uivrla- by abnormally tocatfid t^Dal wvswIb, by 

the prodiiotM of infliuniuatioii Rrouud the kidney or around the womb, 

by cancerouM deirpiieralioii of tlie uleruH, by prolaptte, Terdoim, or tumors 

of th<' w()ird>, by uvuriiiti ttiiiKii-si. by cuicur of tlw rectum, ot*. ; ob^trui-tiiui 

to the ovftciiatiMii of the bhidder by prosbtUo Uypertrophy, urethral Klrii:tur«. 

fkbiDKmis. When riny of tbess condilioiia ia reooOTUxed, the po>sHibilil>' of 
lydroncphrovi)!. with conitoquciit reool iitrnj>liy and iu«mtn, should be kept 
ill iiiiml : for cvou before n pmnoiiEired rt-iial tiiiuor is (lct«ct«d, ui-a-uim 
may be nlnIlif4^sted^ — a familiar oh-iorvntioii in ciuuiit of ut<>rin« cancer. 

AsKhvoiIy rttated, lunny of the conditions through which hydroaepbro«iL8 
Ub acj|uired cnunot be rt'iro^iized, luitl aitf not even Kuspected ditrmg the 
flifn of thi'i pali<!nf. Kiicli uru tliu cjuwh in which jK>st nmrti'ni an libnnniiAl 
atlAcbtuent of tbe ureter to the pelria i» diiKOvcreil. Lfig;nive relates a curi- 
ous iustanoe in which tbe reteotiaa uf menstrual fluid in une of the cavities 
of • bifid, ntonis had cJiuwd compramiQa of tJie uret«r of tbo miidc Mi<h^, r9- 
Bultin;;: in hydroncplitrixiK nod iitmpliy of tlie ktducy. In n ca«e which I 
examined nt tlie Kuiolfsiiitul in Vionim, a man »f v.iity-four Tcara old, tliere 
wras found pronounced liydi-otiephi-oHi>} on one fade, tbe Obber kidney nod 
uret«r bein^ uoimal ; tbo (.-uukc for the retention of fluid wm found In a 
Rrnihll myoma, not pm IwjC^' nu n bran, which wim Iiitmttfl juKt at ihti veKicnl 
ori&ce of tbe ureter iu such a way ott to obotruot the jnusaajne of Hiiid 
through it 

There remniti also r few cases iu which even post-mor4^m examinntinn 
his failed to ruvt'nl an im]M'dimcnt to tbo cwTipc <if uriii*. It in hi^'hly 
probable lluU in such raKcs thoro hnx exiat/vl a mnli>onlion of tlie uterus, 
n perimetritic inflammation or other abuormaUty ,at the lower ]x>rtion of 
tli« ureter, which hiul been cither overlooked i>r whose awodalion with the 
digt«tMlod renal polvis haA not been noogoized ; or there mfty have existed 



i 



S44 



PtSEASBS OF TUB VBI5AKT OKGAXS. 




ft nlmlsr Jocia«taoD of mocooB membnui^, or uipilar cnmUare some- 
wlwre in tba coona of llw imltr or fielru, wliicb hm mcsprd delrrtion 
or awn bcMi oblttent«d hj the nuuupubitioii of tfae iwtH dariag Autop^. 
It U donbtko* posnble, moreover, that the calculi «uich origioUed a b^ 
dronoiifanMas maf in th« coane of time cmiuble and diasppear, ao Qatt do 
ooDorelioii ta fooad pofil-morteni. 

iforbid Anatomy. — ^Thia vahwaocoMiiiK lo tho d«give of the distaotkn. 
£i proooimced mnph tlie tiuoor noRiwts merelf of a tnnmbnuKMis sae d)»- 
tended with fluitt and containi dj; a few fmpmenla of reoitl ttssne ; at aa 
enriivr atace Ibo kidnty iH rei^^fjiiiziiblr, its curtical purtton oomprFswd. ita 
ealyoM eidiirged. In interiDedialA sta^M tba kidney in foond hm a cap ntr- 
mounting the disUiidtM} mw. If tbe o1»tn>cli>uu Iw lur«t«d low in the 
uret<-r or io tlie blmldcr or arethm, a rorT(>snnndiiig diatention of the 
tir«l«r i« ohtUH-ve'l, tli« or(;An BO[netim«« fttlnioiug tbe r.-dibr^ of tbp miuU 
iottatiDe. Ttio hydroiK-phrosis is uoi- or bi-latcral acconliup tis tfae ol> 
atniAtioo tnt^ilvoa one nr liotli tirrt«rR. If limiWd to nno aiie. tlie otiter 
ki'.luer w usaally hypertrophic) ; if )>tlat«ml or men exceaaiire on one aide 
only. lij*pcrtropliT of tlio licnrt i» a coininoii feature. 

Th<! umt-T wirffu-o o( tlie nvi is tuwially smooth, thon^h oft^n linM wilh 
uHnaty ingredieiitri nmt aotnetiiufa uWrnti^d. Tbe ijiuintity of fluid may 
amount to thirty (Cirlewicx) or thirty-<^iT | Dunreirhf r) htVes : in a raw 
nienli<>n^d by TtobertH thirty galloDfl of fluid were found post mortem. TIte 
Mlui« of tliu litjuid viLrivs; oometiiiieti it ctiutoioH urinniy udt* in appre- 
ciable (juantity, wliiln at other liinei^ it nppro\imatr« the rliameter of fieram. 
Kehror reports n caac in which Iba aae coiitaiiiQil n considerable quantity of 
KM, suj^mtKHl to bo carbonic arid ; the addition of aretic acid to tbi- eoo- 
tcaU of tho toe muxml tlu* (iirthrr ovolntton of )*»». Thifi eatip is of pnwv 
tical iiitereul, aiuce tho ]>re!Wtitn- of tine gna caused a tympanitic renouaiire 
upon prrcumiou, nn unusiinl feature in casea of kydronepbrtiaiiv which 
Riiflht Uai) to orrorn nf din^oua. 

It is iia|>oitaut for ]mr]io(tf!t of din^Tiosia to note tlie vnrinHona which 
nuir occur in the ehemiem eonipoailion of tho flniil eontaineil in a dis- 
teii<l(-d ronal peb-is. So long a* tbe kidney contimien tn jHrform iln fiinc- 
tiuuH, fiucli fluid will contain chumcteriKtic iiritiary inpi-ilitiilM, ti»]>ceiidly 
im-a, and perhnjiR n.\w> iirie lu-id, imlirain, ercntiniii : choleKtr'niie in tilso a 
frcniinitt iitgnWicnt, After tlie diMorgaiiizntioti of the kidney has reached 
Kiim a tU-^^rco an to iirrcsl the finictiona v( the oi'tran, tlit- clianivtmetui 
iuprciienta of tho iirino may di«ippo-iv (utircly frnm the fluid : indeed, 
the accumuhilion of ratiUTbid ]mKlu<'Is niiiy pwiduire n lliiiil whose eoinpo- 
aitinn nffbnla no clue to ita orijfin. tfcheteliH rejiortM a case fmin ta- 
mnrrli'a clinic, in which tlie fluid withdrawn by agpimtion wnn of t-olloid 
nature, contmning albumen, cholrfilerino, inuoiii. and parnlbiiiin!!], but no 
area, whereupon tlie diaguojiig of oviuiau tuniOTmaiUiide. I'lie ojieration 
revealed hydronephroHiB. 

.Sifmjitrimit. — IJiMteuLion of the pelvis and ureter may cause vorioua 
symptoms ihie to proKmn* iipnn other ortpinH, and may. on the other hand, 
exist without pi-onoii m-pil or dclinili! Kvuiptoimt iif any kind. The featurea 
of llio case must iiatiirallv deupiid iipiiii ilie size of Ibfi tiiniof. and tvpc- 
oially upon the oauee of the ofiHti-uclion Tlie syinploma mo»t fwquruHy 
cnnijdiuncd of arc a etnist- of fiilti(<>>» and pidn in tbv loins and i;rr>in, paiu 
Rrrniiul the neck of tlin blaihbT, enittttant dpHirc lo urinate, nbBtinate con- 
etipntioD, idiortuesa of Jireatii from iaterference with the action of the din- 
phi-aKm, SonK'timcn the paticiit'n iitteiilion is first diieeted lo the region 
of tho kidu«^ by Huddou x^u fuUowtut; violent motion ; euch jiaiu aiay be 



■ 



p 

¥ 



DIdGASKS OF THE KID.VKV. S47 

foIlnwcMl l>y chill, favor, and voiniting. Tliase Bymptoms (iro moat apt to 
occur hi crises of wriTidcrinjf kiilnoy, iu wltich obHtruction ih bikModIj- in- 
duced by u v)i'iti<,'(i ill the po&iUuii of tlio orgau, iti cunod vt audduu dis- 
lodgmont of onlculus. eU;. 

InteriDitteDb chiin(;cit in tbo qiiiuitity and character of tUo urine consU- 
tuta an c»R(uifiiuuat ttymptom uf Lbu L-ouditiou ; a complete olunire of the 
piuiiaUy obstrui-t^-d iirutiT in f»lluwcil by the espiil«uD of clear urine in 
dimiiusticd or ii<>riu:il (luuiitity avconliu;:; to tliv dc^rru of cDinpuiiaatory 
hyp*rtropiiy rtf tii(> ot.hor fcidiipv niid of tjio loftvontrit-lc; n jwirtiiil romoral 
of tlio impi-'iliiiic-iit {imch tisii clifkii^'e in poalUoii at ita obntnuttiti^rali^ulus) 
is followfiil Uy a Hiiculfii ini-Ti-nsn in the quantity of urine mpcUcd. vrhicb 
ia ott^n fioinowhftt turbid. During the temporary oljsti-uetion a tumor 
m»y bccomo ujip^ireiit iti tho ri^^'inii of Ihn kiilii<-y, ur n prtiTioux MWt^lliug 
is (ifridoilly inci-eitHed ; with tbo inc^reiuie iii liie amount of iirliio oxpellcd, 
tJiia awelliuj; subsides. 

TU« uiiiiu itnclf may nflbrd no {HMntivn sympfoms ; eridoDOOB of pyclitta 
— iimcuit. piia. and hlood— arn frnijucutly present, but do not uocesaarilr 
lii(li<Bitu hyibonophroaia, Polyurift, caused by hypertrophy of the left 
heart, 19 a frequeut Bymptom. Tina rardiac hj-])ertrDphy deserves Ua 
more ntt^nlion tii ti «ym]>ti>iu of hviIroiiophroBia thiui it commonly rotwiroa 
II result** fit>iD tln! atrL>pliy of llifi rt-iud ntrui-lurcs ciiiiscil by HOiiipnttiaioH 
by the tumor: ami thia ntmphy is often aggravated by an iirtuol and in- 
depeudeiit reunl iii tliunmritioti. 

AiWr ibo diaU-ulivu liit.-< uttaini-d a cvrttui] size, a tumor 14 purcisivvd 
thron^Ii 1li<: iiliLlDmiiml wall; it may c von be nossiblo to dlfttinguitth tlio 
drntcuili-vl iitvu-r Tlio tumor in fiiod (oxcept 111 Ibe cii«e of a wandcriug 
bicliioy) anil ll('» behind thu «>laii. Flurtuaiion mti^* be ilotucttid. Tliiii 
tumor may maiiitinn for ytmn* the same <liiwni<irtnB, and thon wjddrtdy iii- 
(■i\-nA<> in tdzu widiout iippai-oiil i^rouud. Altcrnutiiif^ en1ui'(^ni«ut otid de- 
creasn of tbe ttimor, thu latter amounting ereti to total disappearance, has 
b<:«tt observed in coiiMcquonco of vnnnttions in the amotiut of obstruction ; 
thuso pb<momoiiu were «d|KK;LuUy proiiouDccd in n out.* of wandoring kid- 
iioy witli hyilronrpbrnRiti, erideiitly in oontiequeDce of variations in the 
■mount of curvnture of tho mobile ureter. 

Various comjiUcations may conceal tho primury nfTeolion ; Hueh lu-o Lho 
refitdtu of adhoMioji of the no to ndjtiRODt orgnnH. Tho formation of tboHi 
bands it iiccouipaaied with aliaip pains and t«nilt'rnea8 upon preaauro ; 
mill the attiiehnieal of tbo me muy displace or compress ucighborint; 
ori{»iia. odiuiik;; disturhauees ivhogo origin it* obticuro. Coniprcsfiion of 
the colon oi-c-jiwioiis olwttiiiate conatipation and nu uc?i:uinulatii>it of tieces ; 
of till- Hlimvu'li. dvsp[!]H)ia. imiiriea, and vomiting ; of llie lun^^ dyi^Doea ; 
uf tlic )ii:4irt. jMlpitution, etc. Uydi'Dnophroiua on the loft sidr.< promM tlio 
apleen and liiuicx upvtitrd, the heart lotvurd tbo median hiiu, tbu Klomatsh 
and Ininircrite colon lownrd tho richt ; if on the ri^dit side Uio tumor din. 
pW^M thn liver npwonl toward the left nud fi-oiit, the tranaverao colon 
dowuwanl, and cRasea the storaacb to aanume a nrarly vrilical poHitioii. 
The adjaneot colon — aaceitclinf; or desponding according to the hiiIc af- 
fuclod — in pushed towiu-d thv mvdiim lino, hut kIUI licui in front of the 
tumor. 

SuppunUion rany take phir!« around the ano. niarkod by chilla fever, 
irre^'iihr Hweala, diarrhtsit, enutciatioD, etc. ; occaaiouiUlv perforutlOD oo- 
uun into the poritouGiiin. the iulesline or other organ, lu ouo Cfwe Dittet 
ubwrvffd Bpootiiiicouit ruptiirv of tbu diatoaded pelviM and of the cone- 
aponding rcuol artery. 



S48 



DISEASES OF TUE UKIX&KY OKUAK8. 



Complete nnarin may ocmir middenly ; in fart, it tam hecn obs^rred as 
the first symptom wliiob aroused auspinon of bydrouc-pLi-oftUc For the 
prodnction of onumt it is not neooiwurj tltitt botli urvtcns biiould be ob- 
iitnict(Hl \ty calculi or otlter irDpfHliiueiit : for r ^mpatlietic KiippretiMon of 
the iiriiuit^ socn-lion in one kidiH-r i-ati occur wii«u tl]« iirvtcr of tbe otber 
Bide iti siuldctily nl>4itnir.teiL. This is a nu^ event, since Utc uml of aetxe- 
fion in ono kidney usually ezeitas the uth«r to iaoreoBBd Mtivilj and hy- 
pertiophy. 

The ctmme an<J tCTtninaticm of liychonep1iio«it twj in diflcrent oasM. 
Ilo most favornblo rrwulta* o«5ciir in tlmno <-nn-4 proiluc-pd br rcn«I taIcuU ; 
in tliowe tin: coucrt-tivn U eometinies wft^iied aud eaca|w». an i-vcut fol- 
lowed "by nn nrroat of tbe renal (tiwirder : or tbe olHtrurtiou may Iwt otHn- 
pl'Cte, Iradui^ to fttrophv of the kiilae^. nnt-tit of oeoi'elioD. nud ultliuute 
BluiTeUins of the mc. If the obstruction to tlio i-snijHt of uritic fontdst in 
n maliwsition of Ibo nt^-niu or n pclvw ititlnmmfttioi), a ivwoviil of tbe cause 
and hence of tlie efli-i-t ia itonieliiiieH rwliicvwl In moat fiiiM^t>, Inm«-vcr, 
the obstruction cannot bo remore<), perhnpn not cren detected ; and a fatal 
result fiDolly cDsuetj either from urfcmin or othtr complication. 

Cncmin, acute vr clirouic, from ntrupbj of thv reuul riulMtmicca or 
fmra BpriouK otrntniction in the urinary eliannpl, is a fr(>({iient orcnntTuw, 
and one which may arise without previous suspicion of the existence of 
bydronqihroaa Tbo orij^ of anclt untmiu. indeed the imlurc of the 
»-(nptomt( proflneoii by it, oft<'n paw* immcogniziyl in Iboup rnitpfi of hy- 
drone pbrosipi i» which tbe obftlnictioii is locaited in tbe lower part of tlio 
urinary ctumnel ; I have examined jMst moi-lem four cases of fatal uiifjnia 
from cancer of tbe iitoni«. where but litilo of tbe rcuni liseuc i^mniued, 
althouf^h no (b:t^idcd ttiinur wan ]M?ri!<-]}tili)e tluMiii^h ihi; iilxluniiiiiil wall ; 
in two of Uieju> ciuiea no Mifipicion of hydronephroicis was cntt^rtntned dur- 
ing life. 

I/uignoKia, — A poisitivo rccof^iiit ion of liydroiiciilirosia is |>ot«ibIc onfy 
vhvn a Hnctiinl.i |]^ tumor in apparent. Wilbonl tiiix Hviujiloin n coiiJmU 
lire can be baaed upon a kuouied^e of the exialenoe of an iuipi'ditm-iit in 
the urinury <5hniinol, cnliruloiis pyeUtia, sharp pains over the kidney, sud- 
den variations in tlio <iiiuiitity of iiriuo. ljra>tnic Kymptoma in cases of 
uterine cancer, or other kiiuwn obflti-uction to the exit of urino, aliould 
nliio direct attention to tiiis possibiUtv. 

After a fiiictiia.tins tumor in developed, there still reniniiis inucb <Iif- 
Gculty iu di3tin;;uir<Liii^ byilroncplu'oiti't from oviiriun cvkI iinti hydatids of 
tlie ki<lnoy. Tbo hitttorv nnd mode of development mny fin'titsb valuable 
information, especially in tbe dietiuction between bydronrpbi-UBJu nnd oir»- 
ritn tumor. Tlio f(n'mer ia first noticed at the upper piiri of the abdomen, 
just under or below the Inst rib ; tliero is nft/'ii a biwtory of iirinnrj- dia- 
ordei-K — bn-umtiiriti, tlio piixKn<^n of pravt-l, renal colio, vtc. ; un ovaritui 
tumor nsndly begin!* in tbe tliiic or inf^rninal retnon ; it ia conminnly amo- 
cialed with aotue diaoider of monftniation ; Ibe utenis in dis]>lft<-ed and 
usually tinmovablc. There ia notbing about a renal tumor which uvcd 
affect tiio litems ; y^t tbiti or^an may exhibit a diBiJlacemEHit and lixaliou 
from imU'jHndont cnn^OH coexiatiiif; with tbo hTdronophroais ; indeed, 
Huch maJpoHition may Iw tbe cause of the jielvic dititenlion. 

The esajninatiou of the tumor itself inny enable one to diatibfnu^h be. 
twcon tbo two oHcrtinnn ; liimori* of the kidney are nsuidly locjiUd beliind, 
VbOK of tbe ovan- in fttmt of the Inrjie int^tttinti ; Uie fonuer urv ax n rule 
fixed, the latter movahle. thoujjh esceptiona occur to till of these p;euerul 
rule*. Exploration through the rectum as practised by Simon baa occa- 



DISEASES OF TUK KIDNHT. 



249 



sionally funiUticd vidiinl)l« iitfomuiUon m lo tlio oiif^in nnd lnontton of n 
tumor. IiillAtioii of the intesline (Wells) or its tlisU'iilioii wilJi wstor (Si- 
moD] liftK Iwen recommended aa aa aid in outlining tlie tuuior bjr {uttjui- 
tion. 

Kxaniinaliun of the RontontH olitnincrl In- lu^pimtioti laay fiimi^li pod- 
iive iofoiiaaiioii ; yet suizli puuctiire bt uot di-vtiid of <laii{;t'r, kiucu tvea 
wlien itiosl ciiii.-fiillv pnrfonufd, it hnn been fdUowf^i b_v local siipiiumtioD 
and ovpn poritonilia— probably iH-oittiBe tlio thin fluid bo TMdily McapoB 
tbrouj;li even a small opBiiiiin. Tin? pnrm-ticti of urcn in conBiderablt* (piiiu- 
tity (.! to .5 per ceutj «ii<l of uric jurid itmy hn (.-onsiilered proof of the 
renal ori^n of tite tumor. eHiieKially if (dliiiinun bo nbaeut or pi-e^jut iu 
very hiihiII quuulity (not lo exceed .1 jierccnt.) ; yet tlic dIkh'ucc uriirinnr)' 
in^ivdinnt.i, and ovcnthe prejwnta nf mrulbiimon nnd coltoiil iniittx^rs does 
not uecoflftHrilT prove i.lio ovitrJun oriffiii of tlie swellui^. The ^i-anular cell 
which Uiys.lale pronoiiuc^cd I'liKnick-ristic of uvnniiu cysts is found also in 
certniii rcntil lutiKira. An abundiuiiw of cyliiidrioal Cfills imlicatcs an ora- 
rifiu timicif, of siiuamons oella a kiydrauepbratiiB ; yet «i«h fi-lU nrti not ul- 
wayH found in conBideinble quantity, and even wlion present do not jiiatify 
a positive diasii'^siii Iii fnct, in Hpife of nil di.iKntistic precnutioni^ tlie 
inotst iskilful niu'^^oonK, iiirliiding billrotb itiiil Esiiuu'cli, Imvti iuLhIuIuid by- 
drnni*pbivi«JH for oTnrinn tnranr. 

Tbere is another meosiu'e vrtiicbmij^ht fkimish means for a poeltive dta> 
tinclioii hutnuL-n hydruutplji'usis and other tluctiiutii];; tuniom in Iht; icuul 
wgion — cat fiotcnxn tion "f the iiretei". Thi^iRiuynt i>rni'tjrtilly iinpouublo 
in the male, tltouj^h turlimfttely the iliflSculty of rei^ojjuiang bydi-onejAro- 
bIr iH lent in males than in fenmltN, in whom contusion with ovnrinn tumoi"a 
msy oociir. TJii> one olijo'.-tion to tho (-luptoymeiit of tliis mnnipnlatiou in 
dtftV-rvutiol diaKUOiu» in tlw dilUculty of itM (-\<srutioti ; Simuu'a uu-tliod in 
utbtiti-tfiwlor}-. nnd (Irltitfeld'.'i reiiiiiresn pra^^tised hiuid ; but I'nwlik k can 
be readily porfortiiod nnd should be einplnyed- 

A diliticirtiuii of tiydroiiophroKtH fnnn rcniil liydatidK hau »<iinrt4mcit been 
nmifi hr n pvevioui* bixtory of cchinopoci-i, by tho dpt'^dion «f a dUttnct 
hyibitid thrill, elc. 'Xlie c-waiio of booklets with the urine in, buwever, the 
only absolute distinctive fcaturu of rcmil ltydnliil<;: the thvill Iins been 
elicited in CMOS of ttmplo hydronepbrosia. Tlie fluid of a liyduliil c}>it 
ordinarily voutaius au vxc«so of c-omiui^u »alt, more tliau in fuaud iu any 
other ttimor oxwpt oncisioiwl coaeH of hydronpiibmsiB. 

Tumors of the Uidney cau itsnnlly be distin^^ui'ihed from those of tho 
lircr by palp'tliuu mid by tiusL'iibach'H method — the tuHiitioa of the »toiu- 
Bch with enrbouii' noid (pw. whei'oby tlw liver in pifiwod forward ngainst 
th« abdominal wall, while the kidney ia covered by the dittteiidej stouiach. 

Trvnlmc/il. — This must vary with thocniuo ; if reniUcalcnUbediacovcrwl 
or 8ii8pect«i], tho treatment should bo nn attempt to i-entore t.li<>ao ; if no 
C3um be apparent, n i^rofiil txaniiiiatiiin of tlii' hnvcr pi)rtiou of the iiiinsry 
tr:vct. and in females, of the nt^nis and [>erimetnti(- tiMHite, nhnuld be niatle ; 
urethral Btrictiire, iiteriae dtHphic'euienl. etc.. shoiiM ha corrected. Gentle 
prc«turc upon bbo tuuior aud alou); the ureter has been thcd ; but siuve 
niptum of thn sac is n poMibility. such manijiulntion must bo porformed 
with extremi-' tfaution if at all. Uc)l>«rlH refers u> n nnn3 in nliioh (he tumor 
WIS " diligently manipulated in ever>- direction with the aid of a Inbricntiug 
ointment on altemat« mominf^a After the third manipulation the patient 
Kuddonly ]MU(iKHltiWg«;(iiuuttity of urine, tmd the tumor forthwith MiLNudod, 
nnd did' Dot ngaia return ho long as the imtient continued under obMrvo- 
Uon." 




UtO 



DISEASES OF TUB CmSABT ORGANA 



Il«peate<I ]>unch]r« of tli€ aa£ bu been pra'!ti8e<l, Bomctimcs with rom- 

S>ii^tii-c Kiicciiw and in ottx^r cn^cs mtli falnl rvsult. In & caee related Ity 
loberts, pifjlit (iimrtR of lluid wrc nitJiiiravru iu Jiiiiiuii'}', 1852, ami three 
ftnO a lialf qunriH in Deoc-inbcr of tli« isaiiie yi^nr ; on Kitcli OL-cmtion it was 
uoticcd Ibut after eoiiic of tlie fluid vaa removed, the remainder flowed 
idou;; tliG urwtt'r. Tbu gmtitaQt reuiain«d we]] for eigbt veare, when tierea '■ 
(|iiui'li( w<T(!n^iiiii ii'uior«;d ; •omo montim Inter rupture of tlKisnc nnd fatal 
pcriliiiiitiei ciiftiieil. The ranee of the hyilmiiephroKift was (oiim.l iu the ar- 
raii;,'<'iiiciit ftf the iin:-t*r, which enterod tho pelvia oldiiim-ly thnmgh ita 
wail. Tliii nnntomipdl ppciilinritj' (which hnn been reptiiltdly olwerved) 
«xpLutte<l the f:tc't that whi'ii the prcKstn'e h:id been relieTvii In- thv remnvai 
of Kiiiii'; of tin; lif^tiid, thu nriniiiiiiiig ci>t)t4:ii(N of till.; stic ciM-iipotl niong the 
luituriU cbaimeL 

VnrionH Burjjicul meiwiires hnvfi nt different times been employed for the 
relief of thin coTnlitioD. with varying defji-eea of buccchs. Puncture aod 
subac(]ueiit iujfi^tiuu of iodino hiivo caused tiic ohl)t«rntiou of the buc but 
arc liable to indut^o dnngcroiiH auppuintinn. Fre« IneiKion had been tnvl« 
into the KtP, followed by druiiinj;« tuid injections of iodine ; the incision 
bsM been luiide usually in the lunilwr region, ocHiaHioiially thmiinb the ab- 
doiiiinnl wall ; K.jnig nisdc the Utter opemtion with double diviaioii of tho 
peritom;um : n year Utter it luiuiitv li^ttilu \riui the only ri'iiiiiaul of the dif- 
ficulty. ThcTB iiHUnlly miiiiiiis n jwrnianont fistula tliroiitrh which urine 
es(!njpce, at leuHl until advanced atrophy of the liidney occura. 

Datil (^i-wilcr cxiMjrifiico with tlicMc op(;r:itioiiB hiis been recorded, ao 
mlM nan hn fonntiliited ; ctich cum^ oall» for thorougli invcstigalion and thfl 
exercise of the greateet diacretiou and cai'o on tlie part of tlie Bur^on. 




Sypbilu vv tue KjDKitr, 

Tlie Hviiliililic taint freqacmtly manifents itself in iiii uffccHon of the 
kidn«y. iJpuu iwstrtiiort^-m cxatniuiitiun therw are found piinmiaUi in dif- 
ferent 8taf'<'n. BometimeH as miliary norlules. which ifisiy ryiulily he mistAkea 
for tubprclci", or na InrRS m* [)ea«, enclosed iu a L-onn«ctivc-tiii»iie capsule. 
Iu lliis )w in otliir urtjaii't ^iiiiiiunia are prone to chiT-sy dcytjncnitioii ; tbo 
ehtiflsy miliisca aro uitinmtt^iy I'fplaced by a deatrieiaJ ti>4iue whereby Hio 
kidiiev in deformed and often diWded into lobes such as are seen in the f<^ 
tal kuhiey. IImh lobulation of »j*pbihtic oriciii cau be diKtiii^iished 
from Ihdt which ocours as a nenriirtenco of foitiil funnntion by tin; fullow- 
inj; fi-aliu-cfl : in tliu fonuti- Uic lubulua are irret,'ular, tlie lines of demajx:»- 
tion nomimaed of deatrieial tiRiinii, to whidi the (usually thickeiiGd) dipsiUe 
is adherent ; in the fcelal kiduey the capsule extends over but docs not dip 
into tbo sulci between tlio lubnics. 

Uuminata of the kidney nro multiple mid nro not roeogniaible daring life. 

Syphilis ia reH]Ki»ruliie for caws of Brigbt's disease, both the duviuo 
poTGncbyninlona and interstitial ; and there is reason for Ijelieving that nn 
acuto nepluritis frequently I'esults from the same canse. Syphilitic iKipiiri- 
tis prosfiits no clmmctcrlHlicH whtrciby it can bedi»tiD(,'uished from indam- 
mittion due to othrr oaiwpa ; tho diayiioais must rest upon the existeuce of 
the specific infectioii in the iudividunl and noon the effects of tspcL'ific 
n'mcdius. The oc;currcncc' of nephritis iu a eubjcct of syphiliA should bo 
MSmderod an indication for the omp1o>iiinit of tho iodide of potassitim 
and of niereui-iolit iii tiuiall doses ; it r«Ddei's more favorable the j^ot^gaoais 
of the disease. 



DISEASES OF TIEK KinSET. 



2r»i 



Renal inflUDmaUoii nisy ori>;iiml(> hi cDtii^oiiiUl tut \vt<\l m in acr|iiirocl 



TcmmoDLOKs or -nc Kiukrv. 

TtiberculoBii* occiini in Ut© kitiuey in connection eitber wiUi (jeneral 
tuberuulunin or with tbo Kuuo aStiutiou iu oUiur of lliv ({(^uilouiinitrj or> 
caDK ; in tlie foi'nier vu»o Uie LiiburcIeM nrt) ilisKoiiiiantoJ, in tliu liitlor loual- 
lEeil. 

A» «u iicoompanimeiit of geneml miliary tiibtirfiiilosifl and ofpiilnioiiarj 
consuiuption, railian,* tubercles ar« formed in tbe kiJuy^v. They nro In. 
cated L-bie% in tbe cortv\, nn'l ili-c oftvu lUTBDgcil in ri^ws pNrnlk-1 witb 
the coune of thu stnii^ht ttrleries. The gra; aiWr rt-tukin* t!ieiH< tubt<rcl»i 
oasily (liscortimblv win.'ii tiiov iLre tooated direolly uiidci' the (-.-ipHiib' of th« 
orgnu ; upon aectioii ihev are leae readily <.Usliuji;ui»heil iji tlio nulmtauco 
o( the IciUncy, flApecitiUy if tliw oivjaii bw umeaiir. AhRi'sjihI ioii-s of millai'y 
tubercles into ma«6es im largo tu jioiLx arc found in tbo kidney aa in other 
orguui) : thcKd miiy umlur;^ uhet-Hy dej;euenvtioii. 

Such tubiT''ulo.4i» itf the kidney ia i»o»t fi-oqii<-nt in rhiltlhoivl. Clini- 
cally It iii a ni&tter of little moment, ainee it can be but rarely recojjiilzed 
before death, nnd Iben only by the aHHocintioii of aii obscuiie reuiil affection 
with pronounced tiiborciilt"*!* of other orgmw. Aciwrding to ItosoDstciD, 
uiurui in » fr(.-quuiit nvinptuni of ivmil tubi-iviilodia iu cliildrcu. 

I'rinm.ri/ ri-iuil ttilierculuyi^x Ih rarely IliDilcd to tbe kiilnoy, but usually 
involves other portions of the urinarj- and pnrts of the geuitjil tmct ; in- 
deed, it HL'i-1119 prubiiblu Ihiit tUu tubcri'iilotiis liii.t uftL-n bo^mi in Ibc bliul- 
der, thfl flpididyiiiiM, or tho proxtnti?, and ha» HubiteiiiiciiUy exU>ndfd t4 Uie 
kidney. 

Iu iiLiny cnsoH tubl^rculoltia iti found in other lut ncU an ttic genitt^ 
urinary orf^iuit ; yvt inM-ainvti aic not raiv in wliii.>ii iho <li«fTaj(6 i« cuiitiiiecl 
to the uriuitry tract, having nppareutly ori^anntitd in ft tuberculnjr, ncrofi;- 
lous, or idiujijy pitnileut atiectiou ai xuuie point iu thin tract or iu tJie ver- 
tebral cohinin. 

Mori/id Anatomy.— Primary tuberculosis usmnlly airi'4;t» one kidney, 
moro frc^ttAiiUy tim ri;{bt (Ueukel) ; tba otiier may be i)ei'fe4!tly liealUiy or 
tile scat of chronic ind:uuiui(lion ; in one cane the second kidney was trau»- 
(onned into ii niciUiUiiry rAUCvr (ftosru^ttvin). 

In tho i(i<ln<(y ittelf thero is ohaprvnd n ditTutm inflammation with the 
oggresalion of tnbei-cles into masHPs of varying sine ; a lai''^e part or cveu 
tlie entire organ miiy be li-au)tforined into » clieetiy m:\£i*. At a Inter ntafte 
this clioe^ mnteriid brenkit down ami is expelled u-itli tbo urine, leaving 
ooTitica iu viu'iouk porlioua of the orj^an ; noiuvlinics thu eiitiru Uidocy ih 
tnuutformeil into a hhk cjintnining luinpn of cliprity nintrriaL Tito process 
usually beRiiis in and progreaaas from the papillee. The inereaae in aisM 
of the or^au tiiuy be oxiremu ; Kl«^ba dLiscribea a oute in which the right 
kidney wiw eloven ioehei Io:ig and weighed seTenty otmcoB (instoad of 
fire). 

Tbe pelna of the kidnev is dilated and filled with cheesy miuaes whlob 
oecluilv the nreteiit and tlitie fitvor the development of hy>lronephroaiii 
Uloemlioii of tbo niucou^i inenibi^nnc of the pclviu and the formation of 
fietuloUH openingH into tlio Bun-onndlng ti»f)Uo in a frnqiient occunvuce, 
•onutiiDOa prodiiciuj^ pefincphritis, sbsceaa, or perltoniUs. 

Similar ealargcuicuL uud clicevyidegeuentliuu arv found iu the uxeten^ 



2&9 



maEAsn or tsk msABT ouaisa. 



Um pnvtaK tbs MiBiaal 



tb*' 



itttaaitim, ndibtefUidjtKti 



tlw tnoeoiM owtnbmM of the lihddtr i* frw|Watly skcnted Tbe fit. 



' sileiiilA to U>e Mtutal < 



Seat &H]iMOtly in tbe fcnwls tluo in tlie 



i 



_ oT^nu Mat irwjiMOtiy la tbe [onus uuo in 

nile. 

8<itnetiiii/-« lh» priiiMiT' lenoo k cshM ^tubetealooB) of the Tcrtsbrae : 
or lulirrcruluMa ut Um h i t wl ip al caml, of ilw pentooeum, asd Oif llie 
omim is aino pnm at In naojr jpittiirw uOmtt tobereulosiB ol ratioug 
otjpum aiitl |ntlnioiia>7 oomumptios are foatul 

Tiip fitimaaj of priuuy gentto-arinary tuberculottia is br no mctuis 
dew. Hemlilaiy [nllaeiiee weents to be a factor of iiupnrlant'c iii tulwt^ 
enkiua diiwM* of t ti — f aa uf other otgana. Previmu iudjiiDmatioD of the 
gmttAl otintw aeema to be a iiretltqiosiii^ motnent ; tlie diamse is fonud 
tocMt fn^jueiitly in nuilea atui iluriu^ the pcriml of ncxiial luitivity. Nearljr 
■U nac clwwrvrtl luire been b^ween ttie l^,'e6 of HiUvn iukI fortv-five 
jaua, tlionab in mre ttuftaaoaa it baa hevv se(>n as i-arly a« in tiie Uiinl 
nod Ml la(« Ml tbci aeventipJIi j'^w. Tho patient's hi>>toT;,- u^unUy includes 
A proniriia chronic gouon-h>i:n, cJirouic c,iiDtiti», or «-{fiili<)yiuiliH. In naanj 
OMM tho ivlvnueed atng* of tie prooeM* id the 'pro&tate, aemiiMl T«^d«b 
or ept<ti<lyiuifi ti»ilioal«s that tbe lobercnloHiB begoo iu ibeae parte and sulv 
Bequcutly appcnr^d in tbe kidney. lutt^rvcrmn;; porlboH of die uriiiary 
Inwt — llift ureU>r or tbft bUultU-r, for «TtanipVi — may bo ontircly fif^ from 
tb« nflWtiun wbiub lias a{^t«arcil botb below aiul above. Tuberculoifid of 
UiK kiduey and of tbe gGUitid otfrons in obsen'ed far less fretjuenLly in !&■ 
tiiaJ^'if tbuii ill iiiiiles. 

liyiHfUtrM. — 80 long aa the kidney contxdna only miliar}' and Bubniiliajy 
tubervint tbo ronoKiiition of tlio nlT(^(>tian is iinposittibtc. tlirm^b CDiiWtiire 
l<i (bnt effeirt iiinY be baaed upon tbe exiuteuee of tuberculosis in otJier or- 
(nuin mprrinlly io tlio iteo ilo-uriiiani' tnict. At a. IuUt {jeriud. nbcii pus 
ntid cbttdHV ■niU'K'H nm formt'd uikI McjicU'd with th& nrine. Iiihcrc^idotda o( 
pilht-r tbe kidnt'v or tbe Ijlmbler probubh esiBts. TLe dilTereutial diagno* 
HiH )»c'tne(>n tbe two is often dJfbcult ; for tulH-rcnlotdN of Ibe kiduoy and 
itit pelviH often pio(lnr*« tlie miinitoms of cyHliliB— (ivqiicnt and painful 
uriniition, iiniiiioiiiricid imd pundent urine; Hie exieteuce of tbetre Hynp- 
totii* riopH not tliei-eforp wni'i-ant n dinguosbi of oy&titia III otiier caaeti tlio 
Hymptonis jKiiiit lo tlie kidney na the tieat of tliseHee ; thr patient experi- 
encPH I'xtri-iue piiiu in ibo rcuid ro^ioii, often i>aro3:yhniri1 ; the puia may 
eideiid nloii^; Ibo iivrttor mid to thn nock nf tlie bladder, or may rnillate 
towaiil tlic navel and dowii tlie thigh ; iomefinies there is numbness of the 
lower L'llremily. (>n the otiier band. tiibenTuloHia of the kidney may ntlain 
nil ndvanceil ninao uitbont cnn«ini; any pnin in the reRinn of the organ. 
Aftrr a time n liiiiior may bfconit- jteiwi'tible, due in part to increase in 
ttic nu> iif the kidu«y iL-u'lf, ninl in part to [)i>itenlioii uf the pelvis by the 
nritiu in rutmeijueuce of ubetriiction of tbe iit'clerK by rheftt^' masa c a ; tha 
pxnnliinu nf xuch ntdHSL-a with tlie iiriiii: iiuiy produce reunl colic, and be 
rulldwed by n rttilwrtioii in the size of the renal tunior. In a few rases an 
iiilorni)M<>nt Liinioc bna been ol>»crved : itn appenmiieo in acoompnnied nitb 
severe juiiti. while tbe ui'ino bcconiL'S uiiuauiilly dear and scanty ; after 0. 
time the pain suddenly owwoip, Uie tumor disappears, and tliP urine becomes 
niorv profuHO and tuibid as before. Such pncDomena are caused by tbe 
n>penti*d pliigginjt of the ureter by t'licesy niansii's and fra^rmonta of tis8ii«, 
with oonneqiient liydronepbrosiM. F!tchhor«t obserred for two yeant con- 
liiiDoiiHly u pativnt who exhibited such plivnonieaa o^xry two or three 
w«ukH. 

Tbe urine is nsuallj^ acid and of uoriual ijuautity and q>ecLfic grari^ ; 



DISEASES OF THK KJDNKT. 



253 



I 



erpn sftcr a conBideraUe portion of one kwlney biw been obliteraUd Ly lite 
tiiberciiloiw pniccas, tlic quiuility at Uiu uriiio miiy n:iniuti noriual from tbo 
Ticarious uiciTano of artivily of tlio otiiflr Idiliiry. Jf l>oth orgaiiH are nf- 
feutoi), Uit> ({Uiuitity ot ui-iue ia gmiluuUy dimiiiUbai], au J unemis may ulti- 
mately ocpur. 

The ui-ine oontains pue, &nA in mauy cases minate cheeay massM u 
large ns n pin':* licrul (--aii I)« iHseovfreJ in t\n> mnUuivnl. Thi-Jto nuMM* 
uJToril 8tmii<; Hux|iicioii o( tulierculotiiii in tlin kiduey and On \»\\i», ihough 
tlii^y I'Aii pi-oveeii from the same affection in the proatato or ue<jc of tlia 
blaiMer. 

Since Knell's (IiBCflviiry of tlu' biioillim of IniiercuIoKis Aiul its uoiistiint 
ivssoriatitni witii tulifivuluun It^HJiuiH !u ull or^iiu-i, tlii^ uri^uuisiu liiut Im.-'VIi 
soii^iit in tliR iirimiiy nivilinient from ca»e« of HUHtiecled renal tubemilntiis. 
Jjialeiv cases the bncillus Iiiia been detected (Itoeeitsteiu. Oornil, Ijclit- 
'|i|||^Bal><:^), niiil M'-ctiiin Itas niibsiKpieiidy n^vcidcHl tlio lUHrurocy uf the 
(ItflSWWU. While tilt! prpneiice of tJii» iMnteriiini is cj^rtaiiily positive «vi> 
tleuoo uf tha eusteuco of LuberculouH iiiti«iuniati ou at nome poiut of Hie 

^ urinary truct, tlio tuluro tu diitcvvcr it docH uol prove the nbaencv of sucli 
clianKca. 
If tli<! bltiiKlcr in aJao iuvolveiL d^s-eiiria becomeu a, protuiiieni Kyinptom. 
ThA urino may rciuniu ot-id for u coumilvniblo time, but liniilly becnmfB 
ijiqpk^uac'tiL OL-fjuiuiiiUly tlio urotlim ix ubittnicttji) by a tr:i({iiieiit of lis- 
(M^eniisiii^ rt!t<iiitioii. It i.t to hn retuembei-etl tliat thciur Kvni]it(itnfi of 
TPitical iiritiition may bo present without purtiripatifin of the bln<lili-r in tlie 
tubcri.-tiloiM proL*e)W. In tmuiy iuiitaucos kiilucy and bladder both exhibit 
twbomilous Jf-niiitiK 

IDi4fjnoiiix. — Tli« ilini^nidK of tubaiTuIor dixAa-sfl in the geuito-unnnr; 
Imttt is* botmilupoti the presence of pu« audcbee£^{)nrticle«intkoa«dimc^t ; 
tlio (lalcctiou uf tiibordo bacilli iu thv huiuv ; the Hyuiptouis uf (Icr.iii}^ 
meat of tho kiduvy or bliuldoi'-, noiluliir tlitckrnin^ in tho opidiilyiiiin, 
i>rrt!»t(tlc, or si-mirinl vuHiele ; the e&iiitcuco of tuberculoma in other organ*. 
In the absence of ppiceutiblo clian^'s in tlio«o piirlo of tho peiiito-iirinary 
tract aocessible to tho linger, nnd of iha tuborelo bacilli, tuberculosis of 
I tiuntv oi-giuis ctiu 1)0 lit iiioHt Hu.tpo(-tei1. 

^K In certiiiii ciiiieK intnrinittont Ini^niaturift BMOCinted with oi^cnsional dull 

^^L pain in the loins Itave beeu the only nymptoiUfl observed ; if occoio^iouied 
^K'fe hcolic, ui;;ht-awual)i, oiaaciatiuu, otc, ix suMpiciou of rvmU tubcrculoaa 
^KnOuUI bo Hiitcrr-iiinctL Konij^H olMnrmlJon!) show tlmt tiiK>n>ii1oKiH o( tlio 
arinory triw-t ut ttitmt'LimeH fouud iu individuals with oLrunic (lubHtYtidoiui) 
1 inflaminatinn of viuii>im joiuta Tho exifltance of such " iiito])athic * syno- 
ds vitis tilioulil therefore be tcikeii into considenitiou in (letermioing the nature 
^m of nn olwcun; urtntu'y iM>iiiplniut in Hiirh pAtinntx. Tiiborvuliiin'4 of Uio 
H urinary ti"act, like the sanifi nlTection of the luii«a, vt Imm tjniibie»toine in 
^M wnrtn than in cold woAther, and in a dry and unifoi-m thau iu a iiiciiat aud 
^P cliai);{vabli? cli^aItll■ — a fact of dia;{nostio iiuporlnnce, 

^M It in oft«ii difficullor itnpoMMiblc to deterrniiio the liKiality aDtllimitatinn 

^B of the tuberculouH pitHTitSM in thb urinary Inu't : ilm Kymptoms and oricnry 

~ AppcMminoea rony bn extromidy Hiinilur, whethertlie inllaniinatioti Ih; loralized 

in tlie bladder or the kiducyii. The kidney iti, however, far more fre^pmntly 

ofleot^il than lli« tiloiblcr ; hriictr tlit^ nvM^niiiini of l.i)borciilod!i in the urin- 

k my tmctairordHnHtmniK presumption thai Llie kidney im aOt'ctttd, even tliouj-U 
tlioro be do poMlive Hymptoiuti referable to thi^ orijnu. 
Tubcrculmrit of tli« kidnvr mu.tt be cartrfuUy diiitiuKuisbed in childhood 
from tlie lualigiuutt growtlia and from litiuajtL» ; the latter oouditiou ufteu 




S54 



DISEASES OP TUG VRiyAft? OROAFfS. 



indcMl flooxiHta during r>ar\y life In lulalt^ in whom ron/il cnncer ia rare, 
calculi of iho kidney or of th« bladder may be tuifltaken for tlie tuberculotu 
procewt. 

I'raipiMiiK — Th'; disense i* iuciambU- and iilwiiys t«ii(ls to n Catal termi* 
nation, wiiirh is iiiiually liiistened by tuberciUows of otlior or^^iiH. Thia 
leniiinalioti niny. liowever, be deferred many years; cmes am knovm io 
vrliiob the urinary tmet only vas tbc »cnt of tuberi;ulouB disease, for t«li, 
fifteen, nnd nvcii si'Vfii1<;tu years. Si> lon^,' iis tiie disi-ruu: iti oonfined to ihe* 
in-inary and prnitjd m-srsinit, ila pWK'**-'' i* uMiiidly slow ; yet a fatal re^iult 
limy occur siuldeuly from coiuidiwiliwis nucli »» pvrituuili^ uniuiiu, or 
BPi^oiKliiry gnnenil luilim-y tiiberi-uIosiB, The awruge duration i» cooRtdorcd j 
about one year, 

2Virrti/H(»-T[^^Rem(dif8 nre jiowcrless to affect tlic course of tJic dis 
nnd are nseful only in mil iKntind the itymploiiis. The treatment roquit 
for Bupporliug the patieiifa sti-eugth is essentially that employed iu cm 
afpiUmonnrytuberculosJK— tunica, qnijiiue, iron, and cod-liver oil. TuIwPi^ 
tlusia of the uritiiiry tntct, liko tlio eamo tiffection of the hiri<;6. ia oh a rule 
' tnucli \*:iHi troubk'st>[iiu in warm timii iu cold weather, aud is <^^<|uidly bt^ue-j 
iili'il by rcsidemio in a w.inii, dry, and untfomi climate. This iiLlltiotK-e ofl 
ottnospheric surround ilia's upon the course of the disease eonatiiiatea un 
important itvui in dinf^ioh-is (iu the early HtogtH) and iiJ [Hot;i»oais ; for the 
ini|»rnTenieiit witne«>(ud upon the return of warm wentlior aflcT the oolcl of 
vintiT may decdivi; the paticut and evtsu the physii-ian into the belief that 
recovery hns occurred. 

In tiuhject« who exhibit a scTOfidous or tubercvilotta tendency, pro* 
pliylnxiH lit cxtrc^mcly iiupoi'tiint ; chrmiiiT mipiiunttiun iu the urinary 1r 
— gliwt, cvHtitis, fltf.— may liecome a: focus o? tuberculouii inllanimatioQ,' 
oud should bence be arrested at once. 



CucBa OP THE Kjdxbt. 

OftRCOT rtf the kidney, liko that of other Ol^nn, nwiy be primary or 
seoondorv. Primary tantJt-r OL-cma almost excluaivi-ly in ftaily (ihiUllmod 
and in aJvanced yean*; several caae« are recorded in which it existed at 
birth jAVcigert, Kuhn). nnd some others wh^re it was cbscovered dui'iug 
thu tiiKt three uiouttm of li[«. 

This fretineiicy of pander of thn kidney in early life is quite remarkable, 
unoe the tlisooHe rarely oceiirs in other or^aiiH during cliiUlliond. Thfti 
fact ocuordM witli Cobuheiur» hypothcBi« on to Iho ori;;in of cancer — ita' 
rise from tlio pendatetico of fa'tiil nbermtioim ; for the kidneye, as is well 
Ituonii, lii^j-iii ihfir function eurly in fiutal life and are eNjHH^lly {iruiiu io . 
exhibit a pei-sistenre of embrj'onic i>eruliaritips. .imong twenty-nine case ' 
of eaaeer in varioua organs during childUood reported by Hirschsprung, ' 
fifty-two per cent, were cancer of the kidney ; of tliwi<; Uiirly p'^r cunt, were 
developed duriun tlie firxt five years of life, and tiie reniaimler nronoiis to 
thii tiiuth ypur. In luiother respout. too, cancer of the kidney diffei-s from 
oaiici^r ia peneral, namely, that it is found with far grcaler frei)uoncr in 
inalcntlian in femiUea "this diAcrcneo is lesB apparent iu ehtldhuod tbau 
ill ndnlt life. 

Jx'ctmdfij'y eanrier of tlie kidney may follow carcinoma of Tarious oivl 
gans, 1ml i« un especially b-etpient sequel Io cancer of the tentia. 

Cei'tttin other liinmrs of tlie kidn«-y are iiainilly incliKlin^tiishablc fr 
cancer, and if r»cx)^uzei] at all during life ore deNignat«d by tliis lumai] 




UISRASES OF TIIS KID:r£T. 



25d 



^^Wnvmost lUDonfc tlino 'm BorcomA, wbicti occum nsuilly ft» n mctostalio 
growth and thercforo in both kidtwjys. Pi-inmry sareoma nl tin? kidney ia 
cxir<;iiidy rare ; Kocli bfts recently lepoitt-^i one iu the light kidneT of a 
woman fiftj-livo yniim of uj;'c Slvosui-ctnim him iUmo bct-u DbstTTca lis u 
priiBarv fiffcrlion, MytMarL-oma contninin^ sti-int<«l miiritlo i\hrv» )in« Iw'cn 
(loKuiilxil li_¥ C<jliiilieiui, Marclionil, ami citlii-m »w circurriuy in cliilJren 
(luriiij; llie first fiTe vp-ars of liftt. A'leiioiiia of tUe kidney is according to 
Hturiu not a mro itfloi^tioti, thi^Uftli it is uhually rojjarcleJ as cancer. "Fi- 
broms has been rep iitcdly ob&crvcd aa HmalUnrciiuiscribt-d nodtilcH in tho 
meduLl'iry ji«i-ti<jii ; Wilka (kwribeil n caso in whirli t]io entire right kid- 
noy wiui trHUHfoi'iiiod iiiUi n libi-oun tuuuir, iJio auto]My occurring; ten yeara 
aft«r the [mliautt a woman fifty-tliree youi-a ohl, hail cxiiericncwi pain owr 
the kidney and bud bad biuiiiutui'iii. Lyitiph.'(iiy:ioinn. (ravonioniii, nivsnina, 
li|i(]iiiii, mid ^miiiii hnu: all hixn olNtervod j>uHl-mort«m in tbe kiilnoy, 
but arc rar^'Iy detected diirini; life. 

The kiduey fiirDisihes lesia tima one per cent, of all cancers. Iteiial 
cancer in o(t4.'ii iiKHiii'iutcd, vxjx^riidly in cliildrfn, \Titli c-ali-uli in llio pi-lvia ; 
[wobtibly oitluT f:iv«ii-H tbo dcvelopinout of tbo other; inorlucl bldod-elots 
niul fra^rn><!i>l>4 of tissue acive as uuclei for concretious, irbile cidouli may 

IK by Uicir irritation further Uio (Icvelopnieiit of coiiccr. 

V if'jHnd Aii'it'inn/. — Thwo vary (ircordiiig' tm tho cnriepr ia prinwty or 
WM-oiulary : primary cuiieer is found as a rul<' in oiio kidii*y 'luly, iiiciiit 
freipienllv the rijrht, aiid ncxiirs ns a OifTiiHe infdtnition ; Bccoiidai'y r;ancer, 
on the otiier bund, is usually found in both kiJnej'a anil ns drmimHcnbeii 
noduloB. 

Id rnoitt rasPH of priniaryemir-er Mtwoially tli« kidney is iniicli enlargetl, 
ofleii attaitiiiiK four or five (itues ita nornuU aize and coiistitiitin'* a tumor 
whieb Biay occupy n lart^c portion of tbe pcritoccul epocv. Iu two asuaoe, 

kntic rti])orted by llobertR, the other by Van Den By], tbo growtli weighed 
ovw thirty pounds. 

Ulio Hvirfacc in usually nneren and nodular. Tpon section there ia 
often found a considcmblo rcmunnt of uormjxl rcnril lis;4iie, sharply do- 
linod from (lie caiii^erous muss ^vhiI^h coitstitiit'--« thii remainder of tlio 
organ. The cortes ia chierty. fiomctinnes solely, aflWted. The color ajid 
con»iHleuce of tlio tumor vdry with its etruct are, Uting euuietinics soft and 
ciioopbiUuid, luid at other tiuiCM of ULusuid hurdiK-Kfii The tumor in ox- 
troniely vuttciilar and oftrii e\)iibita estravaiiationa of blood iii it* ntb* 
stanoe and in tbe porinepliritic tisstie ; cavities contaiuiug a dark brown 
fluid luii; disL-o^x-ivd iu the iuteriur of the luana. 

In ooimoiiiiii'iw'e of the sizo of thn tumor, di»placoinont« of ollior abdom- 
iaii orjTima oae fretjueully observed ; apleen, Uvti*, and stouiooh sufibr 
especially in tbis way ; MiuietinicK ))roBHuro of the mass upon the duo- 
dAHiitn lias ooeaaoned dilatation of tlio Atomneh. 

Tlu: nuiccr in often found to luive oxbcnded into adjiiocnt KtnicliirfTii, 
Mptwially the ])elviH and ureter and tlie i-eiud vein. It luay lujipeii tliat 
IMtrticlea of Ibe tumor have obstructed the ureter and thus led to hydro< 
n^broxix. £xt«nsiou of the (^owth into the i%iitd vein luid even the a»- 
cotidin^ TTua cnva. hnn been obnervr-d ; inipl ie.it ion of tho iliae vein by 
continuity bns idso been noted. The Iyiiipli-};lau<U in tht> vii-inity of the 
kidney are usually enUir^'cd wid cancennis. Their enlai'gcnient to(telber 

^ with tbit of the (iineiUMtd organ itiwif may rriult in conipre^ion of vowtela 

H and nerreri uritli coiise(|uuut imiiairuient of fniiutiuu of Uio loivttr «xtr(.-nii' 

H liea — neamlgia. parnlms, aln>phy, cKdeioa, eto. 

H Tbe otber kidney is often of normal appearance except for a slight 



S96 



OP rilS CltlXAKY OnOANS. 



eulargsta^nt ; yet !t fr«i|UL>uUr exliibits some uLiiormiUtty other tluUcI 
mnt-er. Tliutt vlirouiu iii'itbritut, luu^l(.>i(] (Ifgi^iU'iiilioii, oxtraviuntiofis of 
blood in t)i€ ivital &ut»itaiioo unl in tlie jieliifl Imvo lieen uotfid ; in odo 
ciue reporteU hy I>a(lt luid BtMensl^in there waa obaerviicl laednll&i^ can- 
cor of »n« liidiuiy tuiil IuIhtcilIcuum of tlio ottirr. 

3r«tiLsUk.^«H fmui {irliiiary cancer of tlie Iciiliicy ub nut fr«(iu«ut oud are 
(oiuid ckiedyin lite Iun){(i. Coiicer uf lite tentia isoft«u louud, Uiou^U Uia 
1171111117 cbaanclij cwape entirely, 

Syntptonu. — Suuuuitui^ CAQcer of tlte ludiiey lunially rvmuuifi uudJH- 
eow^red (liuiDg lift-. Mmiy ciuma of prinury coniHtr iUho fxlitbit iiu ftyup- 
touiB Upon whicii a poNitive liin^ofliH can be based. 

The cardiual sytuptoms in a typimd case ore tumor, eacheiria. faia, Aumia* 
luria. Ono or luoro of tli'-«o w often alitwut, Uui Knelling taid. cachoxia 
l)eini? Uin niottt constant Minptuois. 

lu L-liiKlrou the tumor uftcu ottaias on ^normoua t>izc<, the ttnolli-ii 
Bbdoincn imvei-sc-J by lai-j;« cutaneous vt-ins eontrimliu^ eliarply witli tbe 
f mil L-i:!i It'll utiil bliMMlWs ii|)])eiiranc-e of tlid rtnuuLiidfir of die body. lu 
udultn tluTo in frci];iiriilly no tnicu of n tuintir. 

IVetBttii'Q and ilLtploi-emeiit of other orpina by the renal eiilarc^«incnt 
oc^rOHioti BViiiptonm which may ininlcad the physician by din>c>tiui; hU 
uttrotion In Hiiptiosed dpi-angcmcnts of Um nliiiwiiUiry nuial. Umrt and 
luLi^% itUiiiiach. livvi-, hjilvcij, ami iiitc^liiicA mny hv forced inlo abtiomu 
poMitiouK. hi aliiiiuly described lu <li>L'wniit;' hydrouepbiMois. MoUir au 
Benson,- i:b&turl>aji<.x« of tbe lo^er cxtrcinity may bo proniincnt and for a 
]uug liiuo uluiuKt tho solo sjiuptuuiK ; tlii'y aro caused i-illicr hy Kiniiilfl 
iMiiipn-Hwon of iirnrM or hy octiiid iiivuHiuu of thu vt.'rtt'bnd c<duiiiH lutd 
the epiiial cord by the iaaUj,-iiant growth. Tbe cancer may ext«iid into, 
these BlrucliireH without ]«\xIucinK an euliWRfnieut diatinutly pi'rceptihlfl ' 
Ihrouffh the ahdoiniDid ■wiiUi*. jViuong Ui« ityiiiiittxiiB thiiM pn*ihic«d nr< 
neunilj^iiut of the Inwer iiiterL-osrlal nerves, of the iliii-himlwir rej^oiu of tlid 
hip-ioiiit and IbiKh— RubjectiiiR the patient to futile trcutmetit for riieu* 
nintixm, fjcialicA, aud neurtilgia ; pnin, itching, miiubucax luid parosifl C^t 
the low(-r extremity are aUo esjierit^ucod. Such syuipluina should direcl 
allunlioiL tu tiif: kidney lu tiie jiusaiblu wjifc of luidi^nnut diaeos^ Of^eiually 
if tbe pntiout be le&tt ttmu live or niore tli:ui eisty y^ivn of a^e. 

I'pdU cartful eiiuuinatiou it imiy be |ic»>ibk> lu detect na culari^inoiit 
of Mn! liidiipy, lumHlly srnsilivo to prrawuro. It, lies im n ruli- In-hiitil Ibu 
tiilwii, %vbi:h in o(t4'ii diitteiided witii t;iis iiml displiiied HOiuewbat toward 
the niGilian line. Light iieirtiiBflion iimy Rive only tho Ijinpanitic 
nnocc of tho iiitoHtine, while deep porcHsi-iou rcvcalH the diduewi of Ui« wn- 
derlyiti-; tiiiiiur. Thia hitti-i' ifi (jeiifijilly hard, uutvuii, perhiijw pif-sentiug 
docidird iiiiiluli-i( upitii itx fiiirfiu'f!, ruid iif Uitiit diHtiiigiii.sbcd fri)iu bydrouft. 
pbrosia; yet Iluctiialion can ofteu he felt in apota in coii8i;->iueuce of tbe 
eollectiun of liiiuid in the (mntieii alreaiiy meutiuDcd ; iudewl. aetiud 
liydi-oiirphniKis is a not iufi-otiiieHt coiiiplipalion whereby the phytucjil 
characUrg of the n«opla»m ari^ ohni'urcd, A iiiiili4,'n(iiit tiiiuor in generally 
seiisitive to preosiirc ; it may exhibit Klij^ht pulnntiuu BU^geBliug an au- 
«iirii«ni, nuiI vascular uiurmurs are ooiiictiineH heard, 

Cochexiii in u pnunintuit and, in ehildrcu, an early ayniptotn. ag^wi'atKtl 
hv pnin and HicGplCBsucw, gwtiic and intmtinal derangomentii, and loas of 
hlixKl. 

The pain is by no nioiuiB constant-nor when preKent nontiuuoua. lu 
BDiiin few cnsi'if it. is iicvir ivfoiTcd to the region "f tin- kidney, hut Li fttlt 
iu the groiu aud the tlil({h ; iu other iiutauces attacks of reuol doUc octror. 



DISRASKH OF THE KIDNET. 



&57 



cbuspl! by obstruction to the ©saipa ot urine by bloo(l.<rlotfl and porficles 

1 [»niaturia i» tm importAiit tuitX frequent, tbou^^b by no uieaua coiiatant, 
tiymptuiu ot n^nuJ t-auctr. It mny occur with or witlioat pain, unil ia 
iH>in(ttimeH noticuil for tho liixt tiiuo iLft«r n blow or otlidr injury to tlio 
biick. Tlie bleedin-; is uut cuustiuit; it may cvasb for ilayn or wi-t-ka auci 
again appear nithout provocation or without pnin. Such liii>mn.turin indi- 
cnt«a as a mle n morbid growth in either the Kidney or the bladder. The 
([iiUDtity of tha blooil may be so slight au to be discTOverable only with the 
mioroncnpc, or bo profiiso iw to occasion nuich ulnitn. Blood-cloU ai-e 
HometuutD p:kssed ; tlietfe inny bu Hlinpcd like quills tuid tiiua indiL-nUi tliat 
tho hemon'bagfl has oraniTed aliovo Ihp uretnrs. itapid pnlnrpnment of 
Iha iumor umy be observed in ooseeijueDce of occluaton of the ureteTB 
by these cK>ts : siu'h ubHtruction in uL'compiuiicd by colicky painH nnd 
oliguria. In mre incilnncr-ti fatal liRmorrhr^fo. from tho renal gmirtli has 
i>ccnrred. 

In a few cn»»i thiTC have boon found, eutiu){;1i*d in the blocxi-clots in 
tlio (inno, pfirtii'lcs of tiK«iio vrliii-li rcn^id wpon niirrosciopic examination 
the cancerous nature of tho ^ro»th. Extreme cAutJou must be exercised 
in RHserting tho canceroiiB origin of indimlual atypical cells which may bo 
found in Ibo nrino; for the nincoiiB infmbrntio »{ tlio urinnry p!uwig«B 
niay iu noritial or calarrlial coiiditiuns fiiriuHh vulU ot t,'ri<nl divursily ia 
aizt? nnd outline. Ajtido from tlio blood and poasihle fragnientn of tiiwue, 
tho urine mny exhibit no abnormality ; idbiiniin'iii'in la oucaeionally ob- 
Ki^rvird, but usually wbcn tlio othtir kidui'y in tho sent of inthtni million. 

TliA «oiirM) of the (liitrMuin varioM cxtri^moly in diiTi>rr!nt imlividunls. It 
seldom lasta tuor« than two yearx after the >1iai.:tivery of positive MViuptoRia ; 
in obildteti it fatal result may ensue within a few weeks, while in adults 
the disense in snid to liuvi> continued for <(□, fifteen, nnd «ven eighteen 
ye»r& Periods otcompamtivu comfort uiid decided iuprovetavut iu LicnlUl 
may altornato with th<> uHual Hviiiptoma. 

Dentb oc^urii from exbaitiition, or trom some complication, such as per- 
furation and jtoritouitis, fatal huinorrliiLgt.'. thrombosis of tlie reiuU vein and 
AultHOtiuont omboliDm in tlio lunga or brain, or perforation extcrually. with 
siibaequent aeptio infection. 

Uiaijnont. — Two (;Iiief syraptoma of renal cancer are tavior and hamaiii' 
ri-i. The foriatrr if) mrolynbsent in children, but in by no meiins a constant 
symptom in odulta; biuina tiiniL, on thu otlier hand, is frequently absent, 
luiving been obHcrvod in only about one half of the caiies ■■cported. 
Morcv)ver, it sometimes uppanrs otilv near the termination uf the case, 
when other »ymptouis bare establishfd tho diiignosis ; and Binec hu-nui- 
turia IK n 8>'mptom of many other affectionw of tlio urinary (nwt, it do« 
not coiiKtitule strong l>1rid^nc^' <>£ tin- cxistiTicf uf rcnid riuiocr etcepl in 
the nlwence of other |x»taiblt* Koiirco)) of liemorrbaue. When it ocrun 
witl>out pnin and unnccompauied by oUior forei^'u ingivdientH in tlie urine, 
and espcciidly when it is iuteruiitteut, tia'mnturia wniTautfl a pn-auui])tiou 
ofreniil or veaicjil i-niiiier. Th« insufllncney of thcw) two dyiuptoms for 
tbe general recognition of cruiei-r «f the kidney is illuatrated in tho follow- 
ing tabic of 115 coses collected by Itohrer : 

Tumor wfts obmrrod iiL, ,,,..,.... 47 cosea (-tl pereonl.). 

Uieiniituria. in 37 cnseti {Xi. per rent.]. 

Tumor nnd hiviti ntnriiL, in 25 cases (2'j |>er ceiit.)i 

Ni-itbcr tunjor tior UicDutturiii, ia.. . 8t! oaac* (31 ptr cvut.^ 
17 



296 



OBOUSB or TH£ CKUjUTT OMJISEL 




BdUd ooljr 2i ttBw ia SO 



IB lyw ablg tMNor, vfaib 
cMBi. fX 6i CMS Bocad Iff BolwrtR, *D ■!>- 

tb CL It is MtewertliT thai » tdlim to 



onlr in miaita : tka ' 
poiithe pnal ol tlM noB-l 



ibUct ■ tauMrio ammal ttnal 

r of sfiimettUt tvaor iaAcbHiliii 

. BBtture of the diAralt^. 
nsoosnitioa of reial auteer m pnctkall; ini|KMBble nakai ■ totDor 
na 1» dat«rted ; ^et the niMtan ot ■ tmnor. nen with i 
bvlsi dow not pAcvwiri]^ cxdads ofbfr aflMtwos, aaea tmama oUwr m>-^ 
iHSmocaU— of til* kidncrr M ««11 m of otbn' tbdomiiM] aijsiis— may 
Meiiligr Um rend ngioo. Tlw Aflti&eiioii unoo^ these m oA«b cxtr«cu«hK 
itiAroli mad MMDctinua iapoaibb. 

Tb« (liffrnotial diagnoiii b kas perpb-xjnj; in cbO<lrM) tlian in adults 
for two raoaoiu : Um ffrmptocna of rani ameer, tmftmaXiv t)if tmuor, 
more pronoaoceil. atMi other «nl*rgenieDt» in the region of the kidiuT - 
ue }»m frMiuml. In the cbiM a Urc@ renal ttunor is tMunllr one of 
UlTM titiam : nMi^irniud ryntie dogmenttion, bydroDsplircMtis, nr pritRitrr 
caoeer. <>atic d^gtnenitioo ia oonf^eDital, it liaa existed front l>irtb aikI ! 
doea not <:atue the conMlitotiODnl i^^^nptoiua tiK>du<^ bj eiDcer. By- 
ilrniiftilirvna iaalaooftcD congenital and in ctiil<1ren frcquc-mly c^liibiiH 
the aUtor [rminiiiuDt iim)]>(oin of renal cancer, naindv liiMiiflltiriA {from 
renal wju'rrplinmt). The (vjn>itnt«nro ain! form of Iho luuior, hut «•• 
pociittUy tli» liiMtorj' of tlw coflc, usuallv render tUc diognoaia between the 
two ea«,ir. 

Ia ulultu Uio recognition of rrnnl mniM-r is !(!»> 4!4-i-tiiii). Even M-lien tm 
nppreruihlft tumor existo it tony be nii8lAkcn for an enlargement of tlut 
liwr, Ki^leea, ovary, pancreas, retroperitonoal prlanda, or forn pcriuephritie 
or jiMom alMMsmu, or fncnl )tiiiHu-lii>n. 

TuiiiMFH of the livpr arc iisnutUy aj«ociat?il willi diwordera ivfemble lo 
tliAt (»rt{iiii ; lliyy exhibit the tiiovfiiit-nt** diiriiii; rtrsjijmtion performed l)_v 
Uki livtir. Util('H» n rcual tuotor hv very Inrgc. the finKont cim umallj \m 
inHinuril'fd bi^twcpn iUi upper hurdt^r unu lliu cdgu of tb« liver. Hie oolon 
(^c)omlly lin« in front of triR k!ilii<iy, IniL nut of the lirer. 

(Ufnirr iJifTimIl.y ia cxpi-nonwd in deciding wbi?tli£T a tiimor of the 
left eiild proceods from the iiidncy or tlio s|jleeD. Thp miiuo {;;riioml priu* 
oijden iiivolvrd in tlm distinolioii lictwc^n remd nm] ln'jiiitii.' imuors mny 
rcndiT till* (IJHlinctiiiii poiMilik'. Souicliiucs lUfi lowfr c-djifc of nn tiiliuTjtil 
snUen c-nn l»n diHliiu-tly gniHjiid mid rpfioRnizcd ; nidi-coTor. a jircvioiis 
lilKlnry of li'ili-oL-ylliiriiiift dii'C'cta suHpicion to lW i«[)!rr:i. NM-erflipless 
iniirinKi'tt of diiitrix^Hi*! nlh^ii iiievilnlilB ; for ptxtftiw >ii*-r»aturin miiy o«'cwt 
in ]i>iiiyi'iiiic |«ttii>nt« witliout nmli^mnt iliwas*! of tlie kidney. Tliiia Rob- 
vrlo ivInli-HsciUMof "(MioriiioiiHenliir^enieiit of tbe Riilecn (liuut.H.'ii'tbiuiDie) 
with jmifiimi luptiiaturid for novt-ml dn;,'R. After A^Mii. soino nmnllis «al>. 
aeqiirnlly, tlio kidneys luid bWldpr wrro found |>i'rf»'ctly hejilthr." It in 
(TPiiPiiiUy )itntt<d ttwt rciiiil liituom nrc di-stiTigiiiidierl from thoaeof tlieLver 
find KpWn Iiy lltflir inimobilily and iai-k of moteui^at during r<«]nmtion : 
thin nd* is not invariable, ainee not only wnndcring kidnt'ji-s, but others 
whtti ninrl) uiilnr^od. niiir l>u euiuly movablo and fullow the inovementK of 
tho iliit|ilirs};in. 

'i'uiuors of the stiMnadi arc oRon associated with gastric symptoiuB aadj 



SISSAaSS OF THK KIDNEY. 



2»9 



I 

I 
I 



gftn be nude to cbange their position t)j inflation of the organ witlt cti- 
l'%onic aci'l pftfl. 

Tnnioni of ihn ovtiry imiiallv lie inimei^iiitely tiiuler tlin ubJumiiuJ wall, 
^bik' tbo»e of the kitftiey are fteparaUfd tram it by the colon and laci|)H of 
intestine. Yet neither at tiicstf i-ulen in nbsolute ; coils of intestine some- 
timee iiitcr»«u« betwctn wq ovarian tumor an.! tlio abtJominiil wnll, nnii in 
two rei'onled in«tiinru8 of cuul-it altecttn}; u-aLiloring kidnevs, tlio reiuil 
tiiinnr was locnted in fn>nt nf tiio inti-stinf. Kelituicc muMt be pbwed 
tartly upoij tlio history — ilinplaoenifiit of tlio utenin, irrr<]:rulant}' in men- 
fltraation, etc, iudicatiiiff rji ovarian ffwwtli, while hoiuiaturia and other 
urinary ttjmptomH sucgost tbe reual origiti of the tumor. FliirtuHtiua 
nnt] Che orlgiiiiLl poiiition of the growth uiuy furnish udditional informs- 
tion ; and lutpiration ml) iimnLlly (f«cidd thn qiicfitton iIofinif.ply. 

Psoas anti perinephritio absoeaaea cwn (;euerully be difttin^fiiisbod by tho 
hi^tor^'. itge, anil nppBaranoe of tbe patient us well utt by tlie peculiar poai- 
tiiiH (if ihti b)W(!r cxtromitjpa of the iiffeeU^d niilo- Tln^y do not isxU-iiJ ho 
high anil have been at eome period iici^mpimifil with (ever. 

Caseous culiirRcintint of retiYipriritunfial glands may present a Inmor 
■whose physicnl cbitntcters simulate those of rcual cancer ; n diMtiiictii>n can 
usunily b(- itiado from the history- and from tli« urinary uppwiniii ccs. 

Impfwlion of fipnen in tho eolon htw ben ropentedly mistaken for renal 
cancer. The consistenc* of theito niasnes, thdr mobility and coinciiJenoe 
with the utitliue of the int«iitiue, Kuffiee for making a diHtinctiou. Thtt 
hiittory and tho imc of catJiorticH or copious iDJectionit vrill decide a doubt- 
ful CftBO. 

After it haH been determined that n given himor proceeds from th« 
liidnoy, tho nnturo of tho growth is to be decided. ThiMoftvn mquires 
Hitpiration of tho tiitiior a.ti<l a niicroaoouio exatniualiou of its contaots — a 
measure whieli shoiUd never be omitted in doubtful iriases, and is less ol> 
jeclioDftble in cases of renal cancer tJian of hydrouepluxtds (with whicli 
the fonucr can »carcoly be <'oii founded). Purticli-it of tuHUO which render 
the diaxiiOHi.-t |>ii<<iiive hnvc bcx^n ohtaiiici] in lliix wny. 

Various uiiuhiial condiuons luay siuiiUate cancer of the liidney. One 
of the ntimt reiuarkahle of these which tias ever come under my notice wiu 
ati unpiiliUithpd cawo obscrvcil in the Vienna (Jvncml Htwi>itjj in tlio wcr- 
Tico of l*rofi'-(wor Dittul. A womriii of ftdvuiicnd ycAre preaeuted a timior 
whieh occupied the right h>-noj7astrie and iliafl rei^onsand oonld be plainly 
f«lt through the thin abdominal wall as a hard mass, Menidtivc to prcMHiim 
and imtDOTAble. The patient h.-ul experienced much pain in ttiitt regiuD, 
TOdiating down the thi>;ha and acroiis the abdomen ; cmAi'intion. had been 
proDouDced for several monthrt. Th' urine contuiiicd a muoll quantity of 
aibum«u. but no other iibnornml iiiKredient. At the time of ailmistiiOD to 
the hrMpitnl, th«^ pntionl was almost dead from exhaustion, and beg^d for 
any operation that would thither nrinovc tho offendut^ object or oo<l her 
life, Tho diagnoaiii was nwule of nmal tutnnr, probably niahgiiiuit, and on 
operiilion for ila removal reluctantly under taken . 

The t.iiuiur proved to bo a muss about eight inches lonjr, and five inc3lPB 
thiffk, anrronndftd by a fibroun flt^taule ; upon incising thia capsule, a aec- 
ond of sitniW appearance came into view. An inH«ion t1)rough tliis noo- 
ond rrupsnle disclosed a highly vftHCiiIar tissae which bled freelynpon erory 
contact ol the finger or instrument. Tite interior of the ma« consisted of 
n dieniY iiiatvrial, the ccoti-nl part of which was liquclied. Tlio attempt al 
Tomoml was abandoned on senoimt of tho hemnrrbago R8 well ob tlie dan- 
gerous eshaastion of the patient. At the autopsy, three days later, it was 




3«0 



DISEASXS OF TEIR ORIXART OKBATTfl. 



toanA ihal tlii« nvws huV no vonDectioo wbntBoCTor with Qui Ici<ln«>T. whidi 
iraa found in uoaitiuii. greaU,Y tliUt«necl anc] compreesed, bebUi<1 thi: tumor. 
Tbe latter had been ctovelupeil in the sh«atli of one of the lumbar oervo*, 
nnd could b« trace<l np to its ontraoce into the gpitutl colutoD. 

/Vofptont— Caiicer ot the kitliicj wbidi does not pcntiit Kurgiii.'a] intcr- 
fenmco is nlwATx f&tnl, Romfitim&s in a ffw months. |M^rlut|M onlyaft^r nianv 
/eoTH ; ttie fatal reault omritm earber in children tliaii in lululta. It 
xliould be remembered tbat the diagnosis in frequently imcerlain and that 
tlw piogaoms sboulil be cturespoiidiiiply wndoeidc^l. 

iVealmvnl. — Tlio uudicid tivuttut'Ut itt entirely Kymptomatic: pais 
flboiild l>e relieved by tlte freo DM of anodynpii and hot foinfutationa over 
tb« loin ; profuse reoal h«tnorrlia^ may be arrested by cold applicatioiiB 
(trer Iho kidney, rcHt in bcil. jindlic acid, or cr^t. Clots of couaiilerBble 
itixft, viiioh cnuBC rctfttitifin by obntnwting iho ur(»Uini, may be (lijq>laco<l 
by tlia catheter aiid broken up by inj«vtIouH of warm water vith or with- 
out pcjiiune. 

In recent y«ar« tht> possibility of rwlical cur« by (fstir^intioii has been 
dcmoii»tmt«d iu isolated oasM by Cz«i-ny, Martin, Barker, I.«ugeubucb, 
and othen). Ilruntzel removed a tibrama of the kidney weitjtiing thirty- 
Kix pounds : and I»Bsen even extirpated an imiuenso augio»An-oina in a 
pro(^iuit womiui, with culire nuicose, TliCM casva aru lus yet too few to 
permit a jvwtilivo opinion an to tbo titilitr and nnftty of Die np<'rntion : it 
would certaiidy be uiiatlviitable in can&s where the size of the ((rowtli would 
indioite that tbe neoplasm bad involveii ))erinephTitic tit»uL-s and ha<l pro- 
dac«d metaslnses; and it would be leas promiftiug in yamig <'litldren, in 
wboiii iHitli kii1u(!ys nrn often nfl'oi'tciil by congenita) iieophism& Tho 
rhancea are retjiirded na most favorable ffbeu tbe growth in^-olvea a vaa- 
doring kidney in an wlult 



HnuTfDS OP TBS KiDXBT. 




Vorioun nomntodo and cestode worm« purasitic in llie human and 
other animtds attain ihcir dtvi-lopuient in snccewuve stagen, whiih may Imj 
pOBBuii in diRcrent animal ho»ts. The tienia eeliinococcus in found in its 
BOturo fitAt« as U)« common tapon'omi of tlio do^'H intestine. The eggsof 
this animal ar« dtachargitl with tfai- fiucv» and may be tjikcu into tbv nil- 
mentary canal of a second hoitt. 'i'hoiiee tlie ])m'asit<i makes ita way to 
various abdominal and thoraciu organs and develops into tlie so-called 
hydatid cystB. 

In mnn these hydatids are not rare, thongb they aro l«w freqiienlly 
found in th<t kidneys thnn in the liver and lung ; iu tliree hundred and 
8izty-.<ax ca-ses Davaine found tb^se rvntJi in the kidnej-s tliii-ty-tbrc* timea 
Tliey mny be funned at any [«'rii>cl of life, inosit frequently btlwMtt twenty 
nnd forty yeara of age ; and are observed oftencr in inidc-'* than in feinnloa 

Mt'rhtii Anatomy. — As a rule but oao ki(ln«y is atloptcd, the left more 
froqiu.'iilly fclmu the right. Tho ryst r»iisintu of n luolbcr-sac, within 
which nre eontftined nvimcrous arnrdlev vesirles (daugbtcr-sncH) flouting in 
n watery fluid These vary much in size, the lurgest contnining a tliini 
generation fKrnnddaughter-Ktws). In rare wwpa the origiiiiJ »ae is tho 
only one present, containing rotbiiig but fluid contents. On tho inner 
wall of eiw?h arte lue found groups of ecliinocoeei, each just liii-ge enough 
to be visible to the n^iked eye, aad oscb provided with four suckers and a 
double row of hooka. 




DISEASES OF TUG KIDNUY. 



261 



"Du eptis Titry in size from that of n b«an to t1ie cHmeTiaiona of an 
Bdnlt ItMo. The niolLer-fyut doL-n nut us a rule ocL-iipy the entire organ, 
pntioDB of l}ir ]iikrcitic-Ii^*iim ntiiiiuniiig iirdiind iL ; this retutl siilistunno t» 
nsuaU}' in a MaU; of ititlannimtion or fatty degcnemUon ; extra vaiULtioDx of 
l)l<xid lu'outitl the cyst wg fr^iuc'iit Aa a rule liut one moUier-f^iit 
ia foiiii<J, tlioupli imiueroiiK bdhiUct one)} aro eomctiuies nvva »c«tt«rcii 
lhrou|{L tb« rvwil tiiwiio. Tlii< wlbcr kidney in iwuiilly Lyporli'oiihii'd. 
Afti^r til" tumor hiw uttjiinoil xnrli nim lUi li> romprriut ndjui'ittit ni^nit. 
aiUieaions oofiir, hiiiding tho ki>lney to the nejr.'h boring li88ue«. In tlie 
HuiJ ooutfotH of the eyst are foucid cboleBt^rine aiid urinary cauHtitueittA, 
particularly urir }M--i<l ami [)lioe|>hitt«a ; tui «xceHs of eoHitim chloride — more 
tbaii ill cniit»iii<Ml in niiy oilier cynt — in n cbrirai!t«riHUo feuturL*. The ifluid 
aontains at iiioat a traoo of albumen, frequently none ; and hnn a specific 
gravity of 1.008 to 1,015. 

Tbtt c^'kIs may reiuftiu HtAtioiiiu^' furyenrH and thvii Hudtlvmly increum 
in MTe ; or Uie or(i;i»uisnis may jic-riHli and utrD|>liy of thu cyat fulluw. In 
this cose the fluiil ia absorbed tuid tUr wtc contracts into a firm maas coa- 
tainiiig calciu-euuH cuiicrelicmH and fat. "The dan^'era atteudant tiiwn 
thoni urc <\»<.'. In pressure iijxin and ndhi'HioiiH to m^ighhitriDg organs, kii]>- 
pitratioii ill and around the c>iit, bui-sCing of the cyf>t iuto the intestine, 
stonuu.-)!, luiifT, or jwritonoum, 

S>jiinit'/m». — ^E<;Viiiiococci of the Itiilncy rarely attract nttcntion until 
K pwrwjjtible ttinior lias Ix-en (irodiired or pprfomtiou occurs ^k)m«- 
timea obni-iire Bytinitoms caused by the pressure or adheeioD of the tumor 
to surrounding orj^rans aro the first indications of their csistenco. Even 
after a tumor in discovi^red, itfl nature nay loii^ rtiiinin unknown. It« 
tfonucciion witJi tho kidney ciui ofli-n bo dct4.-riniD<-d by Uio coiiHidi-niiiaDN 
adrancod in dincuaHtiig the diu;;noHiH of renal cancer ; but the probabil- 
ities are that the entar^^eiucut tu due to stnuo other cauiu> tbau the Gclii- 
noi^>i7cuH. Fltictiinltoti IK a frcijiirnt, but by no means cnn.iLniit, feature ; 
iu flonie inalaticen ii jifrutiar senftatinn— tJie " hydatid thrill" — caused by 
the coUiaifni of tli(i cysUi enclosed in the mottier-snc, is communicated to 
the fingfr iipi>u pidpntion. Thin thrill inn mnipnra lively n*re arniptom, 
au<l is inorimvcr uot diaruvU-nstic uf hvilatidit, Hin(« it but bMtu viicittKl iu 
uaacM oi livdroiicptiroMic. The tiiniur in often pruulttaa, or it may oautte 
sonie pnin by pre^ure ujKin adjot^oot nervca 

Churacterifiliu aymptumt; occur whuu tho L'jsle hunt sud dischar<^ 
thiiir coiitciitM into th« roual pclviii, an dccurriTUci^ notod tti ubout two- 
thirda n( the canes already recorde<l. llie rupture of the aac ia often pro- 
voiced by Wolenco, a blow or full upon the back, or rou(<h riding; ; it may 
bappon in an iiidividuiil wlio biuf never been mixpi^clcd of liarWriug the 
parasite. I^liarp paiuit and a f«eli»<r as if i«oinet]iiiii; had Qviea way 
UMually occur, and nr« folltm-cd by the symptoiua of remil colic, caused by 
tho P(Wbb;;o of tho cystic contents throufth the ureter». i'ain in the loin 
and aloo{j the uretorN, witli or witliuut cbill. vomilin;,'. and fercr indicult) 
UlB paau^ of thtt cyxtit. Xiicwo vymploms tniiy eubi^tdc xiiddcnty ho koou 
aa toe noes have ent«rod tbe blaader, after niiich frei^ucnt aud painful 
urination folluHS. 

The niptum of the cyat in follo^rod by chamctoristic amieamnces iii Lbn 
urine, usuiilly l)«roi-6 Uie indicfttJoria of obittnictioua iu tLu ureten* arc ex- 
perienced. The urine prtiHents a utility appearance and coiitninit nura«r- 
oas oil-drops, fragmeuto of tissue^ shreds of the lining tueubraue of tho 
aac, and hodkli'ta from tho coliimictKX'i Tho nppoarauco uf thebe tiooIt> 
leta or mciubruite (Fig. IT) ia tLu only puaitivc (actor in diagnutdtt. 




36! 



DISEASES OF TUB URINARY »K0AIf3. 



Alter ibe ttu^ hnve readied the bladder Budden r«t«iitioD of the urine 
niuy oL-cuT from tbv obxtnictiioii of tliu urctlira ; the introduction of the 
tutuieUir hiu( in a hv ingtnnccs enrv^td ta n^movA c.j».i» ham tb« bladder ; 
womeu liftT« been kuowu to extract tbe»e bodi<.*s fi'oui tliti urvtJini witli the 
Uiiger ; iu other ciukh the pretMure of the veHicol wall bail been RufBcidDi 
to rupture tlie cirut, eometimea with ti loud soise, followed \>y the eeoauo ' 
i>f [>ii» iind li(]uid. £lilir« cynte ore puBod thruu^li tho uretJtm in the muc 
lut wi>ll m ill tho fnaialo. Tbo anno usnally t^^ntoinx albiiitiuu and blowi 

Tlie uUttL-k may ceaae in a tew houn ; hut there luu^' riiiiiun otlicr 
cysts which iiicreiuso lu aizc und subacqucntly rupture, ocrafiioiiing » repe- 
tition of thoso ph«DomeiuL Ibo ituhi4vi)ueut u-ttockis may happen at inter- 
ToU of houra or yean. 





In 80tRA inRhinccs the contents of the cvsts havo romfiined in tbo 

Selvta of the kidtiey, eoantituting n permanent obatruction aad Ui' 
udng hydiunephroHia ; or the; may reniain iu the bladder aud cxdte 

C^BtitlK. 

The «OEppleto expulsion of the ej-stio contviits may be followed bv spoa- 
toneoua recoven* ; tlie sae and the kidney tihrivel and atrophy, or the saa 
alone nay bo tnuisformed into a shrunken. <-ho«wy mtuw, whilo the kidney 
eootinueti to perform ita fuuctionB. ExU-nm-v Huppumtion in aud amuna 
tba Bac has oecoKiooBlly cnusod pynmia ; olironit! pytlitiiii is another posaible 
wqaeL The hooks may esenpo In other ways tliAa with the urine ; Uiey 
arrire in tlie stomach and are romited : or they reach the int«atine and are 
passed with the fscH-es : thoy may eacftpe through tlie diaphrairni into the 
long and be Azpcctorated ; pvrfunttiou through the musdea and ekin of the 
loin hfflA abo occurred. 

After the expulsion of hydatid cysle of the Icidncy, long intervals of 
perfect health may follow aiid yet repetitions occur ; indeed, it ia impoaai- 
bU) to amert that no cysts remain. 



DISKASE3 OF TUE KIDNKV. 



26» 



Diagnom. — A. positire diogiioulj of renal hjtliibiclti ma ha baaed onljr 
upou the discovery of tlio pivrMiteorof tket>e(ni)lArly(:trfTtilie(I mombrftnea 
ill tlic Nul>jvot of u uiniii tumor. Tito pitrMnoe u( hcHikit iii l\ui iiriiio does 
iiol m-oos^arily lorjiti! the cyKt in the kidniey, lunce livdati<U situated ia 
tlic udlvLL' tisKues have be«n knoi^-u to escape into tb« urinary poaaatjes aud 
be discharged with thu iiriut:*. If tlic parasite}! present have eticapod fii^iii 
tbe kidiify, n diiniuutitiu of iiiis mtiiX luiuur is observed to coincide wiUi 
ilioir up[)ciinuic!G in tlw uiiiie. II no fcliinunnvcti nro foand in tLo urino, 
tbe tutuor niiiy be confounded with liydrouephi'usis or ovatinu cy»l ; if a 
diaUuction 1>& imposflihle train the liiatory and phyuiool pocidioritica (bm* 
diit^o«8 of iTiiiil i-iuit^ir) u>i]>irHtioD of tlia tumor and «xiuniiiatiou of its 
couteotH sbuiiM l>e miiilf- Evi?ii if lo lioLiklvtM nor bliiLldcrs itn* discoveriKl. 
AQ AxocMi -of uoiiinioii sidt atid nliMriiL-^ of ulbtimvn ufford pixiKiimptiro evi- 
dcDce of Uie hydatid orit^in of the cyst. 

A general absence of cuuslitutiutiid HVQiploiuii aad of uriciLry alnor- 
luolitioH chiunctcriKO hy^Iatid cy«t» of tin? kidiipy provious to tlicir rupture 

Tyeaimeni. — During tbe paesaffe of cysts iluwii tlio urolc-r, the lui'oSTircii 
employed for renal ooUg are tndicaleJ. Morphine, ivnnn bathx, gt^ntle 
friction nlont; tho ureter, and n?Ht in bod should be directed. Tbe irrita- 
tion cauwMl by tlie pree^nce of the cyatii iu the bladder bu tioiiiDtiiDVii 
been rdievt^d by tliA iiitroduvtioii of tltti c-athvtvr, in tho oyo of wliicL tliu 
Macs have become entangled. 

Tlie nulirid cure of reual hydatids ban been often attempted, but Boldom 
MM'oiiiplixlK'i). Sinipltt «'viimjuii(>n through n trociir hiM in n few