3!|qnd'3JDJ|aMPUD 'uo||ODnpg '\\vpa\\ NLM001342915 :Y OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY ivaan tvnouvn snidiqsw jo Aavaan tvnoiivn 3noiq3w jo Aavaan tvnouvn snidiqsw jo Aav | ^/ | RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR1 RETURN TO 4 | NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN /N- " 3NI3ia3W ,Q A„ SFP 9 107? NE NATIONAL LIBRARY v-N 3NIOIQ3W JO ABV 1VN 3NIDIQ3W JO Aa\> CINE NATIONAL LIBRARY avaan tvnouvn snidiosw jo Aavaan tvnouvn snidiosw jo Aavaan tvnouvn snidiosw jo Aav !Y OF \* ■ | H^HAN/ | ^•'Jf'^P E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OCTOBEK y DISEASES OF THE URINARY AND MALE SEXUAL ORGANS WILLIAM T. BELFIELD, M.D., AUTHOB OF " KELATIONS OF MICEO-OBGANISMS TO DISEASE" (CAETWBIGHT LECTUEES, 1883); PATHOLO- GIST TO THE COOK COUNTY HOSPITAL, SUKGEON TO THE GENITO-UEINAEY DEPAETMENT, CENTEAL DISPENSABY, CHICAGO ; PHYSICIAN TO THE OAKWOOD BETHEAT, GENEVA, WIS. J PBOFESSOB OF MICROSCOPY, CHICAGO COLLEGE OF DENTAL SUBGEBY NEW YORK WILLIAM WOOD & COMPANY 56 & 58 Lafayette Place 1884 W J 3428 d )%S4 COPYEIGHT, 1884, By WILLIAM WOOD & COMPANY trows printing and bookbinding company, NEW YORK. 4 AS THE CONDITION OF THIS VOLUME WOULD NOT PERMIT SEWING, IT WAS TREATED WITH A STRONG, DURABLE ADHESIVE ESPECIALLY APPLIED TO ASSURE HARD WEAR AND USE. PREFACE. When the preparation of this volume was undertaken, it was the author's hope to present a resume of current knowledge of the topics herein discussed, with comments suggested by personal observation and experience. In the execution of this plan he has been seriously em- barrassed by the brevity of the period allotted for the work, which has permitted no opportunity for a minute scrutiny of pertinent literature, for a careful revision of the text, nor for the addition of a bibliography. Yet, as the patience of the publishers has been already severely tried by the author's unavoidable tardiness, he prefers to submit the original draft of the book, incomplete and crude as it may seem, rather than to postpone still further the appearance of a volume long since due. There is a generally admitted tendency in medical practice to regard diagnosis as a recognition of morbid symptoms only, to neglect an in- quiry into the cause of the phenomena, and hence to practise a routine treatment of symptoms rather than an individual treatment of patients / this tendency contributes largely to what Dr. Bartholow terms " the in- discriminate drug administration which is one of the evils of the time." While it must be admitted that in many instances treatment can be, in the present state of medical knowledge, only empiric, symptomatic, or tentative, yet it is equally certain that available means for ultimate diagnosis^and hence opportunities for rational treatment—are not universally utilized in medical practice. Convinced that a lack of care and thoroughness in the investigations of patients is responsible for many failures in the management of urin- ary and genital disorders especially, the author has endeavored to pre- sent fully the necessity and the means for diagnosis as an essential preliminary to treatment. To this end he has devoted a considerable iv PEEFACE. portion of the book to a discussion of means for the recognition of morbid conditions; has emphasized the familiar but frequently neg- lected facts that cystitis, gleet, albuminuria, spermatorrhoea, are not entities calling for a routine administration of drugs, but symptoms requiring a thorough investigation of the patient; that the microscopi- cal examination of urethral and seminal discharges is quite as essential for the recognition of sexual disorders, as is a similar inspection of the urine for the detection of renal diseases; in short, he has endeavored throughout the volume to portray the important bearing upon treat- ment of the pathological factor in diagnosis. W. T. Belfield. 45 Clark Street, Chicago, November, 1884. CONTENTS. DISEASES OF THE URINARY ORGANS. CHAPTER I. PACK Anatomical and Physiological Considerations......................--- 1 The Kidney, 1 ; The Pelvis and Ureter, 6 ; The Bladder and Prostate, 9 ; The Urethra, 17 ; General Symptomatology, 24. CHAPTER H Methods op Examination................................................ 29 Questions to the Patient, 29 ; Examination of the External Organs, 33 ; Ex- amination per Rectum, 34. CHAPTER HI. The Sound and Catheter................................................ 37 Dangers of Catheterism, 43. CHAPTER IV. Urethral Fever......................................................... 49 CHAPTER V. Precautions to be Observed before Catheterism...................... 59 CHAPTER VI. Digital Examination of the Bladder................................... 63 CHAPTER VH. Inspection op the Urethra—Endoscopy................................. 69 Use of the Endoscope, 71 ; Diagnosis with the Endoscope, 73. VI CONTENTS. CHAPTER VHI. PAGE Determination of the Urethral Calibre by the Urethrometer...... 84 Catheterization of the Ureter, 92. CHAPTER IX. Physiology op the Urine................................................ 95 CHAPTER X. Pathology of the Urine................................................. 100 Variations in the Normal Ingredients of the Urine, 100 ; Inorganic Constitu- ents of the Urine, 109. CHAPTER XL Pathology of the Urine (Continued).................................... 112 Abnormal Ingredients of the Urine, 112. CHAPTER XII. Albuminuria.............................................................. 115 Physiological Albuminuria, 115 ; Albuminuria from Pathological Conditions other than Renal Disease, 118 ; Albuminuria from Renal Disease, 122. CHAPTER Xm. Glycosuria............................................................... 125 Physiological Glycosuria, 125 ; Glycosuria Independent of Diabetes, 125 ; Gly- cosuria in Diabetes, 127. CHAPTER XIV. Effect of Acids and Pigments on the Blood........................... 129 Choluria, 129 ; Hemoglobinuria, 130 ; Chyluxia, 132 ; Lipuria, 133 ; Fibri- nuria, 134 ; Hydrothionuria, 134. CHAPTER XV. Daily Amount of Urine................................................. 135 Reaction of the Urine, 136. CHAPTER XVI. Urinary Sediments....................................................... 138 Unorganized Sediments, 138; Organized Sediments, 143 ; Tube-casts, 147. CONTENTS. VI1 CHAPTER XVH. [E Bedside Tests for Urine, 166. PAGE Clinical Examination of the Urine.................................... 158 CHAPTER XVIH. Diseases of the Kidney.................................................. 171 Venous Congestion, 171 ; Ischaemia of the Kidney, 174 ; Atrophy of the Kid- ney, 175 ■, Amyloid Degeneration of the Kidney, 175 ; Embolism and Infarct of the Kidney, 181; Diffuse Nephritis (Bright's Disease), 182; Acute Nephritis, 184 ; Chronic Parenchymatous Nephritis, 198 ; Cirrhosis of the Kidney, 209 ; Fatty Degeneration of the. Kidney, 220 ; Suppurative Nephritis, 221 ; Pyelitis and Pyelo-nephritis, 224 ; Renal Calculi, 231 ; Hydronephrosis, 244 ; Syphilis of the Kidney, 250; Tuberculosis of the Kidney, 251 ; Cancer of the Kidney, 254 ; Hydatis of the Kidney, 260 ; Renal Casts, 263 ; Perinephritis, 264. CHAPTER XIX. Diseases of the Bladder................................................ 268 Cystitis, 268 ; Tumors of the Bladder, 283; Neuroses of the Bladder, 293 ; Spasm of the Bladder, 294 ; Paresis of the Bladder, 297 ; Incontinence of Urine, 300. DISEASES OF THE MALE SEXUAL ORGANS. CHAPTER XX. Prostatic Disorders.........,....................■■:*■■■/.................304 Prostatitis, 304 ; Chronic Prostatitis, 307. | ^ ' CHAPTER XXL ^<^£_ Functional Disorders................................................... 314 CHAPTER XXH. Seminal Incontinence.................................................... 326 Nocturnal Pollutions, 321 ; Spermatorrhoea, 330. CHAPTER XXHI. Impotence and Sterility................................................ 335 Sterility, 340. DISEASES OP THE URINARY ORGANS CHAPTER I. ANATOMICAL AND PHYSIOLOGICAL CONSIDEEATIONS. The Kidney. This organ is, in consequence of its anatomical relations, so inaccessible to all methods of direct examination, that we are largely dependent for our knowledge of its condition upon the examination of its secretion, the urine. Yet there are a few points concerning it, not recognizable by means of the urine, which may have great practical importance. The slight attachment of the kidney to the surrounding tissues results in the easy displacement of the organ, a fact which has as yet scarcely re- ceived the general recognition which it deserves. Unlike the other ab- dominal viscera, the kidney is provided with no ligaments or other special means of support. The position of the gland, separated as it is from the abdominal organs by the peritoneum, and protected by the spinal column and the last two ribs, secures it in great measure from direct violence ; while the nature of its functions requires neither of the kidney itself nor of the organs with which it is physiologically connected, any change of position in the body. Hence the anatomical provisions for the mainte- nance of its position are very slight. These consist partly of the vessels which enter and leave it, but largely of the peritoneum and of the adipose tissue which surrounds it and the suprarenal capsule ; for the kidney lies between the serous portion of the peritoneum on its anterior surface and the fibrous layer which covers its posterior surface. These attachments afford a support which is by no means inconsider- able. While the vessels which connect the kidney with the aorta and vena cava are quite elastic and easily permit a rather extensive range of move- ment on the part of the kidney, yet the connective-tissue attachments between the renal capsule and the adjacent peritoneum and fat are quite firm. Their importance can be readily demonstrated on the cadaver bv 1 2 DISEASES OF THE URINARY ORGANS. severing the renal vessels, after which it will be found that the usual force is required to remove the organ. While these attachments suffice doubtless in the great majority of in- dividuals to prevent dislocation of the kidney, yet in numerous instances they are overcome by various causes. This loosening and displacement of the kidney from its natural position has been often recognized, and doubt- less exists far more frequently than we are in the habit of believing. It is generally regarded as an anatomical curiosity, rather than a clinical pos- sibility to be kept in mind in the differential diagnosis of abdominal com- plaints. Displacement of the kidney has been often overlooked, partly be- cause of the difficulties of diagnosis, but largely because the physician or surgeon has neglected the possibility of its occurrence. In a recent work Buret has collated more than fifty instances in which obstinate and serious affections were ascribed during life to various causes, and found post- mortem to be caused by displaced kidneys. In no instance was the true cause of the difficulty ascertained before death, and in very few was there even a suspicion entertained that the symptoms observed might be due to displacement of the kidney. In those cases in which no tumor was de- tected, the complaint was pronounced neuralgia, hysteria, chronic peritoni- tis, renal colic, etc.; in other cases in which a tumor was distinctly recog- nized, the swelling was considered an enlargement of the gall-bladder, ovarian cyst, tumor of the liver, enlargement of the liver, displacement of the spleen ; in short, the greatest ingenuity was exhibited in devising mis- taken diagnoses, presumably because the possibility of displacement of the kidney had been ignored. Ebstein records a case in which delivery waa twice seriously impeded by a tumor which could be felt from the vagina. At the autopsy, many years later, this tumor was found to be a deeply situated kidney. So long as the treatment is confined to the administration of drugs, failure to recognize displacement of the kidney, though resulting in lack of success in treatment, can hardly lead to the commission of disastrous blunders; but in these latter days of abdominal surgery, especial care and attention to this possibility is required before operative interference is undertaken. A striking example of the clinical importance of this point occurred in the experience of Billroth. At the time when this distin- guished surgeon performed his first excision of the cancerous pylorus, in February, 1881, his colleague Bamberger had under treatment a middle- aged, emaciated woman, who had long exhibited the symptoms of chronic gastric difficulty, and who had a distinct firm tumor at the pyloric ex- tremity of the stomach; she was believed to have cancer of the pylorus. Encouraged by the recovery and apparent cure of the patient from whom Billroth had excised a pyloric cancer, this patient of Bamberger expressed her willingness to undergo the same operation. After satisfying himself as to the necessity for it, Billroth began the operation for excision of the pylorus by incision through the abdominal wall. He found, however, no cancer nor other disease of the pylorus, but an atrophied displaced kidney pressing upon the duodenum. The kidney was removed and. now adorns Billroth's museum ; the patient died of collapse in twelve hours. The fact that the most important supports of the kidney are the peri- toneal folds accounts for the frequency of renal displacement in women (99£ per cent, of all cases), and explains its almost exclusive occurrence in those women who have borne children. For the laxity of the abdomi- nal walls caused by repeated pregnancies permits the intestines to drag heavily upon their peritoneal attachments and thus indirectly loosen the ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 3 kidney ; possibly an enlarged and displaced womb may by traction on the ureter favor the same result. The absorption of perinephritic fat which accompanies general emaciation also weakens the renal attachments; yet while doubtless favoring renal displacement, emaciation is by no means an essential factor for its occurrence. The alleged relative frequency of wan- dering kidney in emaciated individuals is probably one of diagnosis only; for mobility of the kidney is found post mortem quite as frequently in stout as in spare persons, though for obvious reasons it is recognized dur- ing life almost exclusively in the latter class. While such abnormality in the position of the kidney, congenital or ac- quired, is in general amenable only to surgical treatment, yet a correct diagnosis is a matter of importance to the physician, and often affords the patient great satisfaction, by dispelling the fear of graver difficulty. In all cases of obscure affections of the abdominal organs, and in pelvic, lumbar, and crural neuralgias, a careful palpation of the normal renal region should be made. In case of a failure to locate the kidney by external manipulation, information can often be derived by exploration through the rectum. Albuminuria without renal disease has been observed in several cases of wandering kidney. Since any impediment to the escape of urine through the ureter may, by increasing the pressure in the urinary tubules, cause albuminuria, the occurrence of this symptom in cases of displaced kidney is quite comprehensible. For in consequence of the displacement the passage of urine through the ureter may readily be impeded either by pressure of this duct against adjacent organs, or by the existence of a sharp curvature in the ureter itself. Successive changes of position of a wandering kidney may cause intermittent albuminuria, which may be pro- ductive of diagnostic errors if the renal mobility be not discovered and properly interpreted. The relation of the kidney to the lower ribs is a matter of much interest to the surgeon. As a rule, the kidney may be said to extend from the eleventh rib almost to the crest of the ilium. In some cases the twelfth rib is so short as to be readily overlooked, the eleventh rib being then mis- taken for the twelfth; this error may lead to serious consequences, as was illustrated in an experience of Dumreicher. In performing a nephrot- omy, he made the incision as usual from the lower border of the last rib. To his surprise he discovered that he had opened the pleural cavity. At the autopsy it was found that the twelfth rib in this case was only 3£ cm. long and had been regarded as the spinous process of a lumbar ver- tebra, the eleventh rib having been mistaken for the twelfth. Incited by this accident, Holl examined the ribs of sixty skeletons, and as a result came to the following conclusions : complete absence and abnormal brev- ity of the twelfth rib occurs more frequently in men than in women, and on the right than on the left side. In these cases the position of the dia- phragm is not changed, but a portion of it and of the pleura is unpro- tected by the ribs, and is easily injured by an incision extending to the lowest (eleventh) rib. It is, therefore, desirable that in every case of operation in this vicinity the ribs should be counted from above down- ward and the incision limited to the level of the twelfth rib, even though this bone be absent. The absence of one kidney is a comparatively rare occurrence and yet one possessing great clinical importance. For it is especially in those cases in which the urinary excretion must be performed by a single organ that interference, natural or otherwise, with the functions of the organ causes the greatest risk to the patient. 4 DISEASES OF THE URINARY ORGANS. The congenital absence of one kidney is so rare as to be an anatomical curiosity; I have been able to find only fifty-four cases recorded in the literature of thelsubject. Yet it must be remembered that an acquired defect of one kidney—the abolition of its function by atrophy, fatty degen- eration, cystic degeneration, unrecognized hydronephrosis, etc.—is by no means a rarity. In these latter days operations upon the kidney, neph- rectomy and nephrotomy, have become recognized surgical procedures; and more than one surgeon has, after the performance of a brilhant and skilful operation, seen his patient die of uraemia, and has discovered to his amazement, upon post-mortem examination, that the kidney operated upon was either the only one possessed by the patient, or at least the only one capable of performing its functions. Now since in cases of congenital ab- sence or acquired inefficiency of one kidney the other organ becomes hy- pertrophied and performs the functions of both, no evidence of such deficiency may be discoverable through the urine, since this is perhaps furnished entirely by one kidney ; hence in such cases the operators have had no suspicion of the actual condition, notwithstanding a thorough ex- amination of the urine previous to the operation. Lange removed the right kidney in a woman forty-seven years old. The symptoms, which had existed for three years, had always indicated disease of the right kidney and had led to a diagnosis of pyonephrosis and cystic degeneration of this organ. The correctness of the diagnosis was established upon the examination of the extirpated kidney. The operation was skilfully performed and the patient reacted well; yet complete anuria followed and the patient died on the fourth day of ursemia. The autopsy showed that the left kidney, which had always been considered healthy, was also far advanced in cystic degeneration ; its pelvis and ureter were completely obliterated. Dr. W. M. Polk, of New York, extirpated a misplaced kidney in a girl nineteen years old. The p'atient died eleven days later of uraemia, and the autopsy revealed the congenital absence of the other kidney. In his report of the case,1 Dr. Polk refers to other instances in which the same operation has been followed by the same result from the same singular cause. Such cases have been hitherto quite rare ; but with the increasing fre- quency of operations upon the kidney they will doubtless become more numerous. Hence it becomes an imperative duty for the surgeon who contemplates an operation upon the kidney, to bear in mind the possibility of such untoward accident, and to take every precaution against its occur- rence by ascertaining the presence and condition of the remaining kidney. Fortunately this can be done with certainty in females at least, by cathe- terizing the ureter, a manipulation to be presently described. A congen- ital absence of one kidney has been in many though not in all cases asso- ciated with malformation, anomaly, or defect in other urinary or in the genital organs. Thus in one case in which the left kidney was absent, the left seminal vesicle was very small; in other instances a corresponding arrest of development of the testicle has been observed. In women anom- alies of the vagina and uterus have been repeatedly noticed in cases of congenital absence of one kidney. Such malformation has therefore diag- nostic value in a doubtful case. That the kidney is a portion of the urinary channel as well as a secreting organ is a patent and clinically important fact. We are familiar with the 1 New York Medical Journal, February 17, 1883. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 5 observation that chronic obstruction to the evacuation of urine is regularly followed by dilatation not only of the bladder and ureters, but also of the pel- vis of the kidney and of the renal tubules ; and it is equally true, though not so familiar, that the sudden removal of such obstruction is usually followed by hyperemia and even inflammation of the previously distended channel. It is a frequent clinical observation that the sudden removal of a long- standing impediment to the evacuation of urine is followed by serious local and even general disturbance on the part of the patient. Thus if an old and narrow stricture be cut or rapidly dilated ; if a bladder which is in a state of dilatation in consequence of chronic enlargement of the prostate be opened for the removal of a stone, or even simply evacu- ated by the introduction of a catheter—in these and analogous conditions the patient suffers from chill, fever, often hematuria, anuria, cystitis, or even suppurative nephritis. The injury is usually manifested primarily and chiefly by the bladder; cystitis and pericystitis occur first, and may constitute the entire affection. Yet in these cases post-mortem examina- tion often shows also an intense congestion of the entire urinary tract above the former impediment; hemorrhages in the kidney as well as in its pelvis are not infrequent. i In other cases the sudden evacuation of the bladder is followed by complete anuria and death. In these instances post-mortem examination may show no acute affection of the urinary tract except an in- tense congestion of the kidneys. ' The explanation of this congestion, hemorrhage, and inflammation in the kidney and of anuria following the sudden evacuation of a chronically distended bladder, is found in the anatomical relations of the vessels to the renal tubules. For the minute branches of the renal artery and vein, con- ducting the blood to and from the cortex of the kidney, lie closely packed between the straight tubules in the medullary portion; only a very small amount of connective tissue—the stroma of the kidhey—intervenes be- tween the blood-vessels and the tubules ; the two sets of vessels are indeed practically in contact. Now the tubules of the kidney are in cases of tight stricture or enlarged prostate kept distended with urine whose escape is prevented by the impediment below. This distention of the tubules must of necessity take place largely at the expense of the contiguous blood- vessels, which are correspondingly compressed. So soon as the impedi- ment—the stricture, for instance—is removed, the kidney tubules are emptied, and the habitually compressed blood-vessels suffer engorgement, which may be so great as to cause rupture of the vessels and escape of blood into the tubules and hence into the urine, or even anuria. This congestion of the urinary tract in consequence of the sudden relief from chronic distention is designated as " negative pressure" or " hyperemia ex vacuo." It is a frequent occurrence clinically, and con- stitutes the explanation of many familiar and unpleasant facts in the sur- gery of the urinary organs ; a general recognition of its importance would obviate some of the disastrous complications which are so common in the treatment of bladder, prostatic, and urethral diseases. As already stated, : the bladder suffers primarily and often most severely ; for the chronic dis- tention begins in this organ and may indeed be confined to it without ma- terially increasing the pressure in the ureters and kidneys. Yet while inflammation of the bladder as the result of negative pressure may perhaps be controlled, participation of the kidney constitutes an irremediable and : almost invariably fatal complication ; hence the propriety of mentioning . the subject here. . . , Every surgeon of experience has seen cases illustrating the principle 6 DISEASES OF THE URINARY ORGANS. already stated, though perhaps not recognized as such. It is a familiar clinical fact that one of the perils attendant upon lithotomy in elderly men is the danger of cysto-pyelitis and suppurative nephritis ; and it is a further fact that these occur as a sequel to the operation chiefly, if not exclusively, in those cases in which the bladder has been habitually distended with more or less residual urine. Lithotomy is notoriously safer in boys and youth than in elderly adults, merely because in the former class the bladder and kidneys have not been distended through prostatic enlargement, or strict- ure. Many cases are on record in which serious, even fatal hemorrhage and partial or complete suppression of urine have followed the simple introduction of a catheter in cases of prostatic hypertrophy or narrow stricture. The occurrence of fever after the rapid dilatation of a stricture, after the complete evacuation of the bladder in elderly persons, and after the operation of sounding for stone, is so common that the term " urethral fever " has come into general use to designate them. This term is, when applied to these cases, usually a misnomer. There are doubtless many cases of fever following the introduction of an instrument into the bladder, which can be plausibly ascribed to the impression made upon the urethra; but in the class of cases under discussion the clinical symptoms and post- mortem appearances show that the phenomena observed are to be attrib- uted, not to irritation of the urethra, but to the congestion of the urinary tract, including the kidneys, caused by " negative pressure." The same principle is illustrated in other pathological conditions. Thus it has been repeatedly observed in cases of glaucoma that the sudden re- lief of the habitual tension in the eye consequent upon the performance of iridectomy, has been followed by hemorrhage into the vitreous and retina, though these have suffered no direct injury during the operation; the removal of fluid from the pleural and peritoneal cavities, in cases of chronic pleurisy and ascites, has been similarly followed by hemorrhage from the vessels of the serous membranes which were thus suddenly re- lieved of an accustomed pressure. The oozing of blood from the walls of an abscess, after evacuation of the pus, is a familiar example of the same principle—engorgement and rupture of vessels from the sudden removal of accustomed pressure. The practical deductions to be made from this intimate association of the kidney with the lower portion of the urinary channel will be discussed in connection with the use of instruments in the bladder. It will suffice here to mention an instance showing that the kidney also is involved in the general congestion : Hofmokl relates a case in which he performed lithotomy upon an old man who had prostatic hypertrophy and consequent dilatation of the bladder. A few hours later there occurred profuse hemorrhage, which, however, was not from the lips of the wound. Death occurred twenty hours after the operation. At the autopsy there was found intense hypersemia of the entire urinary tract, engorgement and miliary hemorrhages of the kidneys, and fresh extravasation of blood be- tween the left kidney and its capsule. The Pelvis and Ureter. The presence of supernumerary pelves and ureters is a not infrequent anomaly, though one which possesses but little clinical interest. Three and even four ureters have been found in the same individual, each some- times pervious throughout, though in the majority of instances at least one of the superfluous ureters is occluded at some part of its course. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 7 The abnormal insertion of the ureter into the pelvis is a matter of clinical importance, since it is often responsible for cases of hydronephrosis in which no impediment in the urinary channel is discoverable during life. It has been repeatedly observed in cases of supernumerary ureters, the re- sult being partial or complete hydronephrosis, according as one or all of the ureters were thus abnormally inserted. Such anomalous insertion is a congenital malformation and of course irremediable ; yet the possibihty of its occurrence should be borne in mind in forming an opinion as to the character of an abdominal tumor; for the absence of any history of renal calculi and of other causes for hydronephrosis has repeatedly misled ex- perienced surgeons, even Billroth himself, into an erroneous diagnosis of ovarian tumor, where the lesion was really hydronephrosis. The abnormality of this insertion is usually that the ureter opens ob- liquely into the pelvis, just as its lower extremity opens into the bladder. In another class of cases the ureter is inserted on the side instead of at the bottom of the pelvis, often at the anterior or external surface. This mal- formation results necessarily in the retention of some urine in the pelvis of the kidney, that which escapes being as it were the overflow from the dis- tended pelvis. In some of these cases the recumbent position favors the escape of urine from the pelvis, so that a tumor which has existed at night has almost or quite disappeared in the morning. Kupfer's researches into the development of these organs explain some of these congenital anomalies. He found that the ureter at first opens as a short canal into the posterior wall of the Wolffian body, and is at a cer- tain period turned toward the back of the embryo. At a later date the Wolffian body and ureter make a half revolution (180 degrees) on its axis, the posterior portion now becoming anterior. Sometimes this revolution is not completed, in which case the insertion of the ureter will of course be on the anterior, external, or even posterior wall of the kidney. He ob- served seven cases of such anomalous insertion of the ureter, in four of which hydronephrosis was present. A more frequent anomaly consists in the presence of valves either at the renal orifice or at certain points in the ureter. These valves, which are merely folds of superfluous mucous membrane, seem to originate in the excessive length of the embryonic ureter (which is developed independently of the kidney). Such valves are found far more frequently in the foetus and in young infants than in adults. Wolfler examined the ureters of 50 new-born children ; in 20 of these he found from one to five more or less marked folds of mucous membrane which were situated always and exclusively at the same point, namely, one to one and a half centimetres from the pelvic orifice. In most of these there was a dilatation, more or less pronounced, of the pelvis ; in 10 the ureter was almost or quite im- permeable. In 50 adult cases, on the other hand, he found not a single such fold, indicating that they are often obliterated with age ; yet they sometimes persist, and become more pronounced with advancing age, caus- ing decided hydronephrosis. Thus Billroth operated upon a case in which there was no history to indicate the possibility of hydronephrosis ; the tumor present was considered ovarian, even after the abdominal incision. The cause of the hydronephrosis was a (probably congenital) semilunar valve of mucous membrane at the pelvic orifice of the ureter. The arrangement is likened by Wolfler, who reports the case, to a small aortic valve with sinus Valsalvae and coronary artery, the latter corresponding to.the ureter. The pressure of this valve against the wall of the pelvis by the enclosed urine completely obstructed the ureter. The history of the case showed 8 DISEASES OF THE URINARY ORGANS. that this closure must have been for a long time temporary and transient, and that it had been increased by repeated pregnancies ; in fact the closure had been constant (as shown by the permanent increase of the tumor) since the last pregnancy, three years previously. The anatomical relations of the ureter in the lower part of its course have, especially in females, great practical importance ; for the ureter passes along the side of the supra-vaginal portion of the uterus and of the vagina ; hence displacements, enlargements, and tumors of the uterus, and peri- metritic inflammations, may cause an angular curvature of one or both ureters sufficient to obstruct the passage of the urine. The result of such obstruction may be albuminuria or even hydrone- phrosis. Hildebrandt relates two cases in which he was enabled to demon- strate the dependence of hydronephrosis upon retroflexion of the uterus. In one case the patient complained of extreme pain during micturition, and exhibited a large fluctuating tumor in the left iliac region. Hilde- brandt regarded the swelling as a hydronephrosis produced by obstruction to the ureter caused by the flexion of the uterus, and demonstrated the correctness of the diagnosis by first straightening the uterus with a sound, then introducing a catheter and pressing upon the abdominal wall over the tumor; the swelling rapidly diminished in size and a copious flow of urine immediately followed. The occurrence of hydronephrosis in consequence of cancer of the uterus is a frequent and familiar observation. Blau found that distention of one or both ureters occurred fifty-seven times in ninety-three cases of carcinoma uteri. The immediate cause of death in this affection is often uraemia. The obstruction to the flow of urine appears to be some- times the result of implication of the ureter in the neoplasm, while at other times the ureter itself shows no signs of cancerous disease, but is merely compressed by the enlarged cervix or the thickened periuterine tissue. Albuminuria may also occur in consequence of the obstruction to the flow of urine caused by compression or curvature of the ureter associated with displacements or enlargements of the uterus—a fact of diagnostic im- portance ; for it is well known that an increased pressure of urine in the ureter and pelvis is of itself sufficient to cause the escape of albumen from the glomeruli. This has been demonstrated experimentally by compres- sion of the ureter, and is seen clinically in cases of hydronephrosis in which the ureter is still pervious; for in such cases the urine is transiently or constantly albuminous. The fact that albuminuria may thus result di- rectly from displacements of the uterus or from periuterine inflammations is not so generally recognized as to make it possible to secure data to establish the frequency of such occurrence. I have myself seen one case in which the relation of cause and effect seemed clearly demonstrated. A lady thirty-five years old, the mother of four children, had been frequently troubled since her last confinement, eighteen months earlier, with difficulty in micturition. The act was accompanied with considerable pain and had to be repeated at short intervals. These symptoms had been especially annoying during the last four months. Her last labor had been some- what difficult and had been followed by periuterine inflammation. The urine had been found to contain albumen ; the attending physician sus- pected Bright's disease. Upon examination I found the uterus somewhat enlarged and retroflexed; the urine contained a small quantity (about one- tenth per cent.) of albumen and an occasional hyaline cast, but was other- wise normal. Treatment was directed entirely to the uterus ; in the course of a few months we were enabled to secure a decrease in the size ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 9 and an improvement in the position of this organ ; meanwhile the albumen gradually disappeared from the urine, and the annoying symptoms during micturition ceased. The normal enlargement of the uterus in pregnancy may likewise cause albuminuria by compression of the ureter ; it would seem probable that a similar result may be produced by the pressure of ovarian or other tumors. The albuminuria which is sometimes seen in irritable states of the bladder appears to be due to compression of the ureter by spasmodic con- traction of the muscular coat of the bladder which is perforated by it. Such seems to be the explanation of the albuminuria which occurs when a gonorrhoeal inflammation extends into the posterior urethra and involves the neck of the bladder ; the irritation of the mucous membrane causes a spasm of the muscular layers, in consequence of which the distention oc- casioned by even an ounce or two of urine stimulates the organ to contrac- tion. This same spasm causes compression of the vesical ends of the ureters; hence there results a frequent evacuation of small quantities of slightly albuminous urine. The same phenomenon is sometimes witnessed in consequence of the irritation caused by a calculus in the bladder. In determining the condition of the kidneys preliminary to an operation for stone, it should therefore be remembered that albuminuria may be due directly to the presence of the stone and not to renal disease ; the micro- scope and the patient's symptoms must decide. In other cases spasmodic contraction of the vesical muscles—irritability of the bladder—accompanied by slight albuminuria, may be the result of irritation in the rectum, vagina, or uterus. Tumors in the bladder may obstruct and displace the vesical orifices of the uterus and thus occasion albuminuria, or hydronephrosis, or both. This is true not only of those tumors whose size permits their detection, but also of minute growths in the bladder unrecognizable during life, and even by simple thickening of the mucous membrane. I have observed and recorded ' a curious example of this nature. The subject was a man seventy-four years of age, dead of pneumonia. The muscular coat of the bladder was considerably thickened, and its mucous membrane in a state of catarrhal inflammation ; there was decided enlargement of the middle lobe of the prostate. The left ureter was much dilated and the corre- sponding kidney was hydronephrotic; the right kidney and ureter were normal. The cause for the dilatation of the left ureter and kidney was found in a small tumor situated under the mucous membrane just below the orifice of the left ureter, which was thereby compressed and almost closed. This little tumor was no larger than a small pea, and was found to be a pure myoma. Neither its existence nor the hydronephrosis had been suspected during life. The Bladder and Prostate. The vascular supply of the bladder presents two points of clinical im- portance : first, the venous plexus in the neck of the bladder and prostate anastomoses freely with the radicles of the hemorrhoidal veins; second, the blood returning from the bladder, seminal vesicles, and penis passes through the prostatic venous plexus. Zuckerkandl has demonstrated free 1 Wiener Med. Wochenschrift, May 19, 1881. 10 DISEASES OF THE URINARY ORGANS. communication of the prostatic plexus not only with the veins which empty through the internal iliac into the vena cava, but also with those which empty into the portal vein. This anatomical fact explains various familiar clinical observations : thus elderly men whose habits produce fre- quent or constant portal congestion, are often troubled with dysuria and even mild cystitis, from congestion of the veins around the bladder neck. In such subjects, especially if they also have prostatic hypertrophy, over-indulgence in the pleasures of the table may induce sudden reten- tion of urine. This is caused by the congestion of the prostatic plexus in common with that of the portal system generally. Habitual portal conges- tion may result in varicosities of the vesical and prostatic veins known as " bladder piles," which are occasionally observed post-mortem ; they may produce symptoms simulating stone and their rupture sometimes causes hematuria of obscure origin. These bladder piles are usually, though not always, associated with rectal haemorrhoids. In a few instances hemor- rhage has been observed alternately from the rectal and vesical haemorrhoids; periods of hematuria alternating with hemorrhage of the piles. Chronic congestion of the prostatic plexus produced by portal congestion or habit- ual constipation, doubtless contributes largely to the prostatic hypertrophy which is frequent in old men ; just as chronic venous congestion produces interstitial thickening elsewhere—in the kidney, the skin of the lower ex- tremities, etc. The veins of the penis empty into this prostatic plexus; hence the prevention of constipation is an important item in the treatment of inflam- matory conditions of the penis, prostate, and other genital organs, as well as of masturbation, nocturnal pollutions, etc. For congestion of the por- tal or hemorrhoidal veins or both—hence constipation—maintains a venous congestion of the prostate and penis ; indeed it may aggravate or even in- duce in this way a constant irritation of the sexual organs, manifested by frequent erections and seminal emissions. Distention of the bladder with urine tends to produce the same effect by compressing the prostatic plexus —a fact familiarly illustrated in the erections which occur in healthy men before rising in the morning, when the bladder is filled with urine secreted during the night. In some cases, probably more numerous than we are accustomed to suppose, the enlargement extends from the veins of the prostatic plexus to those returning along the wall of the urethra ; at any rate, enlarged and tortuous veins are occasionally discovered with the endoscope in such cases. These veins may produce uneasiness and painful sensations along the urethra, and they favor profuse urethral hemorrhage upon slight provocation. The vesical veins—those which return the blood from the general paren- chyma of the bladder—also empty into the prostatic plexus; hence any influence which produces a congestion of this plexus tends also to induce general venous congestion of the bladder. Portal congestion, habitual constipation, prostatic enlargement may therefore all cause a derange- ment in the nutrition as well as the functions of the bladder. In mild grades this venous congestion of the bladder may be indicated merely by an increased production of mucus and by vesical irritability—both familiar symptoms of prostatic enlargement, if pronounced and persistent there may occur a decided increase in the connective tissue surrounding the muscular fibres of the bladder as well as some fatty degeneration of these fibres; the result is a loss of the usual muscular tone of the organ, a ten- dency to atony and dilatation. Sooner or later a catarrhal cystitis is de- ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 11 yeloped from this venous obstruction caused by prostatic enlargement; just as eczema occurs on the leg from varicose veins. The nerve supply to the bladder is also a matter of clinical interest. The neck of the bladder, including the sphincter, is supplied directly with spinal nerves, which proceed from the anterior roots of the third, fourth, and fifth sacral; the body of the bladder, on the other hand, obtains its nerves from the sympathetic hypogastric plexus. The spinal centre of the motor fibres is in the vicinity of the third lumbar vertebra. This anatomical difference in the nerve supply of the different muscles of the bladder corresponds to the known physiological antagonism between the sphincter and the detrusor muscles. The former is, in the normal state, completely under the control of the will, while the latter is practically in- dependent of volition. The act of micturition consists simply in the vol- untary dilatation of the sphincter ; the expulsion of the urine is an invol- untary act, except as it is assisted by the contraction of the abdominal muscles. In cases of injury to the spine above the third lumbar vertebra, whereby communication between the brain and the spinal centre of the vesical nerves is interrupted, there occurs retention of urine in consequence of the inability of the patient to dilate the sphincter; when this muscle is dilated mechanically by the introduction of a catheter into the bladder, the detrusor muscles contract as before. Another fact of clinical importance is the distribution of the same nerve (the pudic) to the base of the bladder and prostate, the integument of the penis, scrotum, and perineum, the urethral muscles and mucous membrane, and the sphincters of the anus ; in the female the uterus, vagina, and vulva are supplied by branches of the same trunk, which is distributed also to the base of the bladder and urethra. As a result, irritation exerted upon these various organs—the urethra, rectum, anus, perineum, vagina, etc.—may be manifested by functional abnormality at the base of the bladder. It is a familiar clinical observation that irritability of the bladder, indicated by frequent and painful urination, may be caused by conditions of the most diverse nature in other portions of the area supplied by the pudic nerve. Thus fissures and ulceration of the rectum, habitual constipation, the pres- ence of worms in the bowel, ulceration and inflammation of the uterus, the accumulation of smegma under the prepuce, phimosis, stricture, etc., may not only be accompanied by an irritable state of the bladder without actual lesion of this organ, but may even manifest themselves subjectively by sensations referred to the bladder rather than to the actual seat of the irritation. Hence it is necessary, in every case of obscure difficulty affect- ing the bladder—especially if the subject be a child—to examine also the various other organs to which the pudic nerve is distributed. Conversely an actual irritation of the bladder or prostate may produce abnormalities in the area named—rectal tenesmus, urethral spasm, nocturnal pollutions. The sphincters of the bladder are in the male two in number : one con- sists of a ring of unstriped muscular fibres contained in the vesical border of the prostate ; the other is the striped muscular tube which surrounds the membranous portion of the urethra. Strieker and Dittel demonstrated the function of these two muscular rings in the following way : A dog was curarized, whereby all striped muscular fibres, including those surround- ing the membranous urethra, were paralyzed. The bladder remained full, no urine escaping. Even after a vertical section had been made through the prostate (excluding the posterior edge) no urine escaped. This con- stituted circumstantial evidence that the prostatic muscular ring performed the function of a sphincter. Positive demonstration was furnished by in- 12 DISEASES OF THE URINARY ORGANS. troducing a frog's intestine filled with water from the bladder into the prostatic urethra, and connecting it with a glass tube ; electrization of the prostate caused a decided ascent of the water in the tube. Since in this experiment all striped fibres were incapable of contraction because curarized, it is evident that the contraction observed must have been that of the unstriped fibres in the prostate. Both of these sphincters, the internal or prostatic and the external or urethral, seem essential for perfect continence and control of the urine. At any rate serious impairment or lack of development of one or the other sphincter is accompanied by incontinence of urine. Thus, previous to puberty, enuresis appears often to be the result simply of a lack of develop- ment of the internal sphincter ; for this sphincter is a part of the pros- tate, and this gland, in common with the genital organs generally, remains undeveloped during the first years of life. The compressor urethre, sur- rounding the membranous urethra, which is a striped muscle and under voluntary control, suffices for the closure of the bladder during the waking hours ; but in sleep this control is less perfectly exercised, and because it is not reinforced by the internal sphincter, nocturnal incontinence often results. At puberty the prostate participates in the general development of the sexual organs and the internal sphincter performs its full functions; at this time, if not before, nocturnal incontinence usually ceases. In com- paratively rare cases, enuresis persists after puberty, even until the indi- vidual attains the age of sixteen, eighteen, or twenty years ; in such cases there is an imperfect development of the sexual organs. The enuresis or " weakness of the bladder " of old men can often be traced to an impairment of the prostatic sphincter. In these cases there is, as Dittel has shown by microscopic examination, a fatty degeneration of the muscular fibres of the bladder and prostate, including the internal sphincter. Fatty degeneration of the sphincter only or chiefly is mani- fested by incontinence of urine ; when it affects the detrusor muscles also, the ability to expel the urine is impaired ; these are the cases in which sudden paralysis of the bladder occurs in consequence of overdistention, from holding the urine too long. Fatty degeneration may affect the sphincter in cases of prostatic hyper- trophy, but is more frequent when the prostate is atrophied ; this atrophy occurs oftener than enlargement (according to Dittel twice as often) even in old men. It is an occasional result of gonorrhoea ; hence there is some- times seen as a sequel to gonorrhoea, even in young or middle-aged men, a " weakness of the bladder," which may manifest itself by actual inconti- nence, but more frequently takes the form of dribbling after micturition ; sometimes there is merely a necessity for frequent and immediate urination. Impairment of the external sphincter, the internal remaining intact, is also at times the cause of incontinence. This happens usually as a result of stricture. An inflammatory deposit involving the membranous portion of the urethra must of course impair its muscular contraction ; and as a clinical fact such impairment, manifested by enuresis, is frequently observed in cases of stricture involving the posterior urethra. Even a stricture in the pendulous portion may occasion the same result For when it becomes quite narrow there occurs a chronic distention of the urethra posterior to the stricture ; and this may extend so far back as to dilate the membranous portion of the canal, depriving it of its normal con- tractility. Dilatation of the stricture cures the enuresis by permitting the compressor urethre once more to resume its functions. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 13 In the female the entire urethra, corresponding to the membranous portion of the male, is provided with circular muscular fibres, and performs the function of a sphincter. Cases have been observed by WTinckel and others in which the neck of the bladder and the upper portion of the urethra had been entirely disorganized by vesico-vaginal fistula, and in which after the closure of the fistula by operation, the remaining external portion of the urethra had been found sufficient to constitute a perfect sphincter. The external, voluntary sphincter may in various conditions cease to obey the will. Thus in cases of irritation at, or operation upon the anus or perineum, in states of mental tension, such as prolonged nervous ex- citement, hysteria, sexual exhaustion, etc., there may occur a spasmodic contraction of this muscle which no effort of the will is able to overcome, the use of the catheter being necessary. In other cases the opposite con- dition occurs, the sphincter dilating without voluntary impulse or even in opposition to the will. Thus terror, nervous shock of any kind, and even inordinate laughter may be accompanied by an involuntary dilatation of the sphincter and expulsion of urine. The position of the vesical orifice of the urethra with reference to the symphysis is a matter of clinical importance. It is as a rule located in adults about one inch behind and three-fourths of an inch above the arcus inferior of the symphysis ; in children it is always higher, sometimes even above the bone. The position is influenced by the inclination of the pelvis ; for the urethra is firmly bound to the pelvis in front of and underneath the symphysis ; hence the inclination of the latter influences the position of the bladder neck. In youth the symphysis is more in- clined than in age, and the position of the vesical orifice is correspondingly higher. The distention of the rectum and of the ischio-rectal fossa is another factor which increases the height of the neck of the bladder, for since this cannot recede from the symphysis, such distention must raise the vesical orifice toward the upper border and compress it against the symphysis. Hence it sometimes happens that fleshy old men, in whom the ischio-rectal fossa is full of fat, must defecate before they can urinate, since while the rectum is distended the neck of the bladder is high and the prostatic urethra compressed. In cases of prostatic hypertrophy the vesical orifice moves upward and backward from its normal position. The trigonum—the triangular portion of the floor of the bladder whose angles are located at the vesical orifice of the urethra and of the two ure- ters respectively—is distinguished normally by an abundance of muscular tissue. The upper border of this triangle, stretching between the orifices of the ureters, sometimes becomes hypertrophied so as to constitute a ridge which opposes the entrance of the catheter. In a few recorded in- stances this ridge has become so developed as to constitute a partition be- tween the body of the bladder and that portion below the ureters. In one case observed by Dittel this muscular layer completely shut off the lower section of the bladder from the body of the organ, so that at the au- topsy, after the catheter had reached and evacuated the former, the blad- der still remained full, and was emptied only by a special effort whereby the catheter was forced over the obstruction. Hernia of the bladder, extrusion of the whole or a part of the organ, may occur through the abdominal wall, the inguinal or crural canal, through the foramen ovale, into the perineum, scrotum, labia, vagina, or urethra. The most frequent forms are, in males, the scrotal; in females, vaginal, femoral, and urethral cystocele. These are comparatively rare conditions ; 14 DISEASES OF THE URINARY ORGANS. yet the possibility of their occurrence should be remembered, since a fail- ure to recognize them may be followed by disastrous results. In many of the recorded instances, the true nature of the hernia has not been dis- covered until after death from operation ; since the diagnosis is usually easy, by observing the decrease in the size of the tumor after the intro- duction of the catheter, such mistakes usually result merely from lack of care, and not from inherent difficulties in diagnosis. Inguinal hernia of the bladder is usually a complication of ordinary intestinal or omental hernia, though in a few rare cases cystocele has been found to constitute the entire hernia. It may comprise almost the entire organ or only the fundus, which is connected with the base of the bladder by a narrow channel passing through the inguinal canal. In these latter cases, in which a portion of the bladder is thus cut off from the remainder and protrudes into the scrotum, calculi may form in the extruded por- tion. Vidier refers to a case in which a cystocele containing a stone was considered a bubo, and caustic was applied, resulting in the production of a urinary fistula. Adhesions of the bladder to the adjacent intestine or sac have been frequently observed. In the female, inguinal cystocele is less frequent than in males. It may constitute a swelling of the labium, and may possibly be mistaken for dis- tention or abscess of the vulvo-vaginal gland. Vaginal cystocele occurs especially in women who have borne children and have suffered laceration of the perineum ; it may also result from dis- placements of the uterus ; indeed, a slight degree of displacement of the floor of the bladder is a not uncommon feature in uterine complaints. In cases of vesico-vaginal fistula there sometimes occurs an eversion of the bladder through the opening, forming a red, soft tumor which blocks up the vagina. Crosse saw a case in which the bladder after eversion into the vagina had actually escaped between the labia, forming a tumor exter- nal to the vulva, from which the urine dripped continuously; the orifices of the ureters could be detected. Inversion of the bladder through the dilated urethra has been observed in females, especially during infancy ; it may even be congenital. In adults, it occurs as the result of chronic cystitis, with constant and violent efforts at micturition. In most of these cases the entire parenchyma of the vesical wall is displaced ; but in a few instances the mucous membrane has been detached from the muscular coat and has protruded alone. Noel records a case in which obstruction to the ureters had caused the urine to burrow between the mucous and muscular coats of the bladder; the mucous membrane protruded through the urethra in the form of a transparent sac filled with clear liquid. Urethral cystocele has been mistaken for a polyp. Displacements of the bladder may exist for years without causing symp- toms referable to this viscus; and may even then cause a difficulty sug- gesting disturbance in other abdominal organs. A curious instance of this sort is recorded by Dr. Briddon.1 In this case a boy nine years of age exhibited symptoms of fecal impaction and perityphlitis. A fluctuat- ing tumor occupied the right inguinal region, extending as high as the umbilicus. There were no symptoms indicating urinary difficulty. After making an incision parallel with and one inch above Poupart's ligament, it was discovered that this tumor was the laterally situated and distended bladder. 1 Medical Record, November 26, 1881. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 15 Dr. T. G. Thomas has called attention to the occasional adhesion of the bladder to an ovarian tumor, resulting in a spreading out of the bladder, hke an apron, over the anterior surface of the tumor as high or even higher than the umbilicus. In seven cases recorded, the case had terminated fa- tally either from direct injury to the bladder—the surgeon failing to rec- ognize the complication—or from failure to remove the tumor on account of the adhesion. In a case in his own practice, Thomas succeeded in lib- erating the bladder from its attachments and removing the tumor, with favorable results. Diverticula—loosely called "cysts" of the bladder—protrusions of the mucous membrane between the muscular fibres—are frequently found. In some cases these have no especial clinical importance ; but in most in- stances these protrusions are found in elderly men who have long suffered from prostatic hypertrophy or from stricture of the urethra. In such in- dividuals these diverticula constitute an important factor in explaining the origin and obstinacy of vesical catarrh. For since these sacs consist merely of mucous membrane devoid of muscular fibres, they are never emptied by the contractions of the bladder; indeed they are aggravated and increased in size by such muscular action. The urine, therefore, is not expelled from them, but stagnates indefinitely; the urinary salts are precipitated and accumulate, sometimes aggregated as calculi. A cystitis which originates from any cause is prolonged indefinitely in these sacs; for no medicated injection can be made to enter them thoroughly, nor can the stagnant urine and products of inflammation be removed from them, without especial effort. These sacs frequently perplex the surgeon in still another way, namely, by preventing him from touching with the sound a stone which the symp- toms prove to exist. In many cases the stone is formed and remains in the diverticulum; in other cases a calculus formed elsewhere drops into the sac, where it may remain permanently or only transiently. Sometimes the stone is found now in the diverticulum and again in the body of the bladder, according to the movements of the patient. In such instances the surgeon often becomes an unwilling party to a game of hide-and-seek in his search after a stone, sometimes reaching it with the sound at the first attempt, but failing at subsequent sittings to detect it. Sir Benjamin Brodie relates an instance in which he discovered a stone in the bladder of a man, w 10 however declined an operation. "He went on, in general suffering little or nothing. Every now and then, however, he was sud- denly seized with the usual symptoms of stone in the bladder, and very severe ones too. He then sent to me. I kept him in the horizontal pos- ture, prescribed him an opiate clyster, and in the course of a few days, sometimes sooner, sometimes later, the attack subsided, he was again at his ease and enabled to return to his usual habits. I had been occasion- ally in attendance on him for three or four years, when he was seized with a severe cold, which ended in a pleurisy, of which he died. On examining the body I found the stone imbedded in a cyst near the fundus of the bladder. The cyst was formed in this case not by the protrusion of the mucous membrane between the muscular fibres, but by a dilatation of both tunics of the bladder, the muscular as well as the mucous. The stone was not so closely embraced by the cyst as to prevent it occasionally slipping out of it, and I suspect that this actually happened, and that it was when the stone lay in the cyst that the patient was free from the usual symptoms of calculus, and that his sufferings took place when the stone escaped from it into the general cavity of the bladder." 16 DISEASES OF THE URINARY ORGANS. In occasional instances these sacs have been known to attain enormous size. In one case reported by Dr. Murchison to the London Pathological Society, there was a large abdominal tumor extending as far as the spine of the ilium, the exact nature of which was determined only by puncture and examination of the fluid withdrawn. Fifty-four ounces of urine escaped in half an hour through the puncture and through a catheter simultaneously introduced into the bladder. Coulson quotes from Warren the following case : "A man aged eighty- five, who had suffered from dysuria for several years, met with an accident which caused his symptoms to increase. His abdomen gradually became enlarged as though he were suffering from ascites, and only a small quan- tity of urine could be obtained by the catheter. On examination after death the tumor, which reached as high as the stomach, was found to have been caused by an enormous diverticulum from the bladder, the walls of which were much hypertrophied. On the left side, a little above the neck, was a round opening leading into the larger tumor, which was formed of the peritoneal and mucous coats and held a gallon of urine. From the history of the case it was evident that the prostatic enlargement had led to hypertrophy of the muscular coat. At the time of the injury this tunic had given way, and as time went on the mucous and peritoneal coverings had become distended and formed the enormous cyst." These diverticula are usually the results of a chronic impediment to the evacuation of urine—chiefly prostatic hypertrophy and urethral stricture ; they are therefore commonly observed in elderly adults. They sometimes occur in children also, being frequently produced by tight phimosis or narrowing of the meatus, and they have been seen in cases in which there was no discoverable impediment to the evacuation of urine, and therefore no appreciable cause for their existence. Erichsen mentions a case in which a smooth, fluctuating tumor was found extending from the stomach into the pelvis, in a man thirty-five years old. The tumor could be felt through the rectum, though there was no difficulty in defecation or urination. It was punctured and seven pints of clear urine withdrawn. The patient died of syncope. At the autopsy there was found dilatation of the bladder, ureters, and renal pelves, and two cysts, one on each side, which communicated with the bladder by openings large enough to admit the finger. These were diverticula from the bladder, opening into its cavity about an inch and a half above the orifices of the ureters. The most singular feature of the case was the en- tire absence of mechanical impediment in the urinary channel; both the prostate and urethra were normal. Holmes observed a case in which a large congenital cyst consisting of mucous membrane and peritoneum communicated with the bladder. This was apparently a congenital malformation. Many of the cases of so-called double bladder appear to have been instances in which congenital cysts or diverticula as large as the bladder itself existed. Thus Heyfelder detected by the sound a calculus in the bladder of a boy six years of age. After performing lithotomy, the surgeon failed to find the stone. At the au- topsy it was found that the bladder consisted of two cavities, an anterior and a posterior, connected by an orifice large enough to permit the pas- sage of a sound ; the stone was discovered in the posterior portion, which consisted of mucous membrane and peritoneum. The prostatic urethra or prostatic " sinus " is sometimes, especially in cases of great hypertrophy of the prostate, so capacious as to accommo- date a large quantity of fluid. In a few recorded instances the surgeon ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 17 has been deceived into supposing that the catheter had entered the blad- der, when in reality it rested in the dilated prostatic sinus, from which a considerable quantity of urine had escaped. The so-called " middle lobe " of the prostate is merely a portion of the gland uniting the two lateral lobes which constitute the bulk of the organ. This middle lobe may be much enlarged without any decided increase in size of the remainder of the prostate. It is situated posterior to the vesi- cal orifice of the urethra, and when enlarged it projects from behind for- ward over this orifice. The absorbent power of the vesical mucous membrane has been the sub- ject of much discussion and experimentation. Various authors have been unable to demonstrate such power of absorption and have utterly denied its existence ; among these is Sir Henry Thompson. More extended and accurate observations have, however, demonstrated that the normal mucous membrane of the bladder absorbs, though far more slowly than mucous membranes generally. The reason for this difference appears to lie in the absence of secreting (and therefore absorbing) glands. For the epithelium of the bladder consists of several layers of cells, the uppermost of the squamous variety ; this is practically impervious to fluids. It is only the follicles, which are lined with a single layer of cells, that offer a favorable opportunity for absorption ; and in the bladder these follicles are few and are located almost exclusively in and around the trigonum. In cases of disease or injury to the mucous membrane, whereby the normal epithelium is removed, absorption may occur with extreme rapidity, a fact to be remembered in the use of injections into the bladder in cases of cystitis, hemorrhage, etc. ; for when the lining epithelium is removed, either by instruments or by morbid conditions such as catarrh and ulcera- tion, the contents of the bladder are brought into close proximity to the vessels of the submucous tissue, whereby absorption is facilitated. The mucous membrane of the urethra presents a marked contrast in this respect to that of the bladder, since it readily and quickly absorbs. This fact—which possesses physiological rather than clinical interest—is readily explained by the anatomy of the part; for the urethra is lined by only a few, in some parts by a single layer of cylindrical cells, and is richly provided with secreting and absorbing follicles. The tolerance of the bladder to mechanical and chemical irritants is re- markable, and is scarcely appreciated. Strong solutions of nitrate of silver and even the undiluted solution of the perchloride of iron have been in- jected into the bladder without provoking a pronounced reaction or caus- ing much pain. This can be safely done only through a perineal opening ; for the urethra is extremely sensitive, and a few drops of such solutions applied to it cause intense pain and sharp inflammatory reaction. Hence such irritant solutions should not be injected through the urethra, since it is practically impossible to prevent contact with the mucous membrane of this channel. When, however, the bladder has been rendered accessible by a perineal incision, either for exploration, lithotomy, or for the relief of cystitis, strong solutions may be employed, if necessary. The Urethra. The mucous membrane of the urethra is furnished with numerous microscopic racemose glands, called Littre's glands. There are, moreover, in the mucous membrane tubular pockets, the so-caUed lacune of Mor- gagni, which may have the depth of an inch or even an inch and a half. 2 18 DISEASES OF THE URINARY ORGANS. These are located chiefly upon the roof of the urethra, though also found in its sides and floor. In the interior portion of the pendulous urethra these pockets attain their greatest depth, and are usually located so that their open extremities are toward the meatus ; in the posterior portion of the pendulous urethra and in the membranous part, on the other hand, the open ends of these pockets are turned inward, that is, toward the bladder. This is not an occasional or exceptional arrangement, as might be inferred from the standard text-books on anatomy and on genito-urinary diseases, most of which assert that the lacune all open toward the meatus ; a few mention the fact that in a few instances such follicles have been seen opening in- ward toward the bladder. In reality the lacune of Morgagni exhibit in every urethra, male and female, this diversity of arrangement—those of the anterior portion opening outward and those of the posterior portion opening inward—a fact which I presented and illustrated to the Royal Society of Physicians in Vienna in 1881. Whether or not this peculiar arrangement of the lacune in the pos- terior portion of the urethra has special clinical importance, remains to be proven. During the discussion in the Vienna Society it was suggested by Professor Dittel that the obstinacy of gonorrhoea in some cases might be due to the participation of these lacune in the posterior portion of the urethra; that the inflammation may persist in these follicles, inaccessible to injections or other medication, after the general urethritis has subsided. It would also seem that these lacune afford a favorable opportunity for the accumulation of urinary salts; possibly folliculitis, which sometimes occurs independently of gonorrhoea as well as during the course of that in- flammation, is favored by the anatomical arrangement of these lacune. In the female I have repeatedly found, post mortem, these follicles distended with epithelial debris and inspissated pus, even to the size of a hazel-nut. In the female the follicles are unusually deep and numerous at and around the external orifice of the urethra. In 1854 Singer, then assistant in the Clinic for Syphilis in Vienna, demonstrated the dependence of ob- stinate gonorrhoea upon the participation of these lacune ; in several cases of gonorrhoea, both vaginal and urethral, the discharge persisted in spite of all medication until applications were made directly to these individual follicles. As their orifices are located external to and just below the mea- tus, they can be easily slit up if necessary. In the male, too, a similar measure may be necessary. Phillips (quoted by Bumstead and Taylor) states that he cured four obstinate cases of gleet " by introducing a direc- tor along the upper surface of the urethra until its extremity entered the lacuna magna, and then slitting up the wall of the follicle with a narrow bistoury." The mucous membrane of the urethra in the male is, in the flaccid con- dition of the penis, thrown into numerous transverse and longitudinal folds. These favor the arrest and retention of solid ingredients of the urine which may be precipitated in the bladder; they constitute, moreover, one of the obstacles to the introduction of instruments. If the urethra were more generally examined at autopsies, and especially if the examina- tion were made in situ, the occurrence of such folds as a pathological fac- tor would probably be demonstrated more frequently. Possibly some so- called strictures of large calibre, congenital and acquired, are really due to unusually large folds of urethral mucous membrane. Saccular dilatation of the urethra is occasionally witnessed, not only as a result of stricture, but also without apparent causes. In the few cases which have been observed in females, it was assumed that the dilatation ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 19 had been furthered by compression of the urethra by the child's head dur- ing confinement. Such dilatation sometimes causes uneasiness and pain during micturition, dribbling of urine, and may even induce a slight gleety discharge from the irritation of the mucous membrane caused by the re- tained urine. In females, and often in males, a slight protrusion can be detected in the course of the urethra ; yet the dilatation may be discover- able only by the use of the urethrometer or endoscope. Congenital abnormalities of the urethral mucous membrane are not in- frequent, and possess considerable clinical importance. Among these are occlusion of the canal by simple adhesion of its walls, hypertrophy of the epithelium, saccular dilatation, and congenital stricture. These may occa- sion retention of urine in the new-born, and various anomalous symptoms, such as enuresis and dribbling, in subsequent years ; an unsuspected dila- tation and hypertrophy of the bladder, nephritis, and even uremia (seldom recognized as such), may occur in a child as the result of an undiscovered congenital impediment to the evacuation of urine. Occlusion of the urinary channel through the simple adhesion of op>pos- ing mucous surfaces occurs in varying degree and at different localities of the urethra. The adhesion of the prepuce to the glans is a frequent oc- currence in the new-born, and is known to cause numerous morbid symp- toms. The examination of the parts, and if necessary the separation of the prepuce from the glans, should be made at the birth of every male infant. Adhesion not infrequently occurs between the lips of the meatus, and may exist anywhere in the course of the urethra. Englisch, who has in- vestigated particularly this subject, found forty-six cases of simple adhe- sion between the walls of the urethra in new-born infants. In other instances the occlusion of the canal consists not in simple ad- hesion of the mucous surfaces, but in an obliteration of the urethra to a greater or less extent by cicatricial tissue. The same observer collected 39 cases of this sort in infants ; 14 were found in the fossa navicularis or at the meatus, 6 in the membranous and 2 in the prostatic portion; in 1 case the entire urethra was obliterated, and in 6 others the canal was oc- cluded at several places. Englisch has also called attention to the congenital occlusion of the ori- fice of the sinus pocularus, in the prostatic urethra, as the cause of reten- tion of urine in the new-born. Such occlusion is followed by the disten- tion of the sinus through the accumulation of secretion from the glands lining its walls. He found this abnormality in over seven per cent, of numerous dissections of infants ; sometimes the sinus was distended to only a slight degree, constituting an unimportant encroachment upon the prostatic urethra ; in other cases it was so distended as to rival the bladder in size, constituting a fluctuating tumor extending from the posterior margin of the prostate and filling up the space between the bladder and rectum even as high as the recto-vesical fold of the peritoneum. In most of these cases the bladder, ureters, and kidneys exhibited the inevitable effects of urethral impediment to the evacuation of urine ; hypertrophy and dilatation of the bladder, hydronephrosis, and even atrophy of the kid- ney was found in infants as the result of this distention of the utriculus. The possibility of this abnormality should be remembered in those cases of retention of urine in the new-born in which no occlusion of the urinary channel is visible ; the impediment is readily overcome by a catheter, and the utriculus can be emptied by pressure between a sound in the urethra and a finger in the rectum. 20 DISEASES OF THE URINARY ORGANS. Congenital organic strictures of the urethra are most frequent at the meatus and in the fossa navicularis, though they are also observed at the bulbo-membranous junction. It is noteworthy that in many of these cases phimosis also exists. This condition of the prepuce should therefore be regarded as an indication for the exploration of the urethra in those cases in which obscure urinary difficulty persists after the removal of the phi- mosis. In cases of congenital as well as of acquired stricture, there may occur dilatation of the urethra and even urinary fistula posterior to the stricture ; in other instances there may be nothing to arouse suspicion of congenital stricture except incontinence or dribbling of urine. I have seen a boy ten years of age, who had always exhibited incontinence of urine in an unusual degree, the urine frequently escaping involuntarily during the day as well as by night. After the measures usually employed had been fairly tried, and had failed to improve this condition, the urethra Was explored and a stricture, apparently organic, which tightly grasped a Charriere No. 7, was found at the junction of the bulbous and membranous portions. The stricture was slowly dilated, after which procedure perfect continence of urine followed. The conditions just described constitute constrictions of the urethra of such small calibre as to be readily appreciated by the ordinary instru- ments used for exploration ; the fact that such decided strictures have been so often recognized as congenital makes it probable that congenital strictures of larger calibre than the meatus, and therefore not discoverable by the usual modes of exploration, which cannot be distinctly recognized, exist and are overlooked. To Dr. Otis, of New York, belongs the credit of having first devised and practised accurate methods for discovering such strictures of large calibre. The experience of Otis and of the numerous surgeons who have been induced to employ these methods has demon- strated the existence of such strictures in a certain percentage of cases. The clinical importance of these strictures has doubtless been overesti- mated by enthusiasts ; yet there can be no question that they are at times responsible directly and indirectly for various abnormalities of sensation and function in the genito-urinary tract—gleet, nocturnal pollutions, etc. The urethral mucous membrane may exhibit marked hypertrophy, the thickening constituting in fact a stricture. In these cases there is usually some increase in thickness in the submucous connective tissue, but the epithelium itself presents the thickening in much greater degree. I have myself examined post-mortem two cases in which the epithelium was about one-twentieth of an inch in thickness, the section resembling the skin from the palm of the hand. In one of these cases the subject was a man thirty- nine years of age, who had experienced an attack of gonorrhoea, and who had an ordinary cicatricial stricture under the hypertrophied mucous mem- brane ; the other subject was a man twenty-one years of age, who, so far as known, had never had gonorrhoea, and whose urethra was otherwise nor- mal. In both cases the hypertrophy existed about half an inch in front of the bulb ; in each there was some increase of the submucous connec- tive tissue below the epithelial thickening. Hypertrophy of the verumontanum is occasionally observed, possibly as a result of masturbation ; in one case I have seen it enlarged to at least three times its usual volume. In this subject there was a decided disten- tion of the right seminal vesicle in consequence of the impervious condition of the ejaculatory duct, which was compressed by and in the hypertrophied tissue. In a few rare cases the veru montanum has attained an enormous size. Civiale mentions two such instances ; in one recorded by De Blegny ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 21 it was as large as a small walnut; the ejaculatory ducts were distended, and contained several hard concretions as large as peas. In the other case the veru montanum was still larger. Both subjects were old men. The muscles of the urethra possess much importance for the diagnosis and treatment of urinary and genital disorders. To the disordered action of these muscles, stimulated by irritation either in the urinary channel, in adjacent pelvic organs, or even in distant parts of the body, are attribu- table many of the so-called functional disorders of the genito-urinary organs, such as enuresis, irritable bladder, dribbling and retention of urine, abnormality in the ejaculation of semen ; indeed there can be no doubt that organic stricture of the urethra itself can be so closely simu- lated by spasmodic contractions of the urethral muscles as to deceive the surgeon. The following muscles are so situated as to compress by their contrac- tions various portions of the urethra : 1. A ring of unstriped muscular fibres situated in the posterior portion of the prostate and surrounding the vesical orifice of the urethra (the in- ternal sphincter). 2. Unstriped fibres in the pubo-prostatic ligaments, drawing the blad- der and prostate toward the symphysis. 3. Unstriped fibres in the ischio-prostatic ligament, compressing the prostatic urethra from above. This muscle and the pubo-prostatic fibres probably assist in the ejaculation of semen. 4. Striped muscular fibres—the transversus perinei profundus muscle —lying immediately behind the anterior layer of the triangular ligament and enclosing the membranous urethra and Cowper's gland. 5. Striped circular fibres (continuous with the last named) surrounding the membranous urethra. All these muscles (excluding the internal sphincter) are collectively termed by Hyrtl the compressor urethre ; they constitute the external sphincter of the bladder. 6. The bulbo-cavernosus, which arises from the central tendon of the perineum, encloses the bulb of the urethra, passes forward on either side of the penis, surrounds the corpora cavernosa, and terminates in a mem- branous expansion on their upper surface. This muscle is a powerful compressor of the urethra, whose action is witnessed in the jetting expul- sion of the last drops of urine ; it assists in the erection of the penis by compressing the dorsal vein and the erectile bodies. 7. The corpus spongiosum is richly provided with unstriped circular fibres throughout its whole length ; indeed Stilling describes the spongy body as a " muscle through which the urethra runs." Irregular contraction of one or more of the urethral muscles is a not infrequent occurrence in individuals who have suffered from disease of the urethra or even of the rectum. In cases of catarrh of the bladder neck following gonorrhoea, and of exhaustion from sexual excesses, masturba- tion, stricture, etc., there is often some irregularity in urination; the patient feels a frequent desire to empty the bladder, but accomplishes the act with difficulty ; he may be compelled to wait for some minutes before he can void the urine, notwithstanding the fact that he experiences an urgent desire and makes every effort by contraction of the abdominal muscles so to do. In other instances the stream is small and occasionally interrupted ; there may be a dribbling of urine immediately or some minutes after the conclusion of the voluntary act. Irritation in the rectum may occasion similar irregularity of the ure- 22 DISEASES OF THE URINARY ORGANS. thral muscles ; operations upon the anus or rectum are frequently followed by complete retention of urine owing to the reflex spasm of the urethral muscles. Simple nervous excitement or exhaustion may arouse such spasmodic contraction of the urethral compressors as to render urination temporarily impossible. In such cases the introduction of the catheter reveals a de- cided obstacle to its passage—a spasmodic stricture. The possibility of spasmodic stricture is practically denied by Sir Henry Thompson. Of it he says : "It is an exceedingly useful excuse for the fail- ure of instruments. It is a refuge for incompetence. Spasm may prevent the urine from going outward ; I do not know that it ever prevents the instrument from going in." Notwithstanding Sir Henry's scepticism there can be no doubt that spasmodic contraction of the urethral muscles may attain such a degree as to oppose and even temporarily prevent the en- trance of a catheter. Surgeons who certainly understand the introduction of the catheter, and who need no " refuge for incompetence," have placed upon record instances of spasmodic stricture. Thus Dittel has seen it as the result of simple acidity of the urine and in cases of diabetes mellitus, irritation of the anus by worms, fissures, etc. ; and he narrates several cases in which no other cause than mental excitement could be assigned. A Vienna physician was called to see a lawyer who was preparing for a journey and suddenly suffered retention of urine. The physician at- tempted to introduce a catheter, but met an insurmountable obstacle in the membranous portion. The patient was taken to Dittel, who passed a No. 25 F. without trouble. Two years later the same phenomenon oc- curred in the same person. This time Dittel, in attempting to introduce a catheter, met an obstruction in the membranous portion, which yielded only after the catheter had been firmly pressed against it for fifteen minutes. I was once consulted by a medical student, who upon the eve of an ex- amination for which he had been industriously preparing, suddenly found himself unable to evacuate his bladder. By persistent straining he was successful in expelling only a very small amount of urine, which dribbled away in a small and jerky stream. He stated that for several days pre- ceding the occurrence he had experienced difficulty in urination, being often compelled to wait some minutes before the urine would flow ; and he sometimes felt sure that he had not completely evacuated the bladder. He had never had gonorrhoea nor any other affection of the urinary organs previous to that time. After several unsuccessful attempts to introduce different catheters, I succeeded in overcoming the resistance, which was located in the membranous portion, by continuous pressure for several minutes with a small conical metallic instrument. Curious to know whether or not this was an instance of spasmodic stricture, or merely of my " incompetence," I secured the patient's permission to try again, several days after he had successfully passed the examination. At this time I found no difficulty in introducing different catheters into the bladder. That a spasmodic contraction of the urethral muscles should exist is certainly not remarkable. An analogous spasm of the sphincter ani is a fre- quent phenomenon in cases of ulceration of the rectum or fissure of the anus ; indeed, in these conditions a spasmodic contraction of the sphincter of the bladder, causing complete retention of urine, is not infrequent. The sphincter of the vagina exhibits a similar spasmodic condition in cases of vaginismus. It has been asserted that spasmodic contraction of the urethral muscles may exist for years, causing all the symptoms of organic stricture, and so ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 23 closely simulating this affection as to deceive the surgeon into systematic treatment by dilatation or urethrotomy. Tuffnell cites a case where a diagnosis of organic stricture of the membranous urethra was made ; but after a tape-worm which the patient harbored had been expelled, the strict- ure and its symptoms vanished. Dr. Otis is especially sanguine in main- taining the possible permanence of spasmodic stricture, while nearly all surgeons consider it as always transient and temporary. He narrates several cases in his own experience which certainly corroborate his asser- tions, provided there has been no error of observation. In these cases the spasmodic contraction of the compressor urethre has been, according to Otis, the result of irritation caused by a stricture of greater or less calibre in the anterior urethra; his usual experience has been that the catheter meets a decided obstruction in the membranous urethra, some- times yielding to pressure, but often permitting only the smallest instru- ment to pass. After dividing the stricture in the anterior urethra, how- ever, the largest sounds are passed into the bladder without obstruction at the membranous urethra. At a meeting) of the New York Pathological Society, March 8, 1882, Dr. Otis presented the urinary organs of a man who had for twenty years subsequent to a gonorrhoea suffered constantly from frequent, difficult, and painful urination. He had been under the care of many noted surgeons in Europe and America, including Sir Henry Thompson, Civiale, and Van Buren. Neither stricture nor vesical calculus had ever been detected, nor was there any enlargement of the prostate. Various diagnoses had been made. Otis discovered a stricture of large calibre near the meatus and divided it. The operation was followed by almost complete relief from the distressing symptoms, which had been nearly constant for many years, but the patient died on the ninth day from uremia. The autopsy revealed hypertrophy of the bladder and dilatation of the ureters and pelves, but no mechanical impediment to the evacuation of urine. " Dr. Otis thought that in the absence of any other cause, absence of obstruction of any kind to account for the condition of the urinary organs, we must be per- mitted to suggest the possibility of all the difficulty having been produced by spasm reflected from irritation at a distant part. The case was strictly in line with cases which he had presented to the profession before, cases where cystitis, frequent urination, spasm at the neck of the bladder had continued for a long time, and apparently the only difficulty to which these symptoms could be attributed was contraction of the meatus urinarius, not greater than in the present case ; and the proof that the supposition was correct was found in the disappearance of the trouble immediately after division of the contracted orifice." ' Such cases certainly prove that spasmodic contraction of the vesical muscles, even sufficient to produce hypertrophy of the bladder and conse- quent disease of the kidneys, can be exhibited for years without apparent and direct cause. While vesical spasm can certainly be produced by a urethral stricture, the other possible sources of irritation—in the urine, rectum, constitutional taint, etc*.—should not be forgotten; and at the autopsy a careful examination of the urethra and bladder neck should be made in situ, since valvular folds of mucous membrane can be obliterated during the removal of the organ from the body. 1 Medical Record, April 8, 1882. 24 DISEASES OF THE URINARY ORGANS. General Symptomatology. Each of the morbid changes to which the urinary organs are subject is accompanied with certain definite symptoms generally recognized as char- acteristic of the affection. These will be mentioned in discussing these conditions individually. It is to be remembered that the patient's most prominent subjective symptoms often direct attention to some other than the diseased organ, and hence mislead the physician into an erroneous diagnosis. The symptom which creates the greatest impression upon the patient, and to which he always assigns a prominent position in relating his case, is pain. Now there are two points to which pain is referred in nearly all affec- tions of the urinary as well as of the genital organs : these are the neck of the bladder and the end of the penis. Pain at one or both of these points is a symptom of the most diverse disorders ; it is felt not only in affections of the bladder, prostate, and urethra, but also in most inflammatory condi- tions of the ureter and of the renal pelvis; inflammation of the kidney itself, especially that which arises by extension from the pelvis, may be accompanied by pain at the neck of the bladder, though the region of the kidney is entirely free from pain and from tenderness on pressure. In females, affections of the uterus and of the periuterine tissues are fre- quently accompanied with pain and irritability at the neck of the bladder; indeed, a certain amount of dysuria is a regular accompaniment of men- struation in many women. Irritation of the anus and rectum, if severe, stricture, phimosis, contracted meatus, adhesion of the prepuce to the glans, and even an accumulation of smegma under the prepuce, may be responsible for uneasy sensations at the vesical neck. Unusual concentration and acidity of the urine may produce not only a smarting sensation in the fossa navicularis, but also a heavy burning pain behind the symphysis and frequent painful urination. The surgeon is sometimes consulted by young men who are firmly convinced that they have contracted gonorrhoea, because they feel a smarting pain in the urethra and at the vesical neck during the frequent acts of micturition, following a night of debauch including impure intercourse. The symp- toms are caused by the extreme acidity of the urine. Dull pain felt at the neck of the bladder with or without frequent desire to urinate occurs in cases in which no local origin for the diffi- culty can be found either in the urinary or in the adjacent pelvic organs. In some of these cases the symptoms are evidently due to malarial, syphilitic, rheumatic, or gouty taint, since they are relieved by general treatment addressed to the removal of this constitutional taint. In still other cases similar symptoms appear as one of the numerous manifesta- tions of neurasthenia, either general or sexual; just as attacks of severe neuralgia of the stomach occur from the same cause. A lady patient of mine, in apparently robust health, suffered for several months from oc- casional attacks of severe pain in the stomach, for which I could find no other explanation than general exhaustion from mental exertion and anxiety. These painful sensations of the stomach suddenly ceased, but were followed at intervals (independent of the menstrual function) by severe pains at the neck of the bladder, accompanied by painful and frequent urination. Similar attacks are sometimes witnessed in cases of hysteria, for which no reason other than the general condition can be as- signed. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 25 Pain referred to the region of the kidney is rarely caused by disease in the parenchyma of the organ itself, but is often produced by affections of the perinephritic tissues, the pelvis, and the ureter. For the kidney itself appears to be devoid of sensory nerves, which are, however, distributed to its capsule and the surrounding tissue and to the pelvis. The chronic forms of renal inflammation rarely cause pain in the kidney itself, though frequently inducing abnormal sensations at the neck of the bladder. Acute congestion of the kidney, distending its capsule; malignant growths; the excretion of highly concentrated and acid urine; perine- phritic inflammation, pyelitis, disorders of the genital organs, sexual or general exhaustion, are responsible for the pain in nearly all cases in which this is referred to the kidney. In any of these conditions the pain may be felt along the course of the ureter, in the groin, on the inner surface of the thighs, and across the abdomen, even more acutely than in the lumbar region. On the other hand, cases are recorded in which these various conditions (excepting perhaps perinephritic inflammation) have occurred without causing enough pain to constitute a prominent symptom of the affection. Diseases of the pelvis and ureter are usually accompanied by pain, though this is often referred to the bladder, genitals, sacrum, or hypochon- drium, and not perceived in the loin or groin. This is especially often the case during the passage of renal stones. In some instances pain is felt in the course of the ureter, though no renal calculi can be discovered even at the autopsy. In some of these the post-mortem examination has shown inflammation and even ulceration of the ureter. Thus Todd observed a case in which the patient had severe attacks of sharp pain, felt in the right loin and accompanied by obstinate vomiting. These attacks lasted for days or weeks at a time, after which he remained free from them for a variable period, the longest having been four years. The urine contained pus, but neither blood nor crystalline forms were discovered to confirm the diagnosis of renal calculus. At the autopsy it was found that the right ureter was thickened throughout the greater part of its length and its mucous membrane ulcerated at several points ; no calculus was discovered. There are cases, probably more numerous than we are accustomed to think, in which persistent and severe pain is experienced in the region of the kidney, independent of any morbid condition of this organ or its ap- pendages. If there chance to be slight, perhaps transient, albuminuria (as so often happens without renal disease), the physician may be deluded into a diagnosis of renal calculi or even "Bright's disease." In such cases the pain may be due to some constitutional affection independent of the kidney ; a history of malaria or syphilis, of gout or rheumatism can be elicited, or a state of nervous or sexual exhaustion be recognized. Allbut mentions several cases in which occasional attacks of abdominal pain simu- lating renal colic seemed to be dependent upon valvular cardiac disease with hypertrophy, or aortic aneurism. The dependence of pain in the back upon sexual excesses, usually ascribed by the alarmed patient to a kidney affection, is quite generally recognized by the profession ; but the agency of the various constitutional taints enumerated in producing pain in the region of the kidneys is, as it seems to me, scarcely appreciated. Inasmuch as a verdict of Bright's disease is so terrifying to the patient, and if mistaken so disastrous to the physician, the possibility of these causes for pain over the kidneys, even when accompanied by albuminuria, should be remembered and investigated before a diagnosis is made. 26 . DISEASES OF THE URINARY ORGANS. Da Costa relates the following case as showing that the symptoms of renal difficulty can be closely simulated by malarial infection : " A soldier, twenty-four years of age, of fair complexion, and evidently of strong constitution, was seized rather suddenly with pain over the left kidney. The loin was sensitive to the touch, and appeared somewhat red and swollen. The skin was hot; the pulse 100. The urine was not found to be abnormal, though containing a reddish coloring matter. The pain continued for several days, becoming more severe, notwithstanding that, by Dr. West's direction, under whose charge the man was and with whom I saw him, six ounces of blood were drawn from near the affected part. On the fourth day of the disorder the patient was assailed with excruciat- ing pain along the course of the ureter, attended with the voiding, at short intervals, of a high-colored urine. The attack lasted from six o'clock in the evening until five o'clock the next morning, leaving the patient much exhausted, the only relief throughout its duration being obtained from the inhalation of chloroform. At six o'clock in the evening another seizure of equal violence set in, and after the lapse of twenty-four hours again another. Seeing the recurrence of the paroxysms at about the same time of each day, and learning from the patient that a few months before he had had a remittent fever, which had left behind an irregular intermittent, we resolved upon the administration of large doses of sulphate of quinia in the interval between the paroxysms. The seizure did not take place that night; but the remedy being a day or two afterward suspended, the fourth night was again a night of anguish. The antiperiodic was resumed and continued in iessened doses for three weeks. The patient remained, for about six weeks after the last attack, under Dr. West's observation, gradually recovering his health and spirits. When he was lost sight of there was still a dull pain in the left lumbar region, with inability to stand erect, but no return of the excruciating intermittent neuralgic pains." A German mechanic, thirty-two years of age and of robust appearance, consulted me, saying that he was a sufferer from Bright's disease. For several months he had complained of a constant dull pain in the loins, occasionally aggravated by sharp lancinating pains, which extended into the groins, especially on the right side. His urine had been found by a physician to contain albumen. Diligent inquiry into his history failed to reveal any features of renal disease, except that about two years previously he had had fever, head- ache, and some swelling of the feet, these symptoms lasting about a week. During this time he had not been confined to nis bed, but had had pains in different parts of the body, especiaUy in the loins. A careful examina- tion of the patient failed to discover any symptom of renal disease ; there was no dropsy, no cardiac hypertrophy nor increased arterial tension, no polyuria, etc. The urine contained a trace of albumen; in all other re- spects the secretion was normal. Induration of the inguinal glands inspired questions regarding venereal disease, which resulted in the information that the febrile attack, already described as having occurred two years previously, had been preceded by a venereal sore and followed by a skin eruption. Assuming that the pain in the loins was probably an evidence of syphilis, and that the febrile at- tack three years previously had indicated the outbreak of the disease, I administered the usual antisyphilitic remedies, and in the course of a month had the satisfaction of curing the "Bright's disease," so far as the pain in the loins was concerned. Intermittent albuminuria persisted for some months. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS. 27 A young farmer came to me in the spring of 1883 for the purpose of ascertaining whether or not he had Bright's disease. He had been work- ing very hard for a year, had lost considerable flesh, his appetite was im- paired, and his rest much disturbed by pain in the back of the head and in the loins. A physician had treated him for some time without marked benefit, had finally discovered albumen in the urine, and had expressed an opinion that the patient was a victim of Bright's disease. Of several other physicians who were subsequently consulted, some had confirmed while others rejected this diagnosis, according as they had or had not found albuminuria. Upon presenting himself to me, the chief subjective symptom was the pain in the loins, usually of a dull aching character, but sometimes aggra- vated into a sharp pain, radiating from the back into the groin and testi- cle. The other symptoms indicated general neurasthenia. The patient had never had venereal disease, had lived in a malarial region, but had only once suffered from intermittent fever. The urine, examined on three different occasions, showed absolutely no abnormality except a somewhat high specific gravity. He was advised to take certain hygienic and medi- cinal measures addressed to the general health. Ten months later I saw him again in apparently perfect health. Disorders of various of the genito-urinary organs may be manifested for a long time only by symptoms exhibited by other and distant organs, symptoms whose dependence upon the genito-urinary affection is obscure. That phimosis can be the cause of paresis of the lower extremities, and even of curvatures of the spine, has been asserted by Sayre and Otis ; that sexual exhaustion is responsible for numerous and most diverse nervous symptoms has been especially illustrated and emphasized by Beard. Among these are dyspepsia, constipation, palpitation of the heart, dyspnoea, impairments of vision, numbness of the extremities and clamminess of the hands. In the urinary apparatus proper, diseases of the kidneys are especially prone to cause affections of distant organs, whose origin may be long over- looked. Indeed we are so wedded to the notion that disease of the kidney is necessarily accompanied with albuminuria, and so negligent in the ex- amination of the urine, that the absence of albumen, even if but one exam- ination be made, is often regarded as conclusive evidence in excluding renal disease ; and it but too often happens that unless there be special reasons for suspecting kidney disease, no examination of the urine is made. Symptoms of the most diverse nature and affecting nearly all of the bodily functions, are known to result from chronic renal disease. The possibility of renal origin should be remembered in cases of disordered action of the heart, cardiac dilatation and hypertrophy, increased arterial tension, asthma and chronic bronchitis, dyspepsia and chronic gastritis, chronic or frequently recurring diarrhoea, persistent headache, sleepless- ness, cerebral excitement, coryza, the impairment of vision, recurring in- flammations of serous membranes ; for any of these may exist for a con- siderable time without other symptoms directing especial attention to the urinary organs. Now among the numerous causes of renal disease are abnormalities, congenital or acquired, of the lower portion of the urinary tract. The dependence of pyelo-nephritis, hydronephrosis, and uremia upon such anomalies as phimosis, contracted meatus, congenital stricture, etc., is demonstrated; in fact, so intimate are the anatomical and physio- logical relations among the different organs of the genito-urinary tract, so far-reaching and diverse the disorders originating in these organs, that no 28 DISEASES OF THE URINARY ORGANS. examination is complete or satisfactory, whatever the supposed ailment of the patient, which does not include an inquiry into the performance of the genital and urinary functions. The degree to which this inquiry shall be instituted must of course depend largely upon circumstances. It is unde- sirable to attempt a complete examination without special reasons for it, and it is practically inconvenient or even impossible to make a critical ex- amination of the entire urinary tract and of the urine in every case in a large practice. At present, however, errors of omission to investigate are certainly more frequent among general practitioners than mistakes of com- mission by overinvestigation. Every physician who makes a practice of examining the urine and the condition of the genito-urinary organs, even in cases which present no symptoms indicating disorders of these organs, must have seen instances in which the neglect so to do might have or act- ually has misled into an erroneous diagnosis. CHAPTER II. METHODS OF EXAMINATION. When disease of the genito-urinary organs is suspected, a more or less critical examination into their condition is necessary. The means employed in making such examination will of course vary according to the nature and location of the supposed abnormality ; a suspected disease of the pros- tate requires other methods of exploration than a supposed disorder of the kidney. Yet since an affection involving one portion of the urinary tract frequently leads sooner or later to .disorders in other organs, a critical ex- amination of the entire urinary and even genital tract is often required. Such examination may require several or all of the following methods of eliciting information: 1. Questions addressed to the patient. 2. Palpation, perhaps inspection of the abdomen, the groins, the peri- neum and external organs. 3. The introduction of the finger into the rectum (into the vagina in the female). 4. The introduction of the bulbous sound for exploring the urethra; or the cylindrical sound or catheter into the bladder. 5. Examination of the urine. The information acquired by these methods is usually ample for the determination of the nature of a given case. There are, however, additional means of exploration which are less frequently required, but which must be employed in certain cases where the ordinary means are insufficient. Among these are: 6. Conjoined manipulation, the sound in the bladder and the finger in the rectum or over the symphysis. 7. Inspection of the urethra through the endoscope. 8. Determination of the urethral calibre by the urethrometer. 9. The digital examination of the bladder. This is accomplished in the female by simple dilatation of the urethra ; in the male by urethrotomy in the membranous portion. 10. The introduction of two fingers or even the hand into the rectum. 11. The introduction of a catheter or sound into the ureter (practicable as yet in the female only). Questions to the Patient. These should be addressed not only to the condition of the urinary and genital function, but also to the general condition of the patient; for cer- tain affections of distant organs often direct especial attention to possible abnormal conditions of the genito-urinary organs. The questions directed to the state of the urinary function may well embrace the four inquiries 30 DISEASES OF THE URINARY ORGANS. which Sir Henry Thompson advises as a uniform system in examining pa- tients suspected of urinary difficulties. These refer to four symptoms and signs commonly observed in such cases—frequency of urination ; pain in micturition; abnormality in the character of the urine; the addition of blood to the urine. Frequency of urination is a symptom, more or less pronounced, in most affections of the urinary tract, excepting only certain diseases of the kidney. It may be due either to an excessive secretion of urine in consequence of which the bladder is filled and must hence be evacuated at unusually short intervals, or the frequency of urination may depend upon excessive sensi- bility at the neck of the bladder or in the prostatic urethra, with or with- out anatomical lesion in these parts. Frequency of urination from increased secretion of urine is as a rule painless ; from irritability of the bladder it is usually accompanied by a painful sensation during the act. There are, however, exceptions to both of these rules ; frequent micturition dependent upon hysteria, for example, is often accompanied with decided pain, and the same symptom may be observed in cases of polyuria with pyelitis ; frequent urination from pros- tatic hypertrophy or urethral stricture, on the other hand, may be quite painless. Frequency of urination, with or without painful sensations, may be induced by affections of adjacent organs, especially the rectum and the uterus, while the urinary tract itself remains perfectly normal. It should be ascertained whether an observed frequency of micturition is as pronounced at night as by day. If it persist at night, causing the patient to rise several times to void the urine, the fact constitutes pre- sumptive evidence against the presence of calculus in the bladder, and di- rects attention especially to the condition of the prostate and urethra ; for prostatic hypertrophy, chronic prostatitis, and urethral stricture are often productive of this symptom. It is also noteworthy that the polyuria at- tending cirrhosis of the kidneys is often more pronounced at night than by day ; the patient actually secretes more urine during the hours of re- pose than in the waking condition, and is compelled to empty the bladder at shorter intervals by night than by day. Another important subject for inquiry is whether or not the desire to urinate occurs suddenly as well as frequently. A patient often states spon- taneously, as a prominent feature of his disorder, that he experiences sud- denly an urgent desire to empty the bladder, so imperious as to brook no delay. This is especially characteristic of prostatic affections as distin- guished from those of the kidney; it is also witnessed in functional dis- orders—from masturbation or venereal excess—of the genital organs, as well as in cases of irritability of the bladder from affections of the female genitals or of the rectum. Pain upon micturition is a symptom of various affections of the urinary as well as of other organs. It should be ascertained, if pain be experi- enced, in what part of the urinary tract as well as at what period of the act of micturition it is felt; also whether it exist between the acts. A smarting, burning sensation may be felt at the neck of the bladder and along the entire course of the urethra, from stricture, chronic pros- tatitis, or in consequence of extreme acidity or concentration of the urine. The same sensation, usually less pronounced, is a symptom in diabetes and hysteria. Attention has been already called to the fact that severe pain may be experienced over the kidney, along the course of the ure- ter, in the groin, and around the neck of the bladder, in cases where no METHODS OF EXAMINATION. 31 local lesion can be detected in any of these organs, in the genital organs or in the rectum. In such cases the possibility of a constitutional taint from malaria, syphilis, rheumatism, and gout should be inquired into. In many affections of the kidney, pelvis, and ureter, pain is felt almost exclusively in the bladder and urethra, even though no local lesion exist in these parts. In these cases the pain is not especially aggravated dur- ing urination. Pain which is felt only at the end of micturition is usually caused either by chronic prostatitis, cystitis, vesical calculus, or tumor ; it may also be produced by stricture in the posterior urethra. The pain of chronic prostatitis is felt chiefly behind the symphysis and in the peri- neum, often extending along the urethra; the pain caused by a stone is felt chiefly at the neck of the bladder and at the end of the penis. In females a burning pain behind the symphysis is often due to displacements and disease of the uterus. Pain felt around the neck of the bladder before and during micturition is a common symptom of acute and subacute cystitis. Pain felt at some spot in the urethra during micturition is often occa- sioned by a stricture, the urethra behind the obstruction being dilated by the urine; even a slight contraction of the channel may 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 the intervals between the acts. Pain felt especially in the perineum is caused by irritation of the pros- tate or of the bladder neck by inflammation, calculus, tumor, etc. The condition of the urine may be made the subject of inquiry ; whether or not habitual turbidity, high color, peculiar odor, or other characteristic have been noticed, and whether there has been at any time a pronounced sediment. The admixture of blood with the urine constitutes an important feature of the case. The patient's statements in regard to this point are often in- correct ; for a small quantity of blood is not recognized by the naked eye, and on the other hand, he may mistake for blood an intense color observed in highly concentrated urine, or the bright red hue which is communicated to alkaline urine by certain vegetable articles used for food and medicine, notably rhubarb. If he have noticed what he regards as blood in the urine, it should be ascertained whether the blood preceded, accompanied, or followed the stream. The appearance of a few drops of blood at the end of urination is in the majority of cases due to prostatitis ; it may occur in the course of a gonorrhoea from simple congestion of the mucous mem- brane of the pendulous urethra, without involving the prostate ; it may also be produced by a polyp or urethral stricture. In cases of vesical calculus or neoplasm the blood sometimes appears toward the end of uri- nation only, but is usually mixed with the stream. Blood which had been intimately mixed with urine for some time before voiding—as happens when it escapes from the kidney or the pelvis—frequently gives to the urine a dark brown or black color, which is not recognized by the patient as due to the presence of blood. The manner of urination often furnishes information of value; it may be desirable to have the patient urinate in the physician's presence. It may be noticed that he handles the parts carefully, perhaps that he keeps the perineum enveloped in extra clothing—features especially character- istic of prostatic disease. The promptness with which the bladder obeys the impulse to evacuate the urine, the character of the stream, a possible 32 DISEASES OF THE URINARY ORGANS. jerky irregularity of urination, and more or less dribbling at the end, should be noticed. Many patients, especially, though not exclusively, those affected with genital disorders, find unusual difficulty in urinating in the presence of a second person ; hence we are sometimes compelled to rely upon their statements as to the manner of urination. An irregular, jerky stream, appearing somewhat tardily in response to the voluntary impulse to urinate, is often seen in nervous young men, es- pecially those who have been addicted to masturbation. In these cases there is frequently some dribbling at the end of urination or even some minutes after the act is apparently completed; the stream is usually small. These phenomena appear to be due to spasmodic contraction of the ure- thral muscles, they are also caused by stricture of the urethra. A full stream which falls abruptly from the meatus is often seen in cases of prostatic hypertrophy, and may be an important point in diagno- sis in those cases in which the hypertrophy affects only the so-called mid- dle lobe and is not perceptible through the rectum ; the same phenomenon may be caused by a stricture of large calibre in the posterior urethra. Some authors assert that the existence and location of a stricture can be somewhat definitely recognized by characteristics of the stream. Thus Dittel says that if the stream be thin and dropping there is usually a nar- row stricture in the posterior portion of the urethra ; if thin, with short bow and considerable speed, the stricture is narrow, forward, and rather long ; if the stream be broken, the opening is not central. Disease of the genitial organs also may induce the most diverse symp- toms—disturbances of the cerebral functions, special senses, stomach, heart, peripheral nerves, as well as of the sexual and urinary functions. While it would be in many cases indelicate and impertinent to inquire minutely into the state of the sexual organs, yet a general question con- cerning them is rarely out of place ; and it often happens that the patient is anxiously waiting and hoping that the physician will break the ice upon this subject. If some obscure affection of the urethra, bladder, or nervous system seem to exist, the patient should be discreetly questioned as to his sexual habits and functions: the extent of his venereal indulgence, past and present, his virility, etc. Many patients are evidently much relieved when an opportunity for discussing the subject is thrust upon them by the physician's question ; for, while some men, alarmed by frequent pollutions or other genital abnormality, spontaneously direct the physician's atten- tion to such symptoms, many others, even though believing or suspecting that their present symptoms are produced by sexual sins, are restrained by pride and shame from mentioning the embarrassing subject; and unless encouraged and directly questioned, they omit entirely or merely hint at those symptoms, however important in their own minds, which they beheve to be associated with sexual abuses. Other patients are really ignorant that the annoying headache, affection of the eye, palpitation of the heart, or indigestion of which they may complain, are intimately asso- ciated with sexual excesses, etc., and therefore make no reference to these habits. The manner of ejaculation is occasionally a proper subject for inquiry; it is precipitate and often feeble in consequence of venereal excesses ; it is sometimes painful in cases of chronic prostatitis or urethral stricture (of which it may be one of the earliest symptoms); and it is sometimes lack- ing. An examination of the semen with the microscope is often absolutely necessary. METHODS OF EXAMINATION. 33 Examination of the External Organs. The eye and the hand furnish important information, positive or nega- tive, as to the nature of a difficulty in the urinary or genital organs. The meatus urinarius, the glans, and the prepuce should be carefully examined ; a contracted or pouting meatus, an elongated prepuce, a tight phimosis, the accumulation of smegma behind the corona glandis, may constitute the key to a serious difficulty, and are especiaUy to be looked for in cases of neuroses of the urinary or genital organs, such as irritability of the bladder, pain around the prostate, etc. The influence of such factors in prolonging these complaints is especially great in those who have suffered or are suffering from gonorrhoea. . In cases of acute gonorrhoea, the divi- sion of a narrow meatus is effectual in shortening the duration of the dis- charge as well as in diminishing the sufferings of the patient. Sometimes a thin fold of mucous membrane conceals a pocket just behind the lower commissure, the division of which, like the division of a narrow meatus, may relieve obscure symptoms referred to bladder and urethra. The condition of the scrotum and inguinal canal should be observed, the possible presence of varicocele, hydrocele, hardness and thickening of the epididymis and of the spermatic cord be noted. The spasmodic activ- ity of the cremasters, as shown in the constant movements of the testicles, is especially frequent in the subjects of functional or neurotic difficulties of the genital and urinary organs. By some German surgeons this con- stant movement or " hodentanz " is regarded as characteristic of habitual masturbation. The constant presence of moisture at the meatus the " weeping penis," coldness of the penis, clamminess of the scrotum, are occasional symptoms in cases of similar origin. A slight gleety discharge may proceed from stricture (most frequent), from chronic prostatitis, or simple prostatic hypertrophy; or it may be seminal fluid (true spermator- rhoea being more frequent than is generally supposed). Excessive masturbation frequently, though by no means invariabl}r, pro- duces certain changes in the genital organs recognizable by the eye. The penis appears elongated ; the glans is disproportionately large ; the mucous membrane covering it and the post-coronal furrow is thickened, resembling the cutaneous surface ; the veins of the organ become enlarged and tortu- ous ; sometimes the organ appears unnaturally cold, and the lips of the meatus are constantly wet. The scrotum is elongated, the testicles often tender and sometimes remarkably small and soft. The veins of the sper- matic cord are frequently varicose. In the female elongation of the clitoris and of the labia minora, hyper- trophy and wrinkling of the prepuce, are found as the result of masturba- tion ; the mucous membrane of the vagina is extremely hard and resisting, and the calibre of the canal frequently diminished in girls who practice this habit; an increased redness and secretion at the vaginal orifice may also be found. If an inspection of the female genitals be made, the urethral orifice should be carefully observed. Small, but very painful vascular polyps are sometimes detected ; the follicles at the lower border of the meatus some- times furnish a chronic semi-purulent discharge, which is presumed to proceed from some other source ; sharply-defined ulcers just within the urethral orifice are often found in cases of tuberculosis of the urinary or genital organs. The glands in the groins should be examined ; their enlargement may 3 34 DISEASES OF THE URINARY ORGANS. furnish a clue to some obscure disorder. The possible dependence of uri- nary symptoms upon hemorrhoids, fissures or ulceration of the anus and rectum, ascarides, etc., should be remembered and investigated. In the female a vaginal examination may reveal such a condition of the uterus and of the perimetritic tissue as suffices to explain symptoms referred to the urinary organs. Examination per Rectum. The introduction of the finger into the rectum often affords informa- tion which can be acquired in no other way. By means of it the mem- branous portion of the urethra, the prostate and neck of the bladder and the seminal vesicles are rendered accessible to the finger. For this examination the patient is placed upon the back ; the trousers should be slipped down to the knees, a small cushion placed under the sacrum, the knees drawn up and the thighs separated. In special cases it may be desirable to have the patient lie upon his side, the knees drawn up toward the abdomen and the buttocks projecting over the edge of the table or bed. Otis adopts a different position. He says : " This examination will be most conveniently and efficiently made, not in the ordinary way by placing the patient on his back and inserting the finger between his thighs, but seated in a chair you direct him to stand squarely with his back pre- senting ; have him drop his pantaloons and drawers, and with his knees straight bend forward at a right angle." Aside from the indelicacy of this position it is open to the same objection as the position upon the side, namely, that it does not permit the simultaneous examination with the sound which is so often necessary. The patient's muscular contractions necessary to maintain this position are also a disadvantage. After the patient has assumed the position described—upon his back with the hips elevated upon a cushion (an important item)—the forefinger of the appropriate hand, well oiled, is gently introduced. This procedure is decidedly unpleasant to the patient and is apt to be resisted by spas- modic contraction of the anal sphincters ; gentleness of manipulation occa- sions the least resistance and offers the surest means of overcoming it. If the exploring finger causes extreme pain or violent spasm of the sphincter, the anus should be inspected to determine the possible presence of le- sions. Just within the sphincter the finger distinguishes on the anterior wall of the rectum a cord about an inch long, the membranous urethra; some- times the posterior surface of the bulb also can be detected. In cases of stricture at this portion of the urethra, a thickening often of irregular shape but sometimes in the form of a ring can be recognized. At the inner extremity of the membranous urethra there is felt the apex of the prostate gland, rapidily widening as the finger follows it up the rectum. The groove in the middle line, corresponding to the urethra, is usually felt distinctly ; and even in cases of prostatic hypertrophy the point of the catheter can be felt through this groove. The upper border of the prostate, when this is of normal size, can be readily reached by the point of the finger of ordinary length ; sometimes, indeed, the last phalanx can be flexed around the prostate. The sound introduced into the bladder is met by the finger above and behind the prostate. In those cases in which there occurs enlargement of the middle lobe only (which always lies posterior to and projecting above the vesicle orifice of the urethra) its ex- METHODS OF EXAMINATION. 35 istence can be often surmised by the feeling that something unusual is in- terposed between the finger in the rectum and the sound in the bladder. In a few cases it has been found possible to detect with considerable cer- tainty a globular projection from this part of the prostate. The normal prostate is of firm consistence, smooth and symmetrical. At either superior angle the finger can feel and follow the seminal vesicle which stretches upward along the posterior surface of the bladder. Abnormalities of the prostate are indicated by deviations in its size, smoothness, symmetry, and sensibility A decrease in the size of the organ, atrophy, is not infrequent in ad- vanced age and occurs in earlier life as the result of gonorrhoea and con- sequent prostatic inflammation. Enlargement of the gland may be the result of inflammation or of simple hypertrophy; in either case there is usually a symmetrical increase in size, the surface remaining smooth. The acute inflammatory enlargement is indicated by extreme heat and tender- ness and by the projection of the prostate downward over the membranous urethra and backward encroaching upon the rectum. In cases of simple hypertrophy the upper border of the gland is often beyond the reach of the finger ; in other instances this border can be detected on either side but is prolonged in the median line into an indefinable projection, often indicating an enlargement of the middle lobe. Firm pressure upon the abdominal wall above the symphysis may, by forcing the neck of the bladder somewhat lower in the pelvis, make the prostate more accessible to the finger in the rectum. A lack of symmetry in the prostate may depend upon enlargement of one lobe or atrophy of the other ; the latter condition is found after gonor- rhoea and prostatitis. Enlargement of one lobe occurs in cases of tuber- culosis, as well as in simple hypertrophy. The consistence of the gland varies in different conditions. In cases of simple hypertrophy the prostatic tissue is unusually firm ; enlargement from chronic inflammation is softer; in acute inflammation it has a soft, doughy feeling. In cases of abscess fluctuation can often be detected ; in some instances prostatic concretions, lying in the distended prostatic fol- licles close to the rectum, have been recognized. The smoothness of the surface is also to be noted. The presence of small hard nodules raised above the general surface is especially frequent in cases of tuberculosis of the gland ; they are also found in that rare con- dition, malignant disease of the prostate. The sensitiveness of the prostate is much increased in all inflammatory conditions, including the tuberculous ; pressure from the rectum, like the passage of the sound through the prostatic urethra, occasions extreme pain in cases of chronic prostatitis, of habitual masturbation, and of sexual excess. The examination of the gland per rectum is often followed by the ap- pearance at the meatus of a milky or glairy fluid, which should be at once inspected through the microscope. It may be urethral or prostatic secre- tion, gleet, or semen, and should never be dismissed as simple " prostat- orrhoea." If there be no history of gonorrhoea, and no prostatic hyper- trophy, this fluid usually indicates habitual masturbation or excessive venery. The exploration of the seminal vesicles is limited to an examination as to their size, consistence, and sensitiveness. In cases of chronic prostatitis these glands are often quite sensitive and distended in consequence of the occlusion of the ejaculatory ducts by the swelling of the prostate ; a simi- 36 DISEASES OF THE URINARY ORGANS. lar condition is sometimes detected as the result of stricture. This dis- tention of the seminal vesicles may be extreme and may occasion the patient much discomfort, both local and general. It is observed in con- tinent individuals, especially those who have suddenly discontinued a habitual sexual indulgence (e. g., widowers) ; in such persons the unusual rarity of ejaculation may occasion distention of the vesicles, often with unpleasant sensations, irritability of the bladder, and nocturnal pollutions. In some instances the ejaculatory duct is obstructed by concretions formed in the seminal vesicle ; there results a distention of this vesicle and perhaps of the adjacent prostate. Gentle pressure with the finger may serve to dislodge the seminal concretions and reopen the duct. In one case re- ported, a man fifty-five years old, the right lobe of the prostate was much enlarged, projecting both into the rectum and the bladder ; the tumor was quite tender upon pressure. Frequent and painful urination, the pain being felt especially toward the close of the act; the appearance of a few drops of blood at the end of micturition ; dull pain in the perineum, often extending along the urethra to the meatus ; all these symptoms taken in connection with the condition of the prostate, led to a diagnosis of tuber- culosis of the gland. At a subsequent examination, pressure upon the en- larged prostate between the finger in the rectum and a sound in the bladder, caused a gush of whitish matter from the meatus in which small clumps of curdy appearance were seen ; the fluid contained spermatozoa. The tumor of the prostate and all the unpleasant symptoms immediately disappeared. CHAPTER III. THE SOUND AND CATHETER. The introduction of instruments into the urethra may be undertaken tor the purpose of exploring the urethra only, or the bladder also ; in the former case, the instrument should not be made to enter the bladder nor always the prostatic urethra. The habit of passing a sound quite into the bladder, even though the urethra only is the subject of exploration, is not only useless, but may be productive of harm. The exploration of the urethra aims to detect chiefly two possible ab- normalities—a constriction of its calibre, and hypercesthesia, local or general. The canal anterior to the triangular ligament (membranous portion) should be explored with an acorn or bulbous sound (Fig. 1); since for obvious rea- Fig. 1.—Bulbous Sounds. sons the withdrawal of such a bulb constitutes a far more delicate means for detecting and localizing a stricture (especially when slight) than the introduction of an ordinary conical or cylindrical sound. The latter in- strument often enables the surgeon to affirm that a patient has a stricture ; it rarely, if ever, justifies him in asserting the entire absence of strictures. If a No. 9 English sound meets a decided obstacle at some point in the pen- dulous urethra of an adult, there can be no doubt (excluding the presence of foreign bodies, false passages, etc.), that the urethra is strictured at that point; but the passage, without pronounced resistance, of a 9, 12, 15, or even 18 English sound does not prove the absence of a urethral constric- tion which may be sufficient to maintain a gleet or other morbid condition of the urinary or genital functions, for the normal urethral calibre in the adult is rarely less and usually more than 17 English (30 French) ; hence even a considerable constriction may oppose no resistance to a No. 12 or 15 sound. Moreover, a stricture may be so distensible and elastic (re- silient) as to admit, without marked opposition, a conical sound whose diameter exceeds its own ; yet upon the withdrawal of the sound it con- tracts again. While such strictures are found with especial frequency in old men, they are by no means limited to such patients ; and they may escape detection entirely by the ordinary sound, and if detected cannot be definitely located. By the bulb, on the other hand, they are easily recog- nized and located. 38 DISEASES OF THE URINARY ORGANS. The following unique case illustrates, with unusual force, the useless- ness of the ordinary sounds in detecting any except comparatively small or rigid strictures : T. L----, commercial traveller, thirty-five years old, applied for relief from a gleet which had existed about eighteen months, foUowing his third attack of gonorrhoea. He had been under treatment almost constantly by injections and sounds. To my proposition to explore the urethra for stricture, he replied that this would be unnecessary ; that he had once had a stricture which had been dilated to No. 24 ; and that he was now passing every week a No. 24 sound. Supposing this to be a No. 24 French (13 English), I produced the instrument, remarking that its passage did not prove the absence of stricture. To my astonishment he replied that his No. 24 was "about five times as big as that." Having no 24 English at hand I produced a No. 22 and found that it passed into the bladder without any serious resistance. I then introduced a 36 French bulb, the withdrawal of which was opposed quite decidedly at two points two and one-half and three and one-quarter inches from the meatus, a re- sistance quite perceptible to the patient. WTith the urethrometer I found that the calibre of the urethra at these points was only thirty-three and thirty-one. Having ascertained by the endoscope that the mucous mem- brane behind and between the strictures, though congested, was free from large granulations, I advised dilating urethrotomy for the cure of the gleet. As the patient demurred to this I made daUy applications with the endoscope for a week, without perceptibly diminishing the discharge. He then left town on business, but returned six weeks later and expressed his consent to the operation. It was performed without anesthetic, an in- cision two inches long being made so as to include the tissues in front and behind as weU as between the two strictures ; the tissues were divided to 42 French, no division of the meatus being required. A No. 24 (English) was passed daily until the sixth day, when the patient again left the city, the discharge being then a mixture of serum and blood. Two months later he caUed to say that since the tenth day after the operation there had been absolutely no discharge—for the first time in nearly two years. While I have repeatedly cured a gleet by the division of strictures ad- mitting (and hence undetected by) sounds as large as 14, 16, and in one case 17 of the English scale, a stricture admitting a No. 22 English is, in my experience, wholly unique : it suggests a topic for reflection to those who are in the habit of asserting the absence of stricture if the urethra will admit a 15, 14, or even 12 English sound. There are two reasons why so many strictures are overlooked ; indeed, only the pronounced ones (those of small calibre) are recognized by the ordinary method. First the cylindrical sounds fail to detect a slight or a resilient stricture ; second, the meatus, when of fair size, is tacitly re- garded as the measure of the urethral calibre ; for although this relation of the meatus to the urethral calibre is not formulated as a distinct prop- osition, yet it is held in practice by nearly all surgeons who use only the ordinary sounds. For they rarely deem it necessary to enlarge a fair-sized meatus in " sounding for stricture," though just why the meatus is re- garded as an index to the dimensions of the urethra, does not appear; in- deed, we would expect that the meatus, like the mouth of every other pipe designed by nature or art to throw a stream, would be smaller than the channel behind it; and this is found to be true by actual measure- ments. Many excellent surgeons decline to regard as a stricture anything which which will admit a No. 12 English sound ; and in this they follow THE SOUND AND CATHETER. 39 no less an authority than Sir Henry Thompson,1 who says : "If No. 10 or 11 of our scale goes easily—above all, if it is withdrawn without being held and slides out with perfect facility, take my word for it he has no stricture." He inveighs against the idea that the average urethral calibre should be greater than No. 11 or 12 of the English scale, and regards cy- lindrical bougies as adequate instruments for the detection of stricture. It will be remembered that this distinguished surgeon has always been averse to the introduction of large instruments into the urethra ; it was only after long and bitter opposition that he admitted (very reluctantly) that the average urethra is sufficiently capacious to receive the large evac- uating catheter (26 to 30 French), by the use of which Bigelow accom- plished lithotrity a-t one sitting. These gentlemen do not deny the ex- istence of urethral contractions larger than the meatus or than a No. 11 sound ; but merely assert that such contractions are of no practical conse- quence, because devoid of morbid influence. The test must consist in the removal of such strictures in cases of gleet, urethral spasm, neu- ralgia, etc., where no other apparent cause can be found ; and this test, made by numerous competent surgeons, has shown that slight strictures which admit a No. 11, 12, 15, or even larger sounds, are sometimes suffi- cient to maintain a gleet or vesical neuralgia, which ceases upon the re- moval of the urethral constriction. If surgeons who deny or ignore this could be persuaded to make this test in proper cases, their opinions would be entitled to greater consideration. The detection of a slight stricture is one item ; the interpretation of its morbid influence is another. The fact that many an obstinate and intract- able gleet has been promptly cured by the division of slight strictures has led certain enthusiastic surgeons into a habit of ascribing nearly all ob- scure and obstinate genito-urinary complaints to such strictures; as a con- sequence there has been a somewhat promiscuous and often injudicious performance of urethrotomy. The numerous failures to relieve by this method morbid conditions produced by other causes, has brought unmer- ited discredit and distrust upon the whole subject. Even a gleet which is usually (though not always, as Otis insists) dependent upon stricture, may persist after the removal of aU urethral contractions, however slight, and yield only to local applications. The use of the bulbous sound in detecting strictures is restricted by the fact that the meatus is usuaUy smaller than the general urethral chan- nel ; hence many slight constrictions (larger than the meatus) are not recognized. This restriction could of course be removed by division of the meatus ; but this measure, so harsh and often unjustifiable, is never neces- sary—thanks to Dr. Otis' ingenuity in devising the urethrometer. This instrument is practicaUy a dilatable bulbous sound which can be intro- duced closed through even a narrow meatus, and then expanded to any desired diameter in the more capacious urethra. For detecting contractions of the cavernous urethra, therefore, bulbous sounds (or the urethrometer) should always be employed. The largest which can easily pass the meatus is first introduced ; if this meet a de- cided impediment, smaller bulbs are substituted until the obstacle is passed ; on withdrawing the instrument the abrupt shoulder is first ar- rested by, and then, upon slight traction, jumps over the stricture, com- municating thereby a distinct sensation to patient as well as surgeon. The grasp of a spasmodic contraction of the urethral muscles (which is more 1 Diseases of the Urinary Organs, 1882, p. 18. 40 DISEASES OF THE URINARY ORGANS. frequently aroused by a bulbous than by a cylindrical sound) is continuous for several minutes, and gives an entirely different sensation. Hyperesthesia of the urethra, whether general or localized in spots, is also readUy detected by the bulbous sound ; but since this instrument may cause some pain even in a normal urethra, the discovery of sensitive spots should be confirmed by the introduction of a cylindrical sound ; the bulb should, moreover, never be introduced into the prostatic urethra, because this portion of the channel is normally very sensitive, and is prac- tically always free from strictures. Even the membranous urethra should not be invaded by a large bulb ; for in passing the triangular ligament the instrument often causes pain and bleeding ; and it may be tightly grasped and firmly held behind the ligament. The selection of the instrument for exploring the bladder is naturally dependent upon the supposed condition of the parts to be explored, and upon the object to be attained. Thus in old men with prostatic hyper- trophy the neck of the bladder is elevated and the prostatic urethra long; hence a catheter, to reach the bladder, must be longer than usual, and possess an extremely long curve. In children, too, the neck of the blad- der is higher than in adults, and the beak of the instrument must be made correspondingly long. For the exploration of the bladder, where no hypertrophy of the prostate exists, an instrument with an abrupt curve and short beak, capable of being rotated in the bladder, is required. Metallic instruments designed for introduction into the bladder should, generally speaking, be made to conform to the natural curvature of the less movable portion of the urethra, the sub-pubic curve. This curve of the urethra, traced along its upper wall, begins just in front of the pubic bones at the insertion of the suspensory ligament of the penis, rather more than an inch anterior to the bulb ; thence it descends (when the body is erect) attaining its lowest point at the anterior layer of the triangular liga- ment ; it then ascends through the membranous and prostatic portion. The posterior end lies somewhat higher than the anterior. This curve constitutes the arc of a circle three and a quarter inches in diameter (Thompson) ; the chord of the arc runs almost perpendicular to the axis of the symphysis, but is inclined slightly upward from before backward. The urethra is attached at three points in this curve—the suspensory ligament, the triangular ligament, and the pubo-prostatic ligament; these permit, nevertheless, a certain amount of variation in the curvature of the urethra, so that even a straight instrument can be introduced into the bladder. Advantage is taken of this fact in the construction of sounds, lithotrites, etc. : a short abrupt curve facilitates the entrance of the in- strument into the bladder, after which it can be pushed on until the entire beak is contained in the cavity of this organ, the straight shaft occupying the urethra. Indeed an instrument which has no curve, but is straight throughout its entire length, can be by careful manipulation introduced into the bladder without injury. The ordinary metallic catheters and sounds should be constructed so as to conform to the curve of the urethra as measured by Thompson, namely, that this curve constitutes the arc of a circle whose radius is one and five-eighths inch, the chord of the arc measuring two and three- quarter inches. The catheter should have a curve corresponding to one- fourth (90 degrees) of this circumference ; the sound should be shorter, and is usuaUy made with a curvature covering about 60 degrees of this same circumference. When the longer of these two instruments is used, the point arrives in the prostatic sinus when the shaft rests at an angle of THE SOUND AND CATHETER. 41 45 degrees with the horizon (the patient lying upon his back); the point of the shorter instrument rests in the membranous urethra when its shaft is inchned at the same angle. The sounds and catheters in general use are often of faulty curvature, especiaUy at the extremity; this is too long or too straight. Many of the difficulties of catheterization arise entirely from these instrumental defects. Except in especial cases already mentioned, the catheter should not com- prise more than one-fourth of the circumference ; indeed, a shorter instru- ment is often preferable. But in any case the end of the catheter should be so curved that the axis of its extremity forms a right angle with the axis of the shaft; in many instruments it will be noticed that the angle formed by these two axes is decidedly acute. The point of the instru- ment should be not more than one and three-quarter inch from the axis of the shaft; and if it be only one and one-half or even one and one-fourth inch, it is more easily managed, and often quite as serviceable. The sound is made with a shorter beak so that the entire curved portion can be introduced and revolved within the bladder. The introduction of the catheter should be undertaken only when the patient occupies the recumbent posture. The clothing is removed suffi- ciently to afford the surgeon free access to the perineum and external genitals, and to permit the necessary depression of the shaft between the thighs. The operator ordinarily stands upon the left side of the patient, though he must be able to catheterize from either side. Since a rectal exploration is often necessary whUe the instrument rests in the bladder, it is convenient to have the patient's hips elevated upon a small cushion be- fore introducing the catheter. The instrument, previously warmed and oiled, is held lightly between the thumb and first two fingers of the right hand, its shaft placed horizon- tally over the left groin. The left hand grasps the penis, the thumb and forefinger applied so as to retract the prepuce. The organ is raised above the groin, the point of the catheter is then introduced into the urethra, and the entire instrument is slid bodily downward (toward the knees), the shaft stUl retaining the horizontal position. MeanwhUe the penis is drawn over the instrument with the left hand. When the point has penetrated to the suspensory ligament—about as far as it will enter without force— the shaft is carried from the groin to the median line over the abdomen ; then, while the scrotum is grasped and elevated toward the pubes, the upper end of the catheter is gently raised until the shaft assumes the ver- tical position, a movement which should be readily accomplished without force by a single finger. The forefinger of the right hand is now placed over the open end of the catheter, which is then carried downward into the space between the thighs ; during this movement slight pressure may be made, so as to cause the point of the instrument to progress. If there be no abnormality of the urethra, the introduction of the catheter is usuaUy effected in this way without any difficulty ; the impedi- ments which an experienced hand meets are often due to his own anxiety, which induces him to grasp the instrument firmly and employ force in its introduction. No force is required or permitted ; skill in catheterization is exhibited not in overcoming but in avoiding obstacles. Success wiU be favored by selecting a large instrument, not less than No. 9 or 10 English, unless some abnormal impediment, such as a stricture, exists. Since the meatus is usuaUy the narrowest part of the canal, the surgeon wiU rarely make a mistake in selecting the largest instrument ad- mitted by the orifice. 42 DISEASES OF THE URINARY ORGANS. The obstacles which may oppose the entrance of the catheter into the nor- mal urethra are the following : 1. Contracted meatus. 2. The large follicle situated on the upper waU of the urethra an inch or more from the meatus, known as the " lacuna magna." This causes no difficulty if a large catheter be used as directed, though in the introduction of small conical catheters and bougies, it is to be avoided by keeping the point of the instrument on the floor of the urethra for about two inches from the meatus. 3. The symphysis impedes the progress of the catheter in case its point is permitted to project upward too soon. This is apt to happen when the shaft of the catheter is revolved to the median line over the abdomen in corpulent persons; to avoid it the point is depressed. 4. The sinus of the bulb occasions the beginner more difficulty than all the other normal impediments together. For since the urethra is here much larger than in the membranous portion adjoining it, and is more- over easily distensible there occurs a saccular ddatation of the floor of the urethra just anterior to the triangular ligament. The point of the catheter is apt to follow the floor of the canal and be stopped by the ligament. In the effort to overcome this obstruction, the point is sometimes forced through the wall of the urethra, which is here unusually delicate and easily lacerated. The difficulty at this point is overcome by keeping the point of the instrument against the roof of the urethra, and by depressing the outer extremity of the catheter, whereby the point is raised and guided into the opening in the ligament which contains the membranous urethra. The chances of avoiding this obstacle are increased by gentle traction of the penis, whereby the saccular enlargement of the bulbous urethra is obliterated by the stretching of its floor. It is sometimes necessary to place a finger on the perineum or in the rectum, and thus elevate the cath- eter and guide it through the triangular ligament. 5. Spasmodic contraction of the membranous urethra occasionally op- poses the entrance of the catheter. It is usually overcome without difficulty by steady pressure with the point of the instrument for a few minutes. It is sometimes difficult to determine whether the obstruction at this point is a spasmodic contraction, an organic stricture, or the triangular ligament. In the latter case the point of the instrument is freely movable in any ex- cept the outward direction ; while if the instrument be engaged in a stric- ture, either organic or spasmodic, it is perceptibly grasped and retained. The grasp of a muscular contraction is often plainly distinguished from that of an organic stricture ; yet it is certain that the two are sometimes confounded, misleading the surgeon into a diagnosis of organic stricture where nothing but a spasm of the membranous urethra exists. Dr. Otis thinks that this often occurs ; he says: " Deep organic urethral stricture is often simulated by muscular spasm. TJie great proportion of cases treated by gradual dilatation, are treated for deep stricture which does not exist." Such a case—in which systematic dilatation of a spasmodic stricture was undertaken in the belief that it was an organic constriction—has not fallen under my observation. Yet I recently saw a case in which external urethrotomy was proposed for the relief of a supposed organic stricture. The patient was a man of forty, who applied to a prominent local surgeon at a public clinic for relief from frequency and pain in urination. He stated that he had had a gonorrhoea (his first attack) six months previously ; that a gleet had persisted until within a month ; he had used injections and had finally succeeded in stopping the discharge. Since the cessation THE SOUND AND CATHETER. 43 of the gleet urination had been frequent, compelling him to rise several times during the night, and had been accompanied with much pain. The surgeon, suspecting stricture, attempted to introduce a large steel sound ; this was arrested in the bulbous portion. Successively smaller instruments were introduced, until finally filiform bougies were employed. All were arrested at about the same point; the use of the bougies occasioned the patient much pain, and was followed by the appearance of some blood at the meatus. A diagnosis of tight stricture was made, and the patient ad- vised that an operation would probably be necessary. A few hours later he applied to me. I found that a No. 12 English was arrested at the bulbo-membranous junction. Suspecting a spasmodic stricture, I desisted from further efforts, and advised the patient to permit no further mechani- cal interference for three days, in order to allow the swelling and irritation to subside. At the end of the time specified he called again; a No. 12 was again arrested at the same point, but entered the bladder upon the exertion of gentle pressure. As the patient happened to have a large meatus, I introduced stiU larger sounds and found no difficulty in passing a No. 17 English into the bladder. 6. The prostatic urethra in its normal state contains no obstacles to the entrance of the catheter, though the passage of the instrument through it often occasions the patient some pain. A filiform bougie has occasionally entered the orifice of the sinus pocularis. In abnormal conditions of the prostate, however, this portion of the urethra may occasion the surgeon great difficulty and perplexity in the attempt to introduce the catheter. In prostatic hypertrophy the contained urethra may be much increased in length, so that the ordinary catheter is too short to reach the bladder ; or it may deviate from its usual course, to one side or the other, forward or backward. If the middle lobe be enlarged the urethra may acquire an additional curvature before entering the bladder. Most of these conditions can be at least suspected by examination per rectum ; but some of them, especially those dependent upon enlargement of the middle lobe, may es- cape detection by rectal exploration, and be suspected only from the diffi- culty experienced in the introduction of the catheter. It is also to be re- membered that the prostatic urethra may be so dilated as to contain con- siderable urine ; the escape of this urine may deceive the surgeon into the belief that his instrument has reached the bladder. 7. If the penis be not stretched over the catheter, the point of the in- strument may be arrested by a projecting fold of mucous membrane any where in the pendulous portion. Whenever the point of the catheter meets an obstruction the instrument should be withdrawn half an inch or more and advanced again with its point in a slightly different direction. In case there is a probabUity that a false passage exists, the point of the instrument should be guided along- one or the other side of the urethra, since the false passage is probably on the upper or lower surface. It is well to bear in mind also the fact that an organic stricture may exist even though there be no history of gonorrhoea or injury ; since it may result from masturbation or congenital formation. Dangers of Catheterism. These are but few and insignificant if the urinary apparatus be normal, but are numerous and perilous if abnormal conditions of the urethra or bladder exist. Primary disease of the kidneys constitutes no objection to the use of the catheter; it is only in those renal affections which result 44 DISEASES OF THE URINARY ORGANS. from disease in the lower portion of the urinary channel that disaster to the kidneys results from catheterism. Before introducing a catheter it is important to ascertain, as definitely as possible, the condition of the urethra, the prostate, and the bladder. The possible existence of a stricture or of a false passage from previous in- strumental examinations ; hypertrophy of the prostate ; paresis, atony, or hypertrophy of the bladder ; contraction of the meatus and phimosis, should all be the subject of inquiry, for if none of these exist, the dexter- ous introduction of the catheter can scarcely occasion any evU; while in the presence of one or more of these conditions, even skilful catheterism may occasion serious results. The injuries which may follow the passage of the catheter are either direct or indirect. The former are comprised almost entirely in possible mechanical injury to the urethra, and occur only when an undue amount of force is used. They are therefore especially frequent in those cases in which the entrance of the instrument is opposed by a stricture, by en- tanglement in a false passage, or by awkward manipulation in the bulbous urethra. Such injury is indicated immediately by pain and hemorrhage, and subsequently perhaps by a chiU and fever. These symptoms, caused by laceration of the urethra, usually occur within three to five hours after the introduction of the instrument. The indirect injury which may be caused by the introduction of the catheter, even when skilfully performed, occurs especiaUy when the blad- der is unable to evacuate itself completely. This is usually the result of a mechanical impediment in the urinary channel, particularly prostatic hypertrophy or stricture ; hence it is especially in patients afflicted with one or the other of these conditions that the use of the instrument is at- tended with serious consequences. In some few cases faintness and even syncope have been known to follow the introduction of a catheter into an acutely distended bladder, the distention resulting simply from voluntary retention of urine. In the greater number of cases, however, the disastrous results of catheterization have occurred in individuals suffering from strict- ure, prostatic hypertrophy, or other mechanical impediment, causing an habitual distention of the bladder in consequence of its inability entirely to overcome the existing impediment. An inquiry into such cases shows that there has long existed considerable difficulty in urination ; that in consequence of excesses in eating or drinking, exposure to cold or en- forced voluntary retention of urine, there has occurred such an inability to evacuate the bladder as has required the services of a physician. The catheter is introduced, usuaUy without great difficulty ; a large amount of urine is withdrawn; the patient experiences no ill results untU two or three days have passed, when the first symptoms of a condition resembling typhoid fever exhibit themselves. In these cases the result of catheterization is attributable not to any mechanical injury of the urethra, nor to any hypothetical reflex nervous influence, etc., but simply to the removal of an accustomed pressure from the waUs of the bladder, ureters, pelves, and urinary tubules. For the impediment which has resulted in the inability of the bladder to evacuate itself—the stricture or prostatic hypertrophy, for instance—has resulted first, in the habitual retention of more or less urine, and second, in a hypertrophy of the muscular fibres of the bladder which give to that or- gan more than its normal firmness. If the impediment have long existed, a similar dilatation will be found to have affected the ureters, the pelves of the kidneys, and even the urinary tubules. The introduction of the cathe- THE SOUND AND CATHETER. 45 ter, by withdrawing entirely the urine habituaUy retained in the bladder (and perhaps ureters and pelves), causes extreme venous congestion of the mucous membrane in the bladder at least, and in those other portions of the urinary tract which have been distended. In many cases this conges- tion affects not only the superficial blood-vessels of the mucous membrane but also those lying in the parenchyma of the bladder. The result of this congestion—which the Germans call hyperemia ex vacuo, or negative pressure—depends upon its degree, that is, upon the amount of residual urine habitually present in the bladder as weU as upon the degree of hypertrophy, and hence inflexibility, which the muscular walls of the organ have attained. In those cases in which the bladder has suffered but little change, the hyperemia is usually of slight degree and temporary du- ration ; the patient has a chill, some fever and an escape of blood with the urine—the latter due not to mechanical injury of the mucous membrane but simply to the extravasation of blood from the congested vessels. In severer cases this congestion is the prelude to an inflammation, which may affect only the mucous membrane, but often involves the entire tissue of the bladder, resulting in an acute parenchymatous cystitis and even pericystitis ; the bladder-wall becomes swollen and softened and exhibits miliary abscesses ; suppuration may occur also in the connective tissue around the bladder and rectum. The urine often has a fecal odor. In severer cases, those in which the ureters and the kidneys have suf- fered from the habitual retention of urine, the phenomena of vesical irri- tation and inflammation are often masked under the more alarming signs of renal disturbance. As already mentioned, hemorrhage into the tubules of the kidney frequently follows the introduction of the catheter in the class of cases under discussion ; this hemorrhage, like that from the vesical mucous membrane, is the result of the intense congestion consequent upon the sudden removal of the urine which habitually distends the tubules. A high degree of this congestion, produced in cases of great distention and hypertrophy of the bladder, occasions complete anuria. The experience of every surgeon furnishes instances in which the simple skilful introduction of a catheter has been followed by more or less unpleasant results, ranging in severity from slight chill and fever, to a general inflammation of the urinary tract—cystitis, pyelitis, nephritis—or to fatal anuria. The literature of this class of diseases abounds in similar instances which have happened even to the most distinguished and skilful of modern surgeons ; and in warnings as to the possible disasters consequent upon the introduction of an instrument into the bladder. Yet but few if any of our standard text-books upon the subject make a very clear and de- cisive distinction between those cases which may be catheterized without danger, and those in which disaster may be apprehended. In nearly aU cases the danger is ascribed to the introduction of the instrument, rather than to the evacuation of residual urine—the real element of peril. Thus Coulson says,1 "cystitis of a severe and even fatal kind has been known to follow the passage of a catheter or sound. It is only reasonable to assume that in the majority of such cases an undue amount of violence was the cause of the mischief." Again " it seems probable that by reflex action the passage of an instrument along the urethra induces, under cer- tain circumstances, a disturbance in the circulation of the kidney, or in- terferes in some manner with its function." Sir Henry Thompson2 in ■Diseases of the Bladder and Prostate Gland, sixth edition, 1881, p. 37. 2 Clinical Lectures on Diseases of the Urinary Organs, 1882, p. 5G. 46 DISEASES OF THE URINARY ORGANS. speaking of the introduction of the catheter in the treatment of cases of prostatic hypertrophy, refers to the unpleasant consequences often experi- enced, and suggests, somewhat vaguely, a plan for avoiding them, without hinting at the explanation. He says : " I revert to a fact already alluded to, which is one of considerable importance, that although the urine may have been quite clear before the catheter was employed, yet in some in- stances, after its habitual use has been continued for a short period, the secretion becomes cloudy and the patient is feverish and unwell. A stage of constitutional derangement, more or less marked, has sometimes to be passed by those persons who, having long experienced difficulty, suddenly change from their usual mode of micturition to the artificial one. Sir Benjamin Brodie was the first to remark it, and in his valuable lectures called attention to the circumstance that patients might even sometimes gradually succumb with symptoms of low or irritative fever a few weeks after beginning to use the catheter." As to the cause of these phenomena he merely says : "If the patient has been in the habit of retaining perhaps a pint of urine or even more after he has made water, it is a serious change for the bladder to be suddenly and completely emptied two or three times a day ; the organ soon becomes irritable, the urine is charged with pus, and the patient loses appetite, becomes feverish, and there is sometimes considerable danger to life." A knowledge not only of the clinical fact but also of the anatomical conditions which explain it, is extremely important, for without it the surgeon who introduces the catheter is groping in the dark and liable to be overtaken in any case by a disaster which he is unable to explain or avert. Now these cases of prostatic hypertrophy, stricture, and other im- pediments to the evacuation of urine, constitute a large proportion of the cases in which the catheter is required in treating the adult male. Hence the importance of ascertaining in every case in advance the presence or absence of such impediments and of the dilatation and hypertrophy of the bladder consequent upon them. A comprehension of these anatomical relations suggests also the pre- cautions to be adopted in treatment, precautions which are quite as neces- sary in evacuating the bladder for sudden retention as in cases of habitual catheterism. Since the ill effects are traceable to a "hyperemia ex vacuo," a congestion in consequence of the removal of the accustomed pressure caused by residual urine, the first requisite in preventing these iUs is, of course, precaution to avoid this congestion, that is, care not to empty the bladder completely. Sir Henry Thompson, speaking of the use of the catheter in prostatic hypertrophy says, " it is undesirable to empty the bladder completely on every occasion of catheterism during the first few days." It is, indeed, extremely desirable and absolutely essential for the patient's welfare that the bladder should not be emptied completely at all during the first few days. Without further discussion of this item of treatment here, it wiU suffice to say that whenever the catheter is to be in- troduced in cases of retention of urine in individuals who have stricture, enlarged prostate or other impediment which may be reasonably assumed to have caused dilatation of the bladder, care should be taken to evacuate not more than half of the urine, whose quantity can be estimated by pal- pation over the pubes and through the rectum, by percussion of the abdo- men, etc. If this rule were generally observed, the introduction of the catheter would not be held responsible for nearly so many inexplicable and unforeseen disasters as is now the case; and instances of " urethral fever " would be less numerous. THE SOUND AND CATHETER. 47 The evil effects consequent upon the sudden and complete evacuation of an habitually dilated bladder are not confined to the use of the catheter and sound alone. Operations in the deep urethra or in the bladder, where- by long-standing impediments to the flow of urine are suddenly removed, are also fertUe in producing cases of cystitis, pyelitis, and nephritis. The removal of a tight stricture in the posterior urethra by either cutting or rupture, the operation of lithotomy in elderly men, is more or less danger- ous largely according to the condition of the bladder. Lithotomy is noto- riously far safer in children than in adults, other things being equal; the greater safety lies evidently not in the operation itself—for the close proxim- ity in the child of parts to be avoided increases the danger of accident from the knife—nor is it to be sought in the removal of the stone, for there is greater probability of bruising and crushing the parts in the child than in the adult. The reason for this greater safety lies largely in the fact that the child's bladder is free from other abnormalities than those caused by the presence of the stone itself ; there is no prostatic hypertrophy, prob- ably no dilatation and hypertrophy of the bladder, no dilatation of the pelvis and urinary tubules, conditions which are responsible for so much of the mortality following lithotomy in the adult. For it is well known that this mortality arises not from the injury inflicted by the knife in enter- ing, nor by the stone in leaving the bladder, but from the cystitis, pericys- titis, pyelitis, and nephritis which develop in the course of a week or two after the operation. Surgeons are in the habit of gauging the probabili- ties of success after lithotomy in an old man by the " condition of the kid- neys ;" the fact is that the condition of the kidney is, so far as it affects the result of the operation, dependent upon abnormality in the bladder or urethra ; a primary disease of the kidney does not predispose to inflamma- tory reaction after lithotomy, provided the bladder is free from dilatation and hypertrophy. Another possible danger in the use of the catheter is the introduction of materials into the bladder which may excite cystitis. Without discus- sing the nature of such materials, whether they be organized or unorgan- ized substances, it remains an assured fact that cases of cystitis have been definitely traced to the use of unclean instruments. Nor is this surprising when we observe the almost universal practice of cleansing a catheter by simply wiping it on a towel or permitting a stream of water to run through and over it. That instruments should be rendered surgically clean is in these latter days axiomatic ; the best means to this end is undoubtedly im- mersion in a weak (one part to 5,000) solution of corrosive sublimate in water. Carbolized oU or vaseline, frequently employed by surgeons, has absolutely no value for this purpose. As metallic instruments are rapidly corroded by the sublimate, they may be heated in an alcohol flame. However desirable as a routine practice the cleansing of catheters and sounds by antiseptic agents may be, the neglect to do so is followed by se- rious results in comparatively rare cases ; and these are cases in which the bladder habitually fails to expel its contents, and therefore always contains residual urine. The reason for this lies simply in the fact, experimentally as well as clinically demonstrated, that septic materials, organized as well as unorganized, gain no foothold on the mucous membrane of a healthy bladder. Putrid fluids, swarming with the bacteria of putrefaction, have been repeatedly injected into the bladders of dogs without causing the least observable pathological effect. For the bladder at its next contrac- tion expels such fluids entirely, and until injured in some way affords no opportunity for the origin or development of a septic process. It is quite 48 DISEASES OF THE URINARY ORGANS. otherwise, however, if, after the injection of the putrid fluids, the bladder is prevented from emptying itself, by tying a ligature around the penis for example. In this case, while the mucous membrane itself affords no oppor- tunity for septic processes, the retained urine furnishes ample material for fermentation ; as a result, the urine undergoes the ammoniacal change ordinarily exhibited outside of the body, and cystitis follows. A precisely analogous process occurs as the result of the introduction of an (surgically) unclean catheter into a human bladder which habitually retains more or less urine. While, therefore, such a catheter may be used with impunity in the great majority of individuals, its employment in cases of stricture, prostatic hypertrophy, paresis, and atony of the bladder, and other condi- tions in which residual urine is present, is often productive of cystitis. Nor does the damage rest with a simple inflammation of the bladder. For, in the class of cases referred to, the impediment which causes first the dilatation of the bladder and habitual retention of urine in its cavity, may produce, sooner or later, an extension of this condition to the ureters and renal pelves, which then contain a certain amount of residual urine. Am- moniacal fermentation, originated in the bladder by an unclean catheter, extends of course to the urine contained in the ureters and pelves. In such cases pyelitis and suppurative nephritis follow rapidly upon the cystitis. Epididymitis is an occasional result of the introduction of the catheter, rarely after the passage of the instrument only £t few times, but frequently occurring sooner or later in those cases in which the habitual use of the catheter is rendered necessary by prostatic difficulty. Acute prostatitis has in a few instances been occasioned by the intro- duction of catheters and sounds. CHAPTER IY. URETHRAL FEVER. This term has been used to designate the various morbid phenomena which so often occur after operations upon the urethra and bladder. The name expresses the general understanding of surgeons with regard to it— that it is a reflex or nervous phenomenon due to contact of instruments with the extremely sensitive mucous membrane of the urethra. The fact that these symptoms occur without mechanical injury to the mucous mem- brane, may even foUow the skilful and unopposed introduction of the cath- eter, has given rise to the hypothesis that the urethra is endowed with some peculiar sensibility not possessed by other mucous membranes, which can be caUed into action by simple contact of a smooth and soft catheter ; and which, thus aroused, exerts an influence not only upon the organs in its immediate vicinity, but also upon the circulation through the kidneys and even upon the heart itself. Thus Civiale, quoted by Otis, says: " Independent of its local sensitive- ness, the urethra possesses another kind which maybe termed sympathetic. When this sensitiveness is aggravated it may awaken sympathetic response in every organ and function of the body." Gross1 says: " The urethra seems to possess some peculiar morbid sympathies, through which the introduc- tion of the catheter is sometimes followed by unpleasant effects, as partial syncope, shock, epneptiform convulsions, and even death. These occur- rences are most common in persons of a nervous, irritable temperament, or who have suffered from intermittent fever or lived in hot climates ; and cannot always be prevented, however cautiously the operation may be per- formed. The sensibility of the urethra is very great, and hence it is not surprising that the contact of a bougie, however slight, should occasionally be foUowed by great pain in the parts, nervous prostration, and other dis- agreeble effects." Otis2 remarks : " In persons of highly nervous tempera- ment the predisposition to urethral fever is the rule, and any slight me- chanical interference may give rise to it." Coulson 3 says : " The cause of the symptoms of urethral fever is very obscure, but it seems probable that by reflex action the passage of an instrument along the urethra induced under certain circumstances a disturbance in the circulation of the kidney or interference in some manner with its function. It was formerly sup- posed that the symptoms were due to absorption of urine from a wound or excoriation in the urinary passages, but on the one hand the rigor often occurs before any urine is passed, and on the other it is not found that rigors invariably follow lithotomy or internal or external urethrotomy, after all of which operations urine is more or less frequently in contact with a wounded surface of the urethra." 1 Diseases of the Urinary Organs, Third Edition, p. 127. 2Loc. cit., p. 467. 3Loc. cit., p. 39. 4 50 DISEASES OF THE URINARY ORGANS. Sir Henry Thompson ' says: " What is usually termed fever" (after hthotrity) " is a series of phenomena which denote a peculiar disturbance of the nervous system, the product of mechanical interference with the male urethra. Thus a slight over-dilatation of the canal with a bougie, and still more the occurrence there of some considerable lesion, may pro- duce a febrile attack." Nearly all authors agree with those quoted in ascribing urethral fever largely to an extreme sensibility of the urethra, in consequence of which, simple contact—which might be harmless in the case of other mucous membranes—may arouse constitutional reaction. Many writers emphasize the necessity for an examination into the con- dition of the kidneys before undertaking any operation upon the urethra or bladder, as a precaution against serious "urethral fever." They recog- nize the fact that renal disease is often aggravated by such manipulations, but offer no better explanation than reflex action or the contact of urine with an abraded surface. Thus Otis,2 in discussing urethral fever, says: " I hold that in cases of long-standing urethral trouble and in aU elderly per- sons the passage of any instrument through the urethra into the bladder should never be attempted without a preliminary examination of the pa- tient's urine to determine the state of the bladder and kidneys. It is not from the fact that urethral fever in such cases is more likely to occur and with possibly greater severity than in healthy persons that this predisposi- tion is important, but because when it does occur the danger of the reflex irritation extending to the ureters and kidneys and inducing a suppression of urine, is greatly increased, and that suppression so induced is frequently and rapidly fatal" Van Buren and Keyes3 say: " That aU these disorders should depend upon the simple absorption of urine through an abraded surface is in the highest degree improbable. Other forces are at work, and these are probably shock and reflex action, suspending the function of the kidney, often already diseased. The condition of the urine also has much to do with the origin of urethral fever. It produces no effect in contact with a wounded surface when it is normal. When in ammoniacal fermen- tation it is undoubtedly capable, if absorbed, of occasioning septicemic and pyemic phenomena, and unfortunately in bladder and urethral disease the urine is very often more or less decomposed. The extent of the injury done is no index of the amount of fever that wiU foUow. The gentle pas- sage of a smooth sound may cause speedy death, while extensive wounds and lacerations of the canal are often absolutely innocuous, and that, too, where the urine is strongly alkaline." It is evident, from a consideration of the cases recorded, that the term urethral fever comprises several distinct pathological processes ; and it is equally evident, from the opinions advanced by experienced surgeons, that the intimate nature of these processes is generally unknown. Indeed Van Buren and Keyes frankly say (p. 45) "the uncertainty which surrounds that condition known as urethral fever has not yet been entirely cleared up." It is generaUy assumed that there is a reflex nervous action, origi- nated by irritation of the urethra and reflected upon the renal circulation. This is of course pure hypothesis ; there is in many cases no evidence of urethral irritation, while in many others in which extensive laceration oc- curs, no urethral fever or other evidence of reflex action follows. More- over, in those instances in which an aggravation of renal disease foUows the 1 Loc. cit., p. 89. 2 Loc. cit., p. 467. 3 Genito-Urinary Diseases, p. 46. URETHRAL FEVER. 51 introduction of instruments into the urethra, there is no proof that the morbid changes observed in the kidney can be traced to the irritation, real or hypothetical, in the urethra. If the clinical history and the post-mortem appearances be carefuUy in- vestigated, it will be found that these cases may be divided into two gen- eral classes ; first, those in which the use of instruments has occasioned demonstrable and direct lesions sufficient to explain the symptoms on anatomical grounds ; and second, those in which no lesions are discovera- ble, and which are therefore explained by a hypothetical reflex nervous in- fluence. The latter class is generaUy supposed to include by far the greater number of cases of urethral fever, but a careful consideration of the an- atomical relations of the different organs composing the urinary tract, materially reduces the number of cases which cannot be explained upon anatomical grounds. Lesions of the urethra or bladder, caused by the introduction of instru- ments, are held responsible for many cases of urethral fever. In some of these cases the wound undoubtedly becomes the starting-point for abscess formation, phlebitis, and pyemia ; but in most instances the lesion is slight, is indicated only by the escape of blood from the urethra, and is neverthe- less followed by the severer as well as by the mUder forms of urethral fever. In many of these cases there is no reason for ascribing the constitutional effect to the insignificant injury, except that no other explanation is to be found. AU surgeons recognize the utter disproportion between such slight lesions and the severe symptoms which follow, and many attempt to explain the connection between the two by assuming that the passage of the urine over the lacerated surface, and not the laceration itself, causes the nervous reac- tion. This hypothesis is exploded by the simple fact that the chill and fever often occur before any urine has passed over the wounded surface. The suggestion that ammoniacal urine may, by simple contact with the abraded tissue, cause the chiU and fever is opposed by the fact just mentioned, that this reaction occurs before contact with the urine has taken place ; more- over, the urine is in many of these cases not ammoniacal; furthermore, such contact is in many other instances not followed by urethral fever. The aggravation of pre-existing inflammation of the urinary organs is supposed to be induced by reflex action from the irritated urethra. Cystitis, pyelitis, and suppurative nephritis are frequently found post mortem after the introduction of a catheter or sound into the bladder, but that they are produced by reflex irritation has not been demonstrated. Allowing the greatest possible latitude to these anatomical disturbances in the explanation of the abnormal phenomena which follow the introduc- tion of the catheter or sound, as weU as operations upon the deep urethra or bladder, there remain numerous cases, constituting the majority of those observed, which lie beyond the pale of such explanation ; cases in which there is no evidence, during life or after death, of laceration of the urinary passages, or of pre-existing disease of the kidney. These cases comprise : 1. Instances in which chill, fever, and other signs of constitutional dis- turbance are exhibited for a few hours or days after the passage of an in- strument in individuals whose urinary organs, including the kidneys, are apparently healthy. 2. Those in which the patient has long had an impediment in the evac- uation of the urine—usuaUy a stricture or prostatic enlargement—but no evidence of renal disease. Many of these cases terminate fatally, and the report of the autopsy records normal kidneys, except that they are intensely congested. 52 DISEASES OF THE URINARY ORGANS. 3. Those cases in which syncope, collapse, and even death follow im- mediately upon the evacuation of an over-distended bladder. The explanations offered for these cases have been chiefly : (1) shock ; (2) uremic poisoning ; (3) reflex action through the nervous system aris- ing from local irritation by the presence of the instrument in the urinary canal. If the term shock can be properly applied to any of these cases, it must certainly be restricted to those in which the sudden evacuation of an over- distended bladder—whether the distention be acute or chronic—is followed immediately by such failure of the heart as to cause faintness or even death. The well-known case quoted by Sir Henry Thompson is an illus- tration ; in this instance " the old man was placed upright against a wall, the catheter introduced, and six pints of urine were withdrawn in full stream ; but the water had no sooner ceased to flow than the patient fell dead at the surgeon's feet. Fatal syncope had taken place, doubtless in consequence of the rapid removal of so large a body which had previously pressed on the abdominal veins and viscera." Since effects precisely sim- ilar in kind, if not in degree, are familiarly known to foUow the evacuation of large quantities of fluid from the abdominal cavity without any inter- ference whatsoever with the urinary organs—as in cases of ascites and ovarian cysts—it is fair to assume that the depressing influence which causes the syncope in such cases of evacuation of the over-distended blad- der, arises not from any peculiarity of the urinary organs, but simply from the general arterial anemia caused by the sudden intense congestion of the abdominal vessels following the rapid removal of previous pressure. Uremic poisoning cannot be reasonably assumed to explain cases of sudden and immediate nervous disturbance after the use of the catheter, even though partial or complete anuria results; for the interval which must elapse before an accumulation of urinary ingredients in the system could manifest itself as uremia is far greater than that which actually occurs in these cases. Reflex action through the nervous system, originated by local irritation in the urinary channel, is the favorite hypothesis adopted for explaining urethral fever in the absence of anatomical appearances. This idea of " reflex action " is so vague and indefinite, so convenient and heretofore so entirely devoid of experimental proof or disproof, that it has been made a general scapegoat for excusing and explaining urethral fever and other complications of catheterism which could not be explained by direct and visible anatomical changes. Indeed, so simple and satisfying is this theory that it has been employed in many cases where anatomical changes were obvious. Thus Sir Andrew Clark, in his recent paper upon " Catheter Fever" before the Medical Society of London,1 after describing a typical case of remittent fever following the introduction of the catheter in a pa- tient of advanced years with prostatic hypertrophy, says : " The patient, sup- posed to be healthy, but suffering from an affection of the bladder, was a few weeks before my visit enjoined the daily use of the catheter, did well for about a week, then became iU and fell suddenly into the condition in which I saw him. He died within a week of our consultation. With great difficulty permission was obtained to make a post-mortem examina- tion, and although it was made with both care and interest, nothing defi- nite was found outside the bladder, and nothing in it to necessitate or account for death. The prostate was enlarged, the bladder was dilated 1 Lancet, December 22, 1883. URETHRAL FEVER. 53 and thickened—viewed from the inside it was trabecular and slightly sac- cular—the mucous lining congested and in part eroded, and everywhere coated with a grayish white, stinking mucus. There was nothing to be detected in the urethra or kidneys, although they were examined carefully." In seeking to explain the remittent fever which occurs so often, as in this case, at the commencement of habitual catheterism, Sir Andrew Clark says : "It probably begins in the nervous system ; the disturbance of the nervous system reacts in the first instance upon the general metabolism of the body, and in the second instance upon the secretory organs, beginning with the kidney ; that the effect upon the kidney may consist either in structural alterations of the kidney, or (as seems to be much more prob- able) in alteration of the constitution of the blood, that dynamic condition of its constituents in the renal vessels essential to the elaborative action of the secretory cells thereof ; and lastly, that the concurrence of these con- ditions may and often is enforced by septic reabsorption into the blood." The cases in question, similar to that described by Sir Andrew Clark, contained no necessity for a recourse to theories about reflex nervous ac- tion, even if such theories were made far more intelligible and coherent than that suggested ; for these cases are readily explained upon mechanical principles already alluded to, namely, that the sudden removal of urine habitually present in a chronically distended and hypertrophied bladder occasions an intense congestion of the urinary tract which may involve the kidneys as well as the bladder, may even induce such engorgement of the kidneys as to produce complete anuria. The case which Dr. Clark selected as his text seems to have been a typical one of this category ; not only the clinical symptoms, but also and especially the post-mortem appear- ances—the enlarged prostate, dilated, thickened, and trabecular bladder, the congestion and erosion of the mucous membrane—are those regularly found in cases of cystitis and pyelitis occurring in old men with prostatic hypertrophy and dUated bladder, as the result not of the introduction of the catheter, but of the complete evacuation—by the catheter, lithotomy or other- wise—of an habitually distended and hypertrophied bladder. There is, so far as I am aware, no proof, either physiological or clinical, that a chronic and continuous reflex action, purely nervous, is ever mani- fested as the result of a solitary local irritation such as the introduction of the catheter. It may be asserted without fear of contradiction, that any chronic and continuous disorder of the urinary organs, traceable to the introduction of a catheter or sound or other operation in the urinary chan- nel, is based upon morbid anatomical changes and is not of merely reflex nervous origin. The introduction of the instrument may be, it is true, the initial step in the pathological process ; the catheter may empty an habit- uaUy distended bladder, the sound may accomplish the same result by dUating a tight stricture ; but the disastrous consequences which follow in either case are due, not to the contact of the instrument with the suscepti- ble mucous membrane, but to the mechanical congestion in the urinary organs, caused by the sudden removal of a chronic impediment and the relief of a chronic distention of the bladder, ureters, and kidneys. The morbid anatomical features of the case may be overlooked, or may be un- appreciated, but they are nevertheless present. Yet there are doubtless cases in which reflex action, purely nervous— that is without perceptible foundation in morbid anatomical conditions —can be properly assumed as the cause of urethral fever. These are acute cases, those in which the initial symptoms are manifested immediately, or at least within twenty-four hours after the introduction of the instrument; 54 DISEASES OF THE URINARY ORGANS. which attain their acme in a few days at most; and terminate either in death (rarely) or in recovery within three days. In all of these there are symptoms indicating faUure of the heart; in the most pronounced this faU- ure may attain such degree as to occasion faintness, syncope, and even death, may be indeed termed "shock." In the less severe and usual cases, this failure of the circulation is indicated by coldness of the extremities and chill. For these phenomena there is a physiological basis. That certain of the pelvic mucous membranes are intimately associated with important nerve-centres is demonstrated by both clinical and experimental observa- tions. Mr. Savory emphasized this clinical fact, during the discussion upon Sir Andrew Clark's paper, in the following words: " Every surgeon must be familiar with the fact, which is confirmed by physiology, that during the administration of anesthetics, after the power of reflex action has ceased in aU other parts of the body, it can still be provoked by irrita- tion about the urinary organs. If you decapitate a turtle and wait for some hours, the power of evoking reflex action dies out part by part, but the last part in which you can evoke it is the region of the cloaca.'\ "I suppose it must be in the experience of every surgeon that occasionally, even in the very young and healthy, a considerable amount of shock is caused by the introduction of the instrument. I suppose it must have oc- curred to. aU of you to see in some cases, even after sounding children for stone, that a decided shock is produced by the operation." It is also in the experience of many surgeons that the introduction of an ordinary catheter or sound, even as far as the fossa navicularis, has been foUowed by chill and decided prostration of the patient; and it is comparatively seldom that a sound or catheter can be passed for the first time through the prostatic urethra even of a perfectly healthy man without causing at least some slight indication of nervous depression. The urethra is not the only mucous membrane whose irritation may have a depressing effect upon the circulation ; for it is a fact well recog- nized by surgeons, that during operations involving the anus and the rectal sphincters a patient under the influence of an anesthetic is peculiarly prone to exhibit failure of the heart or respiration. These clinical observations are supported by the results of an experi- mental inquiry which I made in the laboratory and with the co-operation of Professor Von Basch, in Vienna.1 This inquiry was not undertaken for the purpose of supporting any preconceived hypothesis; indeed, the central fact demonstrated, that irritation of a mucous membrane may be foUowed by pronounced decrease of blood pressure, was discovered accidentally in pursuing another line of investigation. I was enabled to demonstrate that mechanical irritation of the mucous membrane of the vagina or of the rectum near their respective orifices, or of the anus or vulva, caused in curarized dogs an immediate and pronounced depres- sion of the blood column and of the heart's action. This depression amounted in some instances to more than fifty per cent, of the entire blood column—an amount certainly ample to cause decided symptoms of nervous and circulatory depression if induced in the human animal. I was further enabled to ascertain that this effect was produced by a true re- flex action involving certain branches of the sacral nerves, the spinal cord, and the splanchnic nerves ; for the circulatory depression faded to appear 1 Published in Du Bois Reymond's Archiv fur Physiologie, 1882, page 298, entitled " On Depressory Reflexes Generated by Irritation of Mucous Membranes." URETHRAL FEVER. 55 after mechanical irritation, if the sacral nerves on the one hand, or the splanchnic nerves on the other were divided. 8. 94 P3 CI Two specimens of the kymograph tracings are appended (for others see the original article). In the engravings the abscissa is raised, to save space 20 mm. in Fig. A, and 30 in Fig. B; the spaces between the ver- 56 DISEASES OF THE URINARY ORGANS. tical lines on the abscissa indicate the intervals of time, each space repre- senting 20 seconds in Fig. A and 30 seconds in Fig. B. The time and duration of the irritation is indicated by the horizontal lines just above the abscissa; the locality is designated by the accompany- ing letters— V where the vagina was irritated, E in the case of the rectum. It is thus experimentaUy demonstrated, as well as clinically observed, that a mechanical irritation, without injury, of the rectum and of the vagina, may cause, by reflex action ; a decided depression of the general blood pressure. That the same power is possessed by the urethral mucous membrane, I have been enabled to satisfy myself, though not with the mathematical accuracy possible in experiments upon animals, in the fol- lowing way : A fine glass tube is closed at one end with a close-fitting rub- ber cap, and is then fiUed with mercury to such a height that the weight of the metal is sufficient to shut off the current in the radial artery when the rubber cap rests upon the vessel. This is held in a wooden frame, which is also arranged as a rest for the wrist. When the forearm is placed in position in the frame, the tube is lowered untU the rubber cap rests firmly upon the radial artery ; so long" as the blood is propelled with sufficient force to pass the obstructing weight of mercury, the surface of the metal in the tube exhibits the oscillations of the pulse ; by gradually lowering the tube (by means of a rack and pinion) a point is reached at which the mercury ceases to osculate, and the artery is fuUy compressed. A graduated scale attached to the rack and pinion shows the point to which the surface of the mercury sinks at different times before the artery is compressed. In this way a rough estimate of the relative force of the radial pulse under different conditions can be made. Thus it is found almost without exception that the pulse is stronger—that is, requires a greater weight of mercury to compress it—in the recumbent than in the erect posture. In order to observe the effect of the introduction of an instrument into the urethra upon the blood pressure, I have, after placing the wrist of the individual in position and screwing down the column of mercury until the oscillations of the pulse were plainly transmitted, introduced a sound into the urethra. The result varies somewhat in different persons. In some cases, in which the urinary organs were apparently perfectly healthy, the contact of the instrument with the urethral mucous membrane has not produced any decided effect upon the column of mercury; in other in- stances the passage of the instrument has been foUowed at once by a complete cessation of the oscUlations in the tube, indicating that the force of the pulse was diminished ; the withdrawal of the instrument was soon followed by a return of the osciUations. In one case of tight stricture, the introduction of a conical sound until its point was grasped by the stricture occasioned an arrest of the oscillations, which were resumed only after the lapse of several minutes after the withdrawal of the instrument. While this apparatus does not furnish such delicate and accurate regis- tration of the changes in blood pressure as can be secured by a canula in the artery attached to a kymograph, yet it affords a demonstration of the fact that the introduction of an instrument into the urethra, even a normal one, may, in certain cases, cause a depression of the general arterial pressure. Conclusions.—A general survey of the subject suggests that the various morbid conditions which may be excited by the passage of sounds and catheters into the urethra and bladder—comprising among others the somewhat iU-defined groups of symptoms known as " urethral fever "—are due to various causes, chief among which may be named the foUowing : URETHRAL FEVER. 57 1. Reflex action, a purely nervous phenomenon without appreciable anatomical lesion. This may be aroused even by the skilful introduction of a catheter or sound into the normal urethra and bladder; also by the introduction of an instrument for the dilatation of stricture, with or with- out lesion to the mucous membrane. The phenomena of the reflex action may vary in degree from a slight chill and general depression without fever, to anuria, syncope, and collapse ; anuria is to be feared when the kidneys are already diseased. But whatever the degree of the symptoms they are always manifested, when due to reflex action, within a few (3 to 6) hours after the use of the instrument, and may even begin before it is withdrawn. That this predisposition to exaggerated reflex effect of catheterism varies extremely in different persons is well understood ; nor are there any rules for predicting the amount of disturbance which may be excited in any given individual whose urinary organs are in the normal state ; the predisposition is certainly greater in cases of existing disease of the urethra, especiaUy stricture ; and it is usually asserted that the reaction— of purely nervous origin—is greater in persons of nervous and irritable temperament, in those of a gouty or rheumatic diathesis, in the subjects of chronic malarial infections, and (possibly) in those who have long lived in hot chmates. 2. Laceration of the Mucous Membrane of the Bladder or Urethra.—So long as these are of shght degree they seem to have no special effect; doubtless in most cases in which a reaction follows a slight lesion to the mucous membrane, it is traceable not to the wound but to a nervous reflex action such as frequently occurs without laceration. At any rate, a shght injury to the mucous membrane is certainly not of itself sufficient to arouse urethral fever, and in the majority of cases has no such effect. When, however, the lesion is more serious, either because more exten- sive or because its location predisposes to the accumulation and decompo- sition of urine, such laceration may become the starting-point for a pyemic affection. In this case the symptoms are not developed in less than two or three days after the introduction of the instrument. The patient may of course exhibit both phenomena—a nervous chiU due to reflex action and occurring within a few hours after catheterism, and an independent chiU due to septic absorption, occurring one or more days later. 3. Congestion of the Urinary Tract, caused by the Sudden Evacuation of a Habitually Distended {and usually Hypertrophied) Bladder.—This cause is re- sponsible for the so-called urethral fever—which is reaUy the beginning of cystitis, pyelitis, and nephritis—which follows the use of the catheter in cases of prostatic hypertrophy ; and is seen with especial frequency at the beginning of habitual catheterism or " the commencement of catheter life " in old men ; the same condition results from the cutting or rapid dilata- tion of stricture in the posterior urethra, and is responsible for much of the Ulness and mortality following operations for stone in the bladder. 4. An aggravation of pre-existing renal disease by the sudden removal of a habitual impediment to the evacuation of the urine. This is, of course, of essentially the same nature as the congestion of the urinary tract previously mentioned. So far as I am able to ascertain, both from personal experience and from the observation of others, the use of the catheter never excites nor aggravates an inflammation of the kidney except in those cases in which an impediment to the evacuation of the urine has long existed. In this case there exists, as has been already emphasized several times in these pages, an excessive pressure in the ureters and pelves, which may even ex- 58 DISEASES OF THE URINARY ORGANS. tend to the urinary tubules of the kidneys ; and it is the sudden removal of this accustomed pressure by instrumental interference in the urethra or bladder which occasions an intense congestion and aggravation of a pre- existing inflammation ; in fact, this congestion may of itself excite an in- flammation in kidneys which had previously exhibited no signs of such con- dition. If the kidneys be extensively diseased, the introduction of a catheter may be followed by complete and fatal anuria, even though the bladder be normal. In this case the effect is produced not by the evacuation of re- sidual urine and institution of an inflammatory reaction, but simply by the reflex disturbance of the renal circulation. Such reflex anuria may be produced even in normal kidneys, but is more probable if the organs be disorganized by disease. 5. The Introduction of Septic Matter into the Bladder by the Use of Un- clean Instruments.—As has been already stated, such introduction occasions no appreciable reaction in cases in which the bladder is quite normal and evacuates itself completely. But in most instances in which the use of an instrument is necessary, the bladder is not in its normal condition and does not evacuate itself completely. Whenever there exists a habitual re- tention of " residual urine" in the bladder, the introduction of septic matters upon an instrument is foUowed by ammoniacal fermentation of urine and cystitis. If, as so frequently happens, the habitual distention with urine exists not only in the bladder but also in the ureters and pelves, this ammoniacal fermentation and consequent inflammation extends from the bladder to the kidney; such is the etiology of suppurative nephritis or " surgical kidney " as the result of catheterism. ClinicaUy it will be observed that the chill, fever, and other constitu- tional disturbance devoid of anatomical explanation, and therefore ex- plained by reflex nervous influence, are exhibited within a very few hours after the passage of the instrument, perhaps even beginning during its introduction ; while those conditions which are caused by circulatory dis- turbance, often culminating in inflammation, manifest the first symptoms rarely in less than twenty-four hours, and often after the lapse of several days subsequent to the passage of the instrument. CHAPTEK Y. PRECAUTIONS TO BE OBSERVED BEFORE CATHETERISM. These consist chiefly in ascertaining, so far as may be, the presence of any disease of the bladder or kidneys previous to the introduction of the catheter. I wish to emphasize the word bladder in this connection, since many surgical teachers either ignore entirely the condition of the bladder or assign to it a very subordinate place, concentrating their attention upon the condition of the kidneys. An individual who has no stricture, no prostatic hypertrophy, no tight phimosis or contraction of the meatus, no paresis nor atony of the bladder —in short, no inabihty to evacuate the bladder completely—can be (prop- erly) catheterized without danger, no matter what the condition of the kidneys may be. The worst that can be apprehended in such a case is a pro- nounced nervous reaction. This may be so severe as to occasion the friends of the patient much alarm for a short time, and include fever, delirium, and even convulsions ; but it is of temporary duration, and occasions no per- manent disease. So far as I can ascertain by a careful examination of the literature, the only cases of death from " shock " after catheterism have been in individuals suffering from chronic disease of the bladder or urethra, or from acute over-distention of the bladder. Various medicinal agents have been recommended and employed for the purpose of diminishing this liability to nervous reaction from catheterism ; among these quinine and opium have been especially lauded, but, like the rest, have often faded. This failure is not surprising when we remember that the distinction between urethral fever of purely nervous origin on the one hand, and of anatomical source on the other, has not always been clearly recognized by surgeons. The existence of stricture, prostatic hypertrophy, or other condition which may naturaUy induce habitual retention of more or less urine in the bladder, caUs for the greatest care in catheterism. In such cases the in- strument used must be clean—surgically clean—a condition attained by brief immersion in a weak solution of corrosive sublimate, and the bladder must never be at once completely evacuated. Considerable tact and judgment must be exercised in carrying out the last injunction, since we are not always in a position to know just how much urine is contained in the bladder. If this organ be distended with urine, as happens in those cases in which the catheter is required in consequence of the inabihty to void the urine, the quantity can be estimated by palpation and percussion over the symphysis ; in such cases the catheter can be withdrawn when only half or two thirds of the urine is evacuated. More frequent and more susceptible of injury are the cases in which there exists not an acute but a chronic retention of urine, in consequence of prostatic hypertrophy or stricture of small calibre. In cases of the 60 DISEASES OF THE URINARY ORGANS. former class the catheter is introduced perhaps not to relieve an acute re- tention of urine, but as the commencement of the treatment necessary during " catheter life." In such cases it is aU-important that at least half of the residual urine (if this exceed one or two ounces in quantity) be al- lowed to remain in the bladder. If the quantity of residual urine be great —six, eight, or ten ounces—its presence is readily detected by manual ex- amination after the patient has evacuated the bladder so far as he can. It is not uncommon to find instances, chiefly elderly men with prostatic hyper- trophy and thickened bladder, in whom rectal and abdominal examination reveals a tumor as large as the fist after the patient has, as he supposes, voided the last drop of urine. In these cases in which we can detect and outline the still partly filled bladder, we can estimate approximately the amount of residual urine before introducing the catheter, and then having permitted not more than half of this quantity to escape, withdraw the in- strument. In many other cases we cannot determine satisfactorily how much, if any, residual urine remains after the voluntary act of micturition ; in such cases the catheter is introduced and the size of the stream which issues from it noted ; if this be full and strong, it is probable that several ounces of residual urine are present. In any case, however, in which the catheter reveals residual urine after the patient has exerted his entire abil- ity in evacuating the bladder, not more than one or two ounces of this re- sidual fluid should be permitted to escape at the first use of the instrument. Moreover, a saturated solution of boracic acid, equal in volume to one-half of the residual urine removed, should be injected and permitted to remain. Similar precautions should be observed in introducing the catheter in cases of long-standing, contracted stricture ; only a portion of the urine should be removed. In this way, and thus only, can we have an assurance of avoiding the most serious consequences, such as happened in a case which came under the writer's observation (and constitutes by no means an isolated or unique instance in surgical experience). In this case a man was admitted to hospital suffering from acute retention of urine caused by the effects of a debauch superadded to an old and contracted stricture. After various futile attempts with elastic catheters, a small conical silver in- strument was introduced into the bladder, the effort occasioning trifling hemorrhage from the urethra. Nearly four pints of urine were evacuated. The catheter was used three times daily for two days, at the end of which time the patient had regained the ability to void urine. It had been de- cided to dUate the stricture, when, upon the third day after admission, the patient had a severe chill foUowed by fever, prostration, and the usual symptoms of the so-called typhoid condition. The urine became scanty and bloody. At the end of a week he died. The autopsy showed no recent lesion at the seat of stricture, but a hypertrophied bladder with well-marked trabecule and a diverticulum just at the right edge of the trigonum, dilated ureters and pelves. The bladder wall was soft, swollen, and con- tained numerous abscesses from the size of a pea downward ; there was a perivesical inflammation and coUection of pus between the bladder and rectum. The mucous membrane of the bladder was swoUen, soft, injected, and at several places eroded. The kidneys were engorged with blood, and showed under the microscope numerous muiary hemorrhages. In short, the case was one of cystitis and pericystitis in a habituaUy distended and hypertrophied bladder. The cause of the inflammation was not nervous re- flex action nor injury to the urethra, but the immediate evacuation of all the urine contained in the bladder, or the use of an unclean catheter, or both ; a result which might have been avoided had the catheter been care- PRECAUTIONS TO BE OBSERVED BEFORE CATHETERISM. 61 fully cleansed before introduction, and withdrawn when half of the contents of the bladder had escapeV. The exploration with the sound or catheter affords certain information as to the condition of the urethra and bladder. A narrow stricture op- poses the progress of the instrument; and if a conical sound of such size be used as permits the entrance of its point into the stricture, the in- strument is observed to be firmly grasped by the urethra. This condition may be, however, simulated by spasmodic contraction of the urethral mus- cles in the membranous portion ; the similarity is increased by the fact that the adjacent portions of the bulbous and membranous urethra are especially often the seat of stricture. To a practised hand the difference between the grasp of the compressor urethre and of a stricture is usually apparent at once ; if there be any doubt, it can be decided by maintaining a gentle pressure with the point of the instrument against the obstruction. A spasmodic muscular contraction soon yields and resistance vanishes ; while a stricture, though dilating sufficiently to permit the passage of the instrument, still maintains an appreciable pressure and opposition. The passage of the sound along the urethra may also reveal points of extreme sensitiveness; this condition is frequent after gonorrhoea, and may be due to the presence of eroded or granular areas, a question to be decided by the endoscope. The passage of the point of the instrument along the prostatic urethra is usually, even in health, accompanied with an unpleasant, perhaps pain- ful sensation. In cases of prostatitis, the patient experiences extreme pain which may amount even to agony, causing him to scream and struggle to escape the sound. The introduction of the sound or catheter into the bladder should be made when this organ contains considerable urine ; if it be empty, fluid should be injected, whence the advantage of using a catheter rather than a sound for exploring the bladder. By means of the instrument we ascer- tain the sensitiveness, the consistence, the smoothness, and the elasticity of its walls ; the presence of foreign bodies or of tumors ; and an approximate estimation of its normal capacity. In its normal state the lining membrane of the bladder endures the gentle contact of the instrument without experiencing pain ; it is uniformly smooth; it is sufficiently elastic to permit the point of the instrument to carry the waU of the bladder at least an inch beyond its original position, and to expel the catheter to the same extent when the pressure is removed. The short-beaked instrument already recommended can be rotated so that its point makes a complete revolution in the bladder without meeting any decided resistance. In abnormal states the instrument often reveals decided departures from these characteristics. If the mucous membrane be inflamed, or if there be ulceration or a morbid growth present, the contact of the sound causes ex- quisite pain. In general cystitis the mucous membrane is everywhere thus sensitive ; if there be ulceration from a malignant growth or other cause, this sensitiveness is usually locahzed. Hypertrophy of the bladder wall is indicated by the presence of trabe- cule, hypertrophied muscular fibres separated by depressions. In this condition the point of the sound can be felt to scrape over the ridges thus produced. In cases of muscular hypertrophy, moreover, the bladder waU does not yield readUy to pressure with the instrument. The presence of a foreign body or of a growth in the wall of the bladder opposes a localized resistance to the rotation of the sound. Morbid growths as well as calculi 62 DISEASES OF THE URINARY ORGANS. are usually found at the base of the bladder; and it sometimes happens that the only tactile evidence of a neoplasm in the bladder is afforded by the resistance encountered in the effort to rotate the sound toward one side, while it moves readily toward the opposite side. The careful injection of warm water through the catheter into the bladder may enable us to distinguish simple dUatation from dilatation with hypertrophy. In the former condition the bladder yields readily to the entering liquid, and expels it again in a feeble stream ; if there be hyper- trophy, on the other hand, the bladder tolerates but a smaU quantity of fluid, the distention of its waU arousing an irresistible desire for its con- traction, by which the water is forcibly expeUed. In some cases the mucous membrane of the bladder is coated in spots with scales of phosphatic concretions ; these give to the exploring instru- ment a sensation which may readdy be mistaken for the roughness com- municated by hypertrophied muscular fibres. In many instances exploration with the sound is materially assisted by a finger in the rectum or by a hand over the symphysis. In the normal bladder the point of the instrument can be readily detected from the rec- tum, and (except in fleshy persons) above the symphysis. In abnormal conditions various bodies may be so interposed as to prevent such approxi- mation of the finger and the point of the sound. Thus an enlargement of the middle lobe of the prostate may extend so far toward the fundus of the bladder that its upper edge cannot be reached by the finger in the rec- tum. Morbid growths, which are usually situated upon or in the imme- diate vicinity of the trigonum, may also prevent such contact, and can sometimes be defined between the sound and finger. Diverticula of the bladder—protrusions of its mucous membrane between the muscular fibres —are also usually found near the trigonum, and can sometimes be readdy detected by conjoined examination. In one case of prostatic hypertrophy, with consecutive thickening of the muscular coat of the bladder, I was en- abled to feel distinctly the entrance of the sound into the diverticulum with the hand which held the instrument, whde with the finger in the rectum I distinguished its point projecting just to the outer side of the seminal vesicle. By means of the sound in the bladder and a hand over the symphysis, it is sometimes possible to detect a thickening of the anterior waU such as may occur from a morbid growth located in this portion of the bladder. Occasionally a pedicled tumor attached to some other portion of the bladder wall has been detected in the same way. A bimanual examination of the bladder has at times great advantages. This is accomplished by passing two fingers, or even the entire left hand as far as the thumb, into the rectum, while the right hand placed just above the symphysis exerts firm pressure downward and backward toward the rectum. The patient must of course be under the influence of an an- esthetic. In this way the body of the bladder is brought between the ap- proximated ends of the fingers; and if the patient be not too fleshy, the organ can be explored with considerable delicacy. Volkmann states that he has been enabled in this way to detect the presence of a stone as small as a bean. He advises that, in children especiaUy, the object in the bladder be pressed by the fingers in the rectum up against the abdominal wall, where it can be seized and outlined by depressing the skin around it. He has thus been enabled to estimate with accuracy the size and shape of a calculus. The method is, of course, not devoid of danger to both rectum and bladder. CHAPTER VI. DIGITAL EXAMINATION OF THE BLADDER. By the methods already described the condition of the bladder can be ascertained with sufficient accuracy in most cases. They are especially satisfactory in the female ; for a finger in the vagina, with or without the assistance of the hand over the symphysis, affords more definite and satis- factory information than can possibly be obtained by rectal examination in the male. The entire cavity of the bladder is thus brought within the range of palpation ; the trigonum can be outlined, and its apices can be, with a little practice, distinctly recognized. This is an anatomical point of some importance, since by means of a vaginal examination the orifices of the ureters, located at the angles of the trigonum, can be located and re- tained in position whUe a catheter is introduced into them. The introduction of a sound enables the surgeon to explore the vesical waU with this instrument, and to include a considerable portion of it be- tween the finger in the vagina and the point of the instrument in the bladder. Calculi or other foreign bodies (the latter more frequently found in the female than in the male bladder) and morbid growths can thus be detected and outlined. In many instances it is extremely desirable to make a digital examina- tion of the interior of the bladder. In the female this can be readily accomplished by dilatation of the urethra. This procedure, which was first brought prominently before the profession by Simon, of Heidelberg, is readily executed ; but it has been found to contain possibilities of injury and danger which were hardly appreciated by the surgeons who first em- ployed it, and it should be practised only when less radical methods of examination fail to furnish the information required. Simon used, for this purpose of rapid dUatation of the urethra, a series of dilators made of hard rubber. These instruments were seven in num- ber, constituting a graduaUy increasing series, the smallest about one-third of an inch, the largest nearly an inch and a quarter in diameter. They were introduced in succession, each being aUowed to remain from one to two minutes. The largest has a circumference equal to that of the ordinary forefinger, which can therefore be introduced into the bladder immediately after the removal of the largest dilator. These instruments of Simon have been superseded by dUating specula. It is extremely important that a proper instrument be used, since if the dilatation be effected, as is usuaUy the case, by means of some instrument designed for another purpose—such as uterine dilators, polypi forceps, etc. —laceration of the mucous membrane and incontinence of urine are almost inevitable. It is important that the distending force of the instrument should be distributed equally around the entire circumference of the urethra and not upon two or three points only, as occurs when uterine ddators, etc., 64 DISEASES OF THE URINARY ORGANS. are employed for this purpose. The dilatation should be continuous, uni- form, and gradual; the instrument should be so constructed as to permit the exercise of much or little force, according to the resistance to be over- come. The combined dilator and speculum, devised by Stein, of New York, is a most satisfactory instrument for securing these results. If this be properly employed, there is but little danger of serious laceration or more than temporary incontinence ; with it the preliminary incisions of the urethral orifice, which Simon was in the habit of making, are unnecessary. Before using other instruments three incisions may be made, two lateral ones a tenth of an inch deep, and one at the inferior border of the meatus, a quarter of an inch deep. In using Stein's dilator, " the patient being on the back or side and anesthetized, the instrument is introduced and rapidly dilated to a point at which some resistance is felt, when the dilatation is proceeded with more slowly and cautiously, the canal being stretched a few millimetres at a time, the force exerted being in inverse proportion to the resistance to be overcome, and a. sufficient interval of time always allowed to elapse for the tissues to relax before further dilatation is made. In this manner the instrument is gradually expanded to the circumference of the index finger, or if need be to its fullest capacity, which is six and a half centimetres." Dilatation with the fingers alone, so frequently performed, is produc- tive of most disastrous consequences, and is always fraught with danger. I have seen perivesical inflammation and abscess, and even fatal peritonitis, caused by this digital dUatation. The degree of dilatation permissible varies, of course, with the age of the patient as weU as in different adults ; the pain and danger of laceration are proportionate to the rigidity of the canal, which is usually most pro- nounced at the meatus. Simon directed that in patients under fifteen years of age the urethra should never be dilated more than 1.5 to 1.7 ctm. in diameter ; and that in the adult female the cahbre of the canal should not be made to exceed 2 ctm. This is a safe rule ; yet in many instances the dilatation has been carried to a much greater degree without iU results ; both index fingers, or a finger and forceps, have been simulta- neously introduced into the urethra without causing even temporary in- continence.1 When the forefinger is introduced into the bladder, the middle finger of the same hand rests in the vagina, whUe the other hand, placed above the symphysis, presses the abdominal wall downward so as to bring the fundus of the bladder within reach of the exploring finger. Unless every precaution be taken, including anesthesia of the patient, the choice of a proper instrument, the utmost gentleness in manipulation after the introduction of the finger into the bladder as weU as during the dilatation of the urethra, this operation is fraught with danger. In favor- able cases there may occur nothing worse than incontinence of urine for a few hours ; in other instances this incontinence has persisted for weeks or months ; in still other cases—probably only when gross errors are com- mitted—pelvic inflammation and abscess, and even peritonitis, have fol- lowed. Digital exploration of the male bladder can be made through a perineal incision, a method of exploration recently employed and brought promi- nently before the profession by Sir Henry Thompson and Mr. Whitehead. The operation consists simply in external urethrotomy in the membra- 1 Schatz, Winckel. DIGITAL EXAMINATION OF THE BLADDER. 65 nous portion ; the novelty hes therefore not in the operation itself, but in its performance for the purpose of permitting digital exploration of the bladder. A grooved staff is introduced, an incision made in the raphe of the perineum to the membranous urethra, which is then opened sufficiently to admit the index finger of the left hand ; this is then pushed through the urethra to the bladder. If the anesthesia is so complete that the ab- dominal muscles are quite relaxed, pressure with the right hand above the pubes brings nearly every portion of the surface of the bladder into con- tact with the end of the finger introduced through the urethra. The operator carefully observes the condition of the vesical mucous sur- face, whether it is everywhere smooth, or roughened in spots ; thickening of the mucous membrane, projecting villi, and neoplasms may be found ; if bands of muscular fibres with intervening depressions are distinguished, the bladder is hypertrophied ; in such cases a careful search for calculi should be made, since these may be partially enclosed, or even entirely encysted in the cavities between the folds. In one of Thompson's cases (a woman), there was " found springing from the centre of the trigone a firm prominence, externally consisting of some soft structure and almost poly- poid in form ; but on drawing it forward in the attempt to ligature its base, this outer layer was first scratched through, when a hard calculus, about the size of an acorn, was disclosed and enucleated, the prominence disappearing." Otis,1 after performing median lithotomy and searching the bladder for a foreign body in vain, was about to discontinue the exploration when his finger grazed a soft, pendulous body as large as a bean ; this was extracted and found to be an encysted calculus covered with clotted blood. Sometimes a scale consisting of phosphates, or of a pseudo-membrane incrusted with urinary salts, has been detected and removed by the finger-nail; "indeed, it is difficult to say at present what may not be found, as fresh experiences have brought to light conditions to some ex- tent not heretofore recognized " (Thompson). Even if no tumor, calculus, nor morbid condition of the surface be detected, great benefit is often de- rived by the repose secured to the bladder through this operation ; a large rubber catheter introduced through the wound and permitted to remain for six or eight days, relieves the bladder from the necessity for contraction and has sometimes entirely removed the morbid symptoms which led to the operation, by giving rise to a suspicion of a foreign body in the bladder. Digital exploration is justifiable and frequently useful, not only in those cases where the existence of a vesical tumor can be safely affirmed upon the symptoms present, but also in many other instances where the cause of the morbid symptoms may be obscure and undetected. Yet be- fore the surgeon undertakes this operation, he should exhaust all the less serious and radical means of exploration, including a determination of the urethral calibre by means of the urethrometer, and the inspection of the urethra through the endoscope. For these instruments may reveal in a urethral construction, polyp, or granular surface, the source of and means of relieving symptoms which are referred to the bladder—irritability, pain, hemorrhage ; if the morbid influence of shght urethral abnormalities be forgotten or ignored, the surgeon may be betrayed into performing a use- less and unjustifiable exploration of the bladder. Premising that these methods of exploration have been employed, and have failed to explain and relieve the morbid condition, we may accept Sir Henry Thompson's 1 Loc. cit., p. 546. 5 66 DISEASES OF THE URINARY ORGANS. conclusions, based upon an experience of thirty-eight cases, as indications for the performance of urethrotomy in the membranous portion. He says : " On carefully analyzing these cases there appear to be four chief forms of vesical disease, in which the operation of opening the urethra for the purpose of withdrawing the urine altogether by an artificial route, and so suspending the functions both of the bladder and urethra for a time, may render good service. Besides these, there remains a fifth class of cases, namely, those in which the operation is undertaken solely with a view of exploring, when the presence of a tumor may be strongly suspected. " 1. The first class consists of those cases, not unfrequently met with, in which all the symptoms of chronic cystitis have existed for a long period and in a severe degree, and which persist in spite of long-continued and appropriate treatment; while at the same time it is understood that the absence of material cause for the cystitis, such as stone, stricture, vesi- cal incompetence, etc., have been ascertained. " 2. The second class of cases includes those examples of prostatic hyper- trophy and of atony of the bladder in which that organ must be emptied by the catheter many times in the twenty-four hours, and in which painful chronic cystitis is obviously aggravated if not maintained by the necessary process of relief. These are usuaUy cases in which the disease has existed for years, and which have arrived to all appearance at the latest stage, unless complete relief can be afforded. " 3. The third class embraces those cases, less rare perhaps than they have been supposed to be, in which the existence of impacted calculus or of adhering calculous matter may be suspected or may be known to be present by sounding. "4. In the fourth class I placed those cases in which painful and very frequent micturition or bleeding, separately or combined, may have long existed ; without signs of cystitis, the urine being clear, free or nearly so from mucous or purulent deposit; furthermore the cause of these symptoms has baffled the most careful inquiry. On exploration being made no organic change is discovered, no light is obtained on the diagnosis of the case, but the functions of the bladder and urethra are suspended for a week or so, and the patient gets well more or less completely." (It is in these cases especiaUy that the endoscope and the urethrometer—means of exploration which Thompson does not yet employ—should be used before the bladder is opened ; careful inquiry is not baffled until the urethra has been measured and inspected, and the urine examined; and any abnor- malities thus discovered have been removed without relief to the vesical symptoms.) "Of this remarkable history there are six examples in the series, of which three perfectly recovered, besides three others in which great improvement took place but not complete recovery. The result of operation undertaken in the circumstances described as a last if not almost hopeless resource, has been surprising and fraught with great interest. I am disposed to think that there are some persons in whom an attack of cystitis with extreme frequency of micturition having been set up, the want to relieve the bladder every half hour or hour, at first natural and neces- sary, still continues after the local disease has passed away in spite of their efforts to overcome it, as the result of what may be regarded as persistency of a morbid habit in certain constitutions. I cannot further elucidate the pathological condition in any one of them, having discovered nothing by the investigation to account for the symptoms." When we remember that Thompson recognizes no abnormality in the urethra which is not revealed by passing a No. 12 sound, we are inclined DIGITAL EXAMINATION OF THE BLADDER. 67 to the suspicion that the possibilities of diagnosis were not exhausted in these cases by the exploration of the bladder; and this suspicion is strengthened by the meagre details of his cases in which the operation failed to afford relief. In one of these (case 41), the patient was a man aged forty-five. " Many years painful symptoms and treatment for alleged stricture which does not exist" (?). "During last twelve months great frequency of micturition ; now every half hour night and day. Instru- ments have been passed by himself and others up to the neck of the bladder and then failed to enter. Examination shows that the neck of the bladder is distinctly tense, rigid on the lower aspect, but the short-beaked sound passes over it readily in the bladder ; nevertheless there is no stricture, for No. 15 (English) will enter " (?). " April 14, 1884. Exploration. The finger on entering the bladder encountered ruge and a roughened surface of mucous membrane, especi- ally at upper part of bladder. The neck of the bladder was exceedingly tight, grasping the end of the finger like a ring; I divided this at the lower border so that the tension ceased. Free bleeding foUowed. A tube was tied in four or five days. He recovered slowly, and gradually regained power to retain his urine ; the intervals being from two to three hours in the middle of May." Since in other cases the symptoms described have disappeared en- tirely after division of a slight urethral constriction, the calibre of this channel should be carefuUy explored in such cases before the bladder is opened ; the passage of a No. 15 sound is certainly not conclusive evi- dence that the urethra is free from abnormahties, and is therefore slight justification for the operation performed in this case, which ap- parently did not reveal nor remove the cause of the difficulty, and ap- pears to have furnished but little relief. Furthermore, it may not be for- gotten that organic disease of the kidney, as well as undue acidity of the urine, may be manifested solely by symptoms which are referred to the bladder and which suggest the existence of vesical calculus or neoplasm. Otis had the rare opportunity of examining post-mortem a typical case of this sort.1 Frequent and painful urination, pain in the glan penis, vesical catarrh, and an occasional admixture of blood with the urine, had been observed for two years; these symptoms were aggravated by riding in a cart. Careful and repeated soundings had failed to detect anything abnormal in the bladder. A congenital contraction of the meatus had been divided and a large instrument passed through the urethra with but slight benefit. A digital exploration of the bladder through the perineum revealed no cause for the symptoms. Even at the autopsy no explanation of the difficulty was discovered in the bladder, but "the kid- neys were filled with tuberculous deposits." When therefore aU the less direct means of diagnosis have been em- ployed in vain ; after kidneys, urine, urethra, rectum, and genitals have been examined and suggestive abnormahties corrected without relieving the vesical symptoms, the digital exploration of the bladder may be per- formed. It has occasionally revealed a morbid condition which, whUe susceptible to relief, must necessarily escape recognition by other means than digital contact. Thus in one of Thompson's cases (a female) who had for three years suffered severely from frequent and painful micturition, the cavity of the bladder was very small, apparently because the vesical walls were extensively bound together by adhesions ; these were readdy 1 Loc. cit., p. 567. 68 DISEASES OF THE URINARY ORGANS. overcome by the finger. After the operation micturition was painless, though still frequent. This operation has been performed more than fifty times by Thomp- son, Whitehead, and Morris, in cases where the bladder was believed to contain tumors or calcuh; in many of these instances the suspected objects were found and removed through the incision. Thompson recommends it as easy of performance, practically devoid of danger, and capable of af- fording valuable information ; he regards renal disease and cancer as con- tra-indications for its performance. Probably renal disease constitutes, per se, no objection except when it is secondary to habitual distention of the bladder. In one case of cancer of the bladder in which I performed the operation—not so much for purposes of exploration, since the diagno- sis was already established, but as a means for relieving the patient from the torture consequent upon his frequent and painful urination—marked re- lief and decided benefit were secured. The tumors hitherto removed by this method have been chiefly polyps and fibromata. There is undoubt- edly a large field for this procedure also in the detection and removal of certain enlargements 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 fragments of the prostate have been repeatedly re- moved accidentally during the performance of lithotomy, cystotomy, and hthotrity, with great benefit to the patient; by the performance of this simpler and safer operation the same good results might be achieved. CHAPTER VII. INSPECTION OF THE URETHRA—ENDOSCOPY. The attempt to render the mucous membrane of the urethra and blad- der accessible to the eye has been the subject of many endeavors within the last thirty years. That it was possible to bring limited portions of the vesical and urethral membrane within the range of vision was demonstrated twenty years ago, and as a result exalted expectations of consequent ad- vances in urethral surgery were entertained. These anticipations were, however, but meagrely realized ; the few individuals who expended upon the subject the time and study necessary for a proper use of the compli- cated endoscopes then employed, did not succeed in convincing the pro- fession at large that the instrument possessed a tangible value for practi- cal purposes. The endoscope has been and is generally regarded as an interesting toy, whose practical usefulness exists only in the distorted im- agination of enthusiasts. This impression, which still prevails largely in the profession, is based not upon practical experience—for comparatively few practitioners have had an opportunity to learn its use—but is derived largely from surgical writers on these diseases, who possibly express a prejudice rather than the result of ample experience. Thus Sir Henry Thompson, in the last edition of his "Clinical Lectures," says (p. 8): "Imay tell you at once, that if a man has a good and a tolerably practised hand, with a fair share of intelligence, I do not think he wiU gain a great deal by the endoscope ; and if he has not, I think it will be of no use at all." " In ninety-nine cases out of a hundred you can arrive at the necessary in- formation without it." And notwithstanding the repeated demonstrations to the contrary, he persists in saying: "I may mention that no one has yet been able by its means to identify the veru montanum." These statements, which because emanating from so high an authority, are generally regarded as expressing the actual state of the case by those who have no experience with the endoscope, are based upon the use of the complicated instruments contrived by Desormeaux and Cruise. And so far as these instruments are concerned, the statements doubtless represent approximately the actual state of the case. It is quite otherwise, however, with the simple endoscope which has been in the last few years brought prominently before the profession of Germany and Austria by Dr. Josef Griinfeld, of Vienna. By his demon- strations to the Royal Society of Physicians in Vienna, as well as to numer- ous pupils, Griinfeld has shown that the endoscope has in a certain limited field the greatest importance in the diagnosis and treatment of urethral diseases. As evidence of the appreciation bestowed upon it, may be ad- duced the fact that Billroth and Lucke have devoted to the subject one volume of their "Deutsche Chirurgie," which has appeared as "Die En- doskopie der Harnrohre und Blase " by Dr. Griinfeld. It was my privilege some years ago to enjoy the private instruction of 70 DISEASES OF THE URINARY ORGANS. Dr. Griinfeld for many months, as well as to observe the practice of Pro- fessor Auspitz, of Vienna. Through my observation then, as well as per- sonal experience since, I am convinced of the value of the endoscope as one important means in the diagnosis and treatment of urethral diseases. While it is undoubtedly true that the instrument has a practical value for positive diagnosis in comparatively few cases only, yet in these few cases it is absolutely indispensable, affording information which can be acquired in no other way, and furnishing the only rational and successful plan of treatment. Moreover, it has an extensive application as a means of nega- tive diagnosis, that is, of excluding possible pathological conditions, and thus arriving at a correct conclusion. Most of the standard text-books on this subject impart a mistaken impression ; they demonstrate satisfactorily that the endoscope has a very limited field of usefulness, bid ignore its value in that limited field. Even if we admit the accuracy of Sir Henry Thomp- son's sweeping assertion, that " in ninety-nine cases out of a hundred you can arrive at the necessary information without it," it is certain that in the remaining case no definite information nor successful treatment is possible without it; and it is highly probable that in several of the ninety-nine cases actual inspection of the urethra wiU show that the "necessary" in- formation secured without the endoscope is not accurate. That Sir Henry's impressions upon the subject are at least somewhat inaccurate, is shown by his statement that no one has yet been able to identify the veru montanum ; for this can be and has been readily identified by numerous observers. In order to settle aU doubt upon the matter, Griinfeld intro- duced a needle by means of the endoscope into the urethral orifice of the ejaculatory duct in a cadaver in the Rudolf Hospital, Vienna ; the urethra was then laid open by the prosector, Dr. Chiari, and the needle was found at the point indicated. The information which can be derived exclusively by the endoscope is required in comparatively few cases ; the instrument, even in its simplest and most valuable form, does not fulfil the exaggerated expectations which were entertained in the earlier years of endoscopy ; but as an accessory to the armament of the surgeon who deals especially with diseases of the urinary organs, it is absolutely essential. This opinion is, as already stated, the outgrowth of personal observation and experience, and is at variance with that prevalent in the profession and endorsed by most of our standard authorities ; yet it is gratifying to read in the last edition of Bumstead and Taylor (page 108), " It wUl readily be seen that, for the purposes of diagnosis, the endoscope proves itself to be an invaluable in- strument in many cases, as, for instance, in those of urethral polypi, or ex- coriations which might otherwise escape detection. It reveals also the presence and the exact seat of patches of granulations, spots of herpes, etc. And as applications can be made through the tube it enables us to reach these parts directly." Endoscopy is now, so far as the instruments and their manipulation is concerned, one of the simplest and easiest modes of examination employed in the diagnosis and treatment of genito-urinary diseases. There are re- quired endoscopes or urethral tubes, a head or hand reflector, and a source of illumination. The endoscope itself is simply a tube by which the urethral walls are held asunder so as to permit the passage of light rays. The simplest form, and the one which is capable of the most general application, is con- structed, except as to calibre, like the ordinary cylindrical vaginal specu- lum (see Fig. 3). INSPECTION OF THE URETHRA—ENDOSCOPY. 71 The length of this—the " simple endoscope " of Griinfeld—varies from 6 to 13 ctm., exclusive of the external funnel-like rim. For the examin- ation of the anterior urethra only, Griinfeld commonly uses an instrument 10 ctm. long ; for the posterior urethra a length of 12 or 13 ctm. is re- quired. In special cases an instrument 6 to 8 ctm. is sufficiently long. It is of course desirable to use the shortest instruments which confer the required length, since the loss of light increases rapidly with the length of the tube. The calibre of the instrument varies also from 16 to 24 Charriere; the larger sizes furnish, other things being equal, a more distinct view because of the greater amount of light permitted to enter and return through the instrument. For ordinary purposes four endoscopes suffice, two 12 ctm. long each, corresponding to 18 and 22 Charriere respectively ; two others 10 ctm. long, having the same respective diameters. Fig. 3.—Griinfeld's Urethral Endoscope with Conductor. For special purposes other forms are used. For the inspection of the mucous membrane of the bladder in the male, the tube is made from 13 to 15 ctm. long, and its vesical extremity, cut obliquely, is closed with glass so as to prevent the urine from entering the tube. Another instru- ment used for the same purpose is shaped hke a male catheter with a short beak, a portion of whose convex curve is replaced by a plate of glass. These two instruments have but little value in practice, since the inspec- tion of the vesical mucous membrane is opposed by certain obstacles which are practicaUy insurmountable and which are not met in the at- tempt to view the urethra. For practical purposes the simple straight endoscope is the most desir- able and the most generally useful; in fact aU the information of practical value which has as yet been obtained by means of the endoscope, is secured through this instrument; and it is naturally the only one which is useful in a therapeutical way, since it alone permits local applications. In the foUowing remarks, this form alone is designated, unless it is otherwise specified. Use of the Endoscope. Having selected the instrument, shorter or longer and smaller or larger in calibre according to the requirements of the case, the employment of it includes attention to three points especially : 1. The position of the patient. 2. The arrangement of Ulumination. 3. The manipulation of the tube itself. 72 DISEASES OF THE URINARY ORGANS. For the examination of the anterior urethra, the patient may simply sit upon a chair; in order to reach the posterior urethra, the patient must assume such a position as wiU permit an obliteration of the natural curves of the urethra. He should, therefore, lie upon a high table such as is used for operating purposes, the perineum being brought to the edge of the table while the feet, widely separated, are supported by chairs. Any one of the gynecological chairs ordinarily employed in this country answers the pur- pose admirably, since the position required is practically identical with that assumed for the ordinary vaginal examination. The iUumination of the interior of the urethra is secured by means of light reflected from a head-mirror, such as is used ordinarily for examina- tion of the larynx. The best light is by all means direct sunlight; and this should always be employed if it can by any means be secured. By means of it differences in color and configuration of the surface, the pres- ence of dilated blood-vessels, etc., are far more readily distinguished than by any other mode of illumination. In the majority of cases, however, the use of direct sunlight is impracticable, and the operator is compelled to fall back upon artificial sources of illumination. The relative value of these is determined by their briUiancy ; hence an electric or magnesium hght is best, though of course, rarely procurable. Except in rare cases a perfectly satisfactory Ulumination is secured by the reflection of light from a gas or kerosene flame furnished with an argand burner. When such iUumination is employed, other sources of hght should be, as in ophthal- moscopic examinations, excluded from the darkened room. The introduction of the instrument varies somewhat according as a metaUic or a hard rubber endoscope is employed ; the edges of the metal instrument are thin and sharp and would necessarily lacerate the mucous membrane ; hence it is provided with a wooden plug which projects some- what beyond the edge and terminates in a rounded extremity. The hard rubber instrument has thick and rounded edges which require no protect- ing plug for its introduction. The operator stands between the knees .of the patient, grasps the penis between the thumb and forefinger of the left hand and compresses it from above downward so as to convert the natural vertical slit of the meatus into a circular opening. The oiled endoscope is held between the first and second fingers of the right hand, the thumb being placed over the end of the plug so as to prevent its withdrawal into the metallic tube dur- ing the introduction. The end of the tube advances readily in most cases to the posterior extremity of the fossa navicularis, where it often meets some obstruction; this can be easily overcome by slightly rotating the in- strument while at the same time a progressive movement is given it by the thumb upon the plug. No further impediment to the progress of the instrument is felt (in the normal urethra) until it reaches the anterior layer of the triangular ligament. An inexperienced hand frequently en- counters some difficulty, merely because the axis of the endoscope is al- lowed to form a considerable angle with the axis of the urethra and thus impinges upon one or the other, usually the inferior waU. Careful at- tention to this point and correction of the position of the endoscope wiU obviate this difficulty. If it is desired to inspect the urethra posterior to the bulb, it is neces- sary to depress the pendulous portion, so as to obliterate the angle at the bulb and permit the insertion of the instrument into the membranous portion through the opening in the triangular ligament. This requires con- siderable care, and may at first be the cause of much difficulty, since the INSPECTION OF THE URETHRA---ENDOSCOPY. 73 point of the instrument is often arrested in the sinus of the bulb. After the point has been successfully introduced into the membranous urethra, the distal extremity must* be still fm-ther depressed in order to permit the endoscope to traverse the membranous and prostatic urethra. The pas- sage of the instrument through this portion of the urethral canal is usually accompanied with some pain to the patient. In some cases it be- comes necessary even with the longer instruments, to compress the penis in the direction of its length and thus enable the inner extremity of the tube to reach a portion of the canal which normally lies at a distance from the meatus greater than the length of the tube. Thus, with an endoscope 10 ctm. long, it is usuaUy easy to inspect the bulbous and even the mem- branous urethra through this manoeuvre, though the natural length of the canal may considerably exceed that of the tube. When the point of the instrument has reached that part of the urethra which it is desired to inspect, or at least the deepest portion accessible with the tube in use, the fingers of the left hand, which have hitherto sup- ported the penis, are now made to grasp also the funnel-shaped extremity of the endoscope and thus maintain it in position against the natural con- tractile efforts of the urethra to expel it. The plug or conductor is now withdrawn by the right hand and the mirror, attached to the head-band, directed so as to reflect hght into the tube. In nearly aU cases the surface revealed is found covered by moisture, which must be removed in order to afford the best possible view of the mucous membrane. For this purpose a small tampon, made of cotton en- closed in a proper holder, or simply wound around a long slender piece of wood (uncut match stick) is introduced through the tube and pressed gently against the membrane. Upon withdrawing the tampon the field is again inspected, and if necessary again cleansed in the same way. The entire urethra anterior to the point at which the end of the tube now rests can be inspected by gradually withdrawing the instrument toward the meatus. If at any time the operator desires to inspect again a portion of the mucous membrane posterior to the point at which the end of the tube rests, he should not forget to introduce the conductor before making any movement of the instrument toward the bladder ; for the sharp metallic edges of the tube, unless thus masked by the enclosed plug, may lacerate the mucous membrane, or at any rate cause the patient pain. If the instrument used be made of hard rubber, no conductor is neces- sary, and the endoscope can be moved either forward or backward along the urethra without injury to the mucous membrane. In consequence of the thickness of material required and the consequent loss of calibre in this instrument, the metaUic endoscope is for nearly all cases preferable, notwithstanding the peculiar inconvenience caused by the unavoidable em- ployment of the conductor. Diagnosis with the Endoscope. A recognition of abnormal states of the urethra is of course possible only after the investigator has become thoroughly familiar with the ap- pearances presented by the normal urethra in the different portions of its length. It would exceed our limits to enter into a detailed account of the features which characterize the normal and the numerous abnormal con- ditions of the mucous membrane, as observed through the endoscope. It must suffice to point out a few of the most important of these as instances of the scope of the instrument. 74 DISEASES OF THE URINARY ORGANS. The endoscope finds its most frequent application in the diagnosis and treatment of chronic inflammation of the mucous membrane, occurring as a continuation of gonorrhoea, and usually, though not always, accompanied with gleet. In such cases the location of the diseased portions can generally be readily defined by means of the endoscope, and topical applications made with certainty and accuracy. Such diseased surfaces may occupy an extensive area, or may be localized in small patches of the urethra. If the existence of such a surface be suspected and its examination with the endoscope undertaken, it may be advisable to locate it so far as possible by the use of the ordinary bulbous or acorn bougies. The pas- sage of the bulb of this instrument over the chronicaUy inflamed surface usually occasions a more or less painful sensation. It is, however, a sin- gular fact, noted by almost aU who have employed the endoscope, that the location of the diseased patch by the sound rarely corresponds with the actual seat of the pathological condition as revealed to the eye ; the discrepancy is caused by the variation in length which the urethra so readdy undergoes during manipulation. The existence of a localized chronic urethritis is revealed through the endoscope in the following appearances : the middle of the field is usually occupied by a drop or two of pus, the removal of which shows a short, funnel-shaped depression. The reflection of the hght, which in the nor- mal condition causes a bright ring a short distance internal to the tube, now consists of several irregular and often interrupted curves, quite differ- ent both in shape and location from the normal circle. A close inspection of the surface reveals the existence of numerous slight elevations, such as are often observed on the surface of the conjunc- tiva in cases of granular lids. Such a surface bleeds readdy, an escape of blood being perhaps excited by the simple contact of the instrument; while in other cases the lightest touch of the tampon, necessary for the removal of the pus which may be present, causes an oozing from the gran- ular surface. The withdrawal of the tube a short distance so as to bring into view a portion of the normal urethra, exhibits clearly the difference between the characteristics already mentioned and those of a healthy mu- cous membrane. A thickening of the epithelium of the urethra is an occasional, possibly a frequent, condition, which is in some cases at least responsible for a chronic urethritis or gleet. It is the result either of a gonorrhoea or of the frequent and habitual use of instruments, having been noticed in those who have been in the habit of introducing bougies or catheters at intervals during a long period. Li some cases this thickening of the epithelium, with or without an increase in the submucous connective tissue, occasions such a narrowing of the canal as to be perceptible by the sound or bougie ; yet in other cases this epithelial thickening does not encroach upon the cahbre of the urethra sufficiently to be detected by the ordinary means of exploration. This has been repeatedly observed upon post-mortem exam- ination, and has been remarked by Dittel; I have myself seen two in- stances. The frequency of this condition cannot be stated, since without the use of the endoscope it can be determined only post-mortem, and is not usually sought for during autopsies. They do exist, however, and can be easily recognized during life when the mucous membrane of the ure- thra is rendered accessible to the eye by means of the endoscope. They are then seen either as bluish white stripes, or as patches of greater or less area which present the same bluish white color. These usually exhibit a INSPECTION OF THE URETHRA---ENDOSCOPY. 75 decided elevation above the general surface ; sometimes by following them the observer arrives at a point where the projection into the lumen of the urethra constitutes, a decided stricture, while at other times the projection above the general urethral surface is insignificant. This epithelial thickening originates, in some instances at least, in an acute inflammation or in the constant irritation produced by the pas- sage of instruments. In other cases it cannot be traced to either of these causes, its etiology being as obscure as that of certain thickenings of the epithelium of the tongue occasionally observed. The former cases are generally accompanied by a shght urethral discharge, often observed chiefly in the morning, and occasionally furnishing threads —" tripperfiiden "—in the urine. Griinfeld has observed several cases in which this condition of the ure- thra was plainly perceptible ; one of these he demonstrated to the Royal Society of Physicians in Vienna in May, 1879. The termination of these cases is various ; in some the epithehal thick- ening, and with it the symptoms complained of, were readily removed by simple topical applications such as iodine in glycerine, while in other in- stances the treatment adopted seemed quite ineffectual. Tumors of the Urethra.—In the recognition and treatment of urethral tumors the absolute necessity of the endoscope is most plainly marked ; in fact, the surgeon who undertakes the treatment of genito-urinary diseases without employing this instrument is liable at any time to meet a case whose etiology and treatment baffle him entirely, however skilful and fa- miliar he may be with other modes of exploration and treatment. These cases of urethral tumor are probably rare in the male; such at least is the assertion of nearly aU surgical authorities. The rarity of the cases which have been clinically recognized as such is doubtless explained in part by the fact that the endoscope, which affords the only means for de- tecting and recognizing them, has been but little employed. The urethral tumors discovered by other means than endoscopy have been seen almost exclusively post-mortem ; in a few cases the introduction of a catheter has been, much to the surprise of the surgeon, the means of removing a ure- thral polyp which had become entangled in the eye of the instrument. Comparatively few urethral tumors have been discovered even upon au- topsy, a fact which does not necessarily prove the extreme rarity of these growths, since in many parts of the world the urethra is not examined post-mortem except in those cases in which a suspicion of urethral diffi- culty has existed before death ; the systematic examination of the ure- thra during autopsy would doubtless reveal such growths somewhat more frequently. At any rate, during a series of seventy autopsies in which I laid open and examined the urethra, I found two cases in which a weU- marked polyp existed ; in one the growth was a slender pedicled tumor five-eighths of an inch long, attached in the floor of the prostatic sinus, just to the right of the middle of the veru montanum ; in the other a somewhat globular outgrowth of the mucous membrane, as large as a small pea, was found about the middle of the fossa navicularis. It would seem indeed that however rare other tumors of the urethra ought to be, polyps—simple hypertrophies of the mucous membrane- might reasonably be expected with some frequency in cases of previous gonorrhoea or gleet. The enlargements of the papille known as pointed condylomata are, as is well known, the frequent and rapid products of the irritation caused by a gonorrhoeal discharge, the secretion from a venereal sore, or even the accumulation of smegma under the prepuce ; that a simi- 76 DISEASES OF THE URINARY ORGANS. lar hypertrophy should occur as the result of an notation of the mucous membrane of the urethra would seem plausible. That such growths do occur more frequently than the general literature of the subject would lead one to infer is indicated by the fact that twenty-three cases have fallen under the notice of one observer in a very few years. The symptoms caused by the presence of a polyp in the urethra vary extremely, according to the location and size of the growth. In many cases such a tumor seems to have occasioned no particular symptoms, or at least none which have aroused the suspicion of the existence of a neoplasm in the urethra. In other instances the symptoms have been such as are considered indicative of a disturbance (often functional) of the prostate, bladder neck, or genital organs proper. Thus in one case re- ported by Genaudet, a student twenty-two years old who had never had gonorrhoea nor syphilis, began to complain of seminal losses, at first as nocturnal pollutions only; later a loss of semen occurred during the day at stool, as was demonstrated with the microscope. Then followed various symptoms—emaciation, failure of vision, mental sluggishness, frequent urination, dull pain and a sense of weight in the perineum and in the spermatic cord. Cauterization of the ejaculatory ducts, as recommended by Lallemand, was performed. Upon closing the instrument in the urethra a resistance was felt, and upon withdrawal a polyp was found entangled in it. All the symptoms complained of disappeared, and had not returned sixteen months later, at which time the report was made. A case which, through the kindness of Dr. Griinfeld, I had the oppor- tunity of observing, was equally striking; for the symptoms exhibited are such as are referred by the standard authorities to stricture, or prostatic inflammation, or both. A gentleman thirty-five years of age, himself a physician, had seven years previously suffered from an obstinate gonor- rhoea. For several years thereafter he experienced no difficulty, subjective or objective, in the genital or urinary functions. Some five years after the attack referred to, he noticed a shght dribbling of the urine after the apparent completion of the act. This dribbling, at first of occasional oc- currence and insignificant amount, graduaUy became a serious annoyance. He was compelled to urinate frequently; after each act, often even after the clothing had been arranged, a quantity of urine sufficient to saturate the underwear was involuntarily expelled, thus compelling him to change his linen at very short intervals, to escape the urinous odor. On several occasions there was some hemorrhage from the urethra ; twice this was quite profuse, once during intercourse, and once during a simple erection without further provocation. Urination became frequent and slightly painful. The patient at first assumed the existence of a stricture as the cause of the difficulty, but careful examination failed to reveal any contraction in the urethral calibre. Nevertheless steel sounds were introduced almost daily for a considerable period, in the hope of effecting relief. After the failure of this measure, the doctor presented himself to Griinfeld for endo- scopic examination. In withdrawing the instrument, Griinfeld discovered on the floor of the urethra, at about the middle of the pendulous portion, four distinct polyps, the largest about the size of an ordinary pea, and all situated within a space of one inch. These were at once removed by means of the snare, an operation causing some little pain but inconsidera- ble bleeding. The result was entire relief from the symptoms complained of. During the six months following I met the patient on several occasions, and was informed that both genital and urinary functions were normaUy INSPECTION OF THE URETHRA---ENDOSCOPY. 77 performed, and that he had enjoyed, since the operation, entire freedom from the previous annoying symptoms. Various symptoms, subjective and objective, usually produced by other conditions, have been observed in special cases to be dependent upon the presence of polyps in the urethra. Among these are frequent and drib- bling urination, hematuria, a gleety discharge, the sensation of a foreign body in the urethra, cystitis ; indeed, many of the symptoms of stricture, including impediments to the introduction of the sound, have been traced to the same cause. In women, in whom the diagnosis is easily made, urethral polyps are known to cause various symptoms of womb disease, pruritus, painful urination, etc. In one case reported, cystotomy was per- formed in an elderly man to relieve an obstinate cystitis. The patient wore a canula until his death, seventeen months later ; at the autopsy, it was found that the cause of the trouble was a smaU .polyp situated at the vesical orifice, whereby the urethra was completely closed. Dr. H. G. Klotz, of New York, reports l an interesting case, showing the dependence of gleet upon urethral polyps. The gleet had continued since an attack of gonorrhoea, three years previously. Examination de- tected a stricture 13 ctm. from the meatus, admitting No. 14 French ; the passage of steel sounds caused slight hemorrhage. In a few weeks the con- striction was dilated to No. 27 French, but small olive-pointed bougies were always arrested near the seat of the stricture ; the discharge con- tinued almost as profuse as before. Examination with the endoscope re- vealed several polyps in the membranous urethra ; about a dozen of them, varying in size from a canary seed to a pea, were removed in several sit- tings. "Under the apphcation of caustics and astringents, the mucous membrane is returning slowly to its normal condition, the seat of the former stricture being recognized by the scar-like, perfectly white appear- ance of the mucous membrane of the upper wall of the urethra, immedi- ately in front of the seat of the polypi." The diagnosis of urethral polypus can be made with the endoscope only, and the treatment likewise consists of removal or of cauterization through the tube. In cases in which persistent symptoms referable to the genito-urinary tract cannot be explained by anatomical conditions revealed by the usual modes of exploration, the possibUity of urethral polyp should be borne in mind and an endoscope examination made. Such examination requires the most careful and thorough inspection of the entire urethral surface, first in front of the bulb and subsequently, if this examination prove negative, in the posterior urethra. In this examination it is essen- tial to inspect not only the central field as seen when the endoscope is held parallel with the axis of the urethra, but also the walls of the canal. To do this, the endoscope should be diverted to one side and the other, above and below, by making the tube form a shght angle with the urethra. Sometimes a distinct tumor can be recognized in the field of the in- strument ; in many cases attention is first attracted by the sudden displace- ment of the ordinary field by what seems at first to be merely a fold of mucous membrane, which displaces partially or completely the central cone or funnel made by the normal urethra. The new growth pops sud- denly into the field, as it were. A somewhat similar appearance is some- times seen if the endoscopic tube is suddenly turned from the axis of the urethra toward its wall. In order to be certain that the object seen is reaUy a new growth, it is necessary to secure a field in which the usual 1 Medical Record, July 30, 1881. 78 DISEASES OF THE URINARY ORGANS. cone or funnel is partially obscured by the projecting mass. It is also to be remembered that the normal appearance in the prostatic urethra is somewhat similar to that produced by a smaU sessile polyp in the pendu- lous portion, for the veru montanum projects upward from the floor of the urethra so as to partially obscure the field. It is said that an enthusiastic endoscopist once undertook to remove a portion of the veru montanum, in the fond belief that he had discovered a urethral polyp. Pedicled polyps do not usuaUy indicate their presence by thus suddenly appearing in the field during the withdrawal of the endoscope. They are generally visible as bright red protuberances, occupying a larger or smaller part of the field, the remainder of which is composed of a crescentic por- tion of mucous membrane, usuaUy of lighter color than the polyp itself. This crescent varies in size according to the dimensions of the tumor; if the latter be small it may be surrounded entirely by a ring of mucous membrane visible in the field. If the tumor be small and the pedicle com- paratively long, the bright red object can be pushed backward by the movement of the endoscope ; if, on the other hand, it be large, the polyp occupies more of the field as the instrument is withdrawn and may finally completely fill the end of the endoscope, causing, of course, the disap- pearance of the cone ordinarily seen. Griinfeld lays especial stress upon the shadow cast by the tumor when this occupies but a portion of the field ; the shadow increases and diminishes according to the position of the instrument and the amount of the polyp included in the field. Polyps of the urethra vary considerably in size and in the number found in the same individual. The largest yet reported as observed dur- ing life was one detected and removed by Griinfield; this was 25 mm. long and 13 mm. broad. In another case demonstrated to the Vienna Medical Society, five polyps, one as large as a pea, were observed. Simple granulations occurring as the result of gonorrhoea also occa- sionally constitute tumors recognizable with the endoscope. These are usuaUy surrounded by a granular area, as already described ; yet the latter may exist without any distinct granulations of such size as to project into the lumen of the urethra. Such fungous granulations are readily detected with the endoscope as bright red masses, usuaUy covered with a layer of pus and bleeding readily upon pressure even with the tampon of cotton. They are frequently present in cases of gleet, and render the affection ex- tremely obstinate, as in the following personal case : A man twenty-six years of age consulted me regarding a gleet, which had existed for the previous nine months. He stated that five years previously he had had a gonorrhoea, and two years subsequently had been informed by a physician whom he consulted concerning various urinary irregularities, that there was a stricture in the anterior portion of the urethra. The stricture had been dilated up to No. 12 English, and the patient instructed to pass a sound every week—an injunction which he had of course neglected to carry out more than a short time. About a year previous to his visit to me, and therefore two years after the dilatation of his stricture, he had acquired a second gonorrhoea ; the discharge had never ceased entirely. On examination I found a stricture admitting No. 17 Charriere, about one and one fourth inch posterior to the meatus ; there was a slight but constant semipurulent discharge. I dilated the stricture gradually untU it admitted readdy No. 28, expecting that the discharge would probably cease. In this I was disappointed ; for two weeks after the dilatation of the stricture up to the point named there was still a discharge. An ex- amination with the endoscope showed that for three-fourths of an inch INSPECTION OF THE URETHRA---ENDOSCOPY. 79 back of the stricture, the mucous membrane was unusually red and vas- cular. Several minute granular points were observed, and on the right wall was a mass of flabby granulations covering an area about an eighth of an inch in diameter. The removal of this mass with the snare and the application of bluestone to the base and surrounding surface was soon fol- lowed by a complete cessation of the discharge. The conditions already mentioned constitute the greater number of cases in which the endoscope is essential for purposes of diagnosis. There are, however, various other abnormal conditions of rare occurrence, which can be recognized and successfully treated only with the aid of this in- strument. The veins contained in the urethral walls are sometimes en- larged and varicose, a condition which may give rise to various uneasy sensations referred to the glans, the urethra, or the bladder-neck; these varices are readily recognizable with the endoscope. Erosions and Ulcers of the Urethra.—These probably occur as the result of gonorrhoea, causing an obstinate and persistent discharge which defies aU other modes of treatment than topical apphcations. Such cases have never faUen under my own notice, but have been described by various writers on endoscopy. Thus Griinfeld exhibited in the Vienna Royal Society of Physicians in 1877 " a man who had suffered for several years with chronic urethritis, on the under surface of whose urethra two ulcers, visible through the endoscope, were seen. One of these was located be- tween five and six centimetres, the other from one to two centimetres from the meatus. The former was 1 ctm. long, of nearly triangular form. The anterior of the two was of horseshoe shape, the arms being 10 and 12 mm. long respectively. These ulcers were quite superficial and were easily healed by pencilling with a solution of lunar caustic and with sugar of lead" The same observer reports having repeatedly seen gonorrhoea, or rather urethritis, which was certainly not due to intercourse, in individuals who were subject to herpetic eruptions on the glans and prepuce. Examina- tion with the endoscope has shown herpetic blisters within the urethra. He asserts that the cure of these blisters by local applications has been followed at once by the cessation of the discharge. Certain abnormalities of the mucous membrane possessing clinical im- portance are most readily or exclusively detected by the endoscope ; such are diverticula, local dilatations and valvular folds of the urethra. Such abnormalities are rare and have but little importance except after the oc- currence of urethritis ; under these circumstances any of the conditions mentioned may be responsible for the inexplicable obstinacy of a chronic discharge. A case of sac-like dilatation of the urethra is related by Griinfeld:1 "The subject was a medical student who in the summer of 1874 experienced for about four weeks after every micturition a sensation as if a portion of the urine had remained in the urethra ; yet pressure never succeeded in evacuating such additional quantity. The urine was clear. In the summer of 1876 the patient noticed a dribbling of the urine after micturition. The duration of this dribbling as well as the quantity graduaUy increased, so that in 1877 it persisted for two hours after every act and the linen was correspondingly saturated. In the winter of 1877 there appeared after every urination an oval tumor in the vicinity of the bulb, by pressure upon which urine was evacuated. During the period immediately preceding this condition it had been noticed that the ■Loc. cit., p. 197. 80 , DISEASES OF THE URINARY ORGANS. semen expeUed during frequent pollutions was almost completely evac- uated, pressure upon the urethra expelling a drop or two. The systematic introduction of bougies (up to No. 12 English) was unsuccessful in chang- ing the condition, except that the duration of the dribbling at each act was somewhat shortened (1878). The sac of the urethra was seldom com- pletely evacuated. Entrance into a cold bath when the sac was fuU caused a complete evacuation of, the same ; but systematic cold bathing was unsuccessful in relieving the condition. The use of the Faradic current (fourteen sittings) occasioned immediate contraction of the sac, but no per- manent benefit (December, 1878). As the patient suspected the existence of a valve in front of the sac, he presented himself to me for endoscopic ex- amination (January 15, 1879). I found the diameter of the urethra in front of the bulb of extraordinary size, the transverse central figure having three times the usual length. The mucosa was otherwise normal and the urine quite clear. Endoscope No. 24 was used. I proposed thorough penciUing of the sac with tincture of iodine, in order to accomplish con- traction in this way. The result was favorable, inasmuch as after the fourth penciUing the urine was completely evacuated three times. The urethra remained completely contracted for two days after each use of the pencil. The duration of this complete contraction of the sac after a single sitting gradually increased, so that, for example, in the time between Feb- ruary 24th and March 2d, no dribbling occurred, and on the latter date only a few drops remained behind. The pencillings were performed now less frequently, four times in March, three times in April, and once each in May and June. Since that time (two years) the patient has remained well." The endoscope has been occasionally employed in cases of tight strict- ure as a means for discovering the entrance to the stricture and of assist- ing the introduction of a bougie ; it has also been asserted to possess a value in cases of proposed internal urethrotomy. It is said that by inspect- ing the stricture it can best be determined at what portion of the urethra the incision should be made. The cases in which such apphcation of the endoscope has a practical value must be infrequent. The endoscopic examination of the bladder has been thus far a matter of purely scientific interest. Foreign bodies, calculi, the swoUen mucous membrane, portions of tumors, and even the scars of operations have aU been distinctly seen with the aid of this instrument; yet no information which cannot be acquired by other and less objectionable means has as yet been furnished by the endoscope so far as the bladder is concerned. The difficulties which beset the endoscopic examination of the bladder comprise not only those encountered in the introduction of the instru- ment, but also the fact that the field of vision is even in the healthy bladder obscured by the urine ; in abnormal conditions accompanied by an exfolia- tion of the epithelium, and perhaps suppuration in the bladder, this ob- scurity is such as to practically prevent endoscopic examination. Griinfeld was the first to accomplish, by means of the endoscope, a manipulation which might in exceptional cases have extreme practical value—the introduction of a catheter into the ureter. This is of course possible only in females. It had been undertaken by Simon, who reached and recognized the vesical orifice of the ureter, not by the endoscope, but by the finger introduced through the dilated urethra. Simon performed this catheterization of the ureter seventeen times in the living subject, and in aU but two cases was enabled to introduce the instrument as far as the pelvis of the kidney. In attempting to perform the same manoeuvre with the endo- INSPECTION OF THE URETHRA---ENDOSCOPY. 81 scope, he always failed, notwithstanding the fact that the instrument em- ployed was introduced through the dilated urethra and had a diameter of about two centimetres. Other observers, notably Winckel and Rutenberg, also failed to discover the orifice of the ureter. Griinfeld was, however, enabled to reach and introduce an instrument into the ureter of the female without previous dUatation of the urethra—an operation which he re- peatedly demonstrated upon the cadaver. The value of the endoscope for this purpose has been, however, materially vitiated by Pawlik's demonstra- tion that the same manipulation can be readily accomplished without endo- scopic or other instrumental assistance. Therapeutics with the Endoscope.—The value of the instrument is to be found almost as much in the treatment as in the diagnosis of urethral dis- eases. That the local application of remedies should be more successful when directed by the eye than when made haphazard by injections into the urethra is self-evident, and has been amply demonstrated in practice. Local therapeutics with the endoscope require a few especial instru- ments adapted to the anatomical relations of the parts involved. These are : Tampon; Snare; Pencil; Scissors; Caustic-holder; Forceps. Powder-blower; Some of these have a very limited use and are rarely required even in extensive employment of the endoscope. The tampon, pencil, and caustic- holder are indispensable, and the powder-blower frequently convenient. The principles involved in the use of these instruments require no dis- cussion, since the conditions which they are employed to relieve are iden- tical in the urethra and in other mucous membranes, especially the con- junctiva. The general fact is to be remembered that applications to the urethra, especially the posterior portion, should be made with greater cau- tion and conservatism than are required in the treatment of conjunctival affections ; since the reaction both local and general is apt to be greater, and in consequence of the anatomical relations, less readily controlled. The tampon, consisting of a wad of cotton, can be held either in a clamp provided for the purpose, or wound around the end of a fine sound, as is customary in intrauterine applications. The disadvantage of either of these methods arises from the necessity of frequent change of the cot- ton ; for the tampon is in constant use in clearing the field of moisture and possibly blood. Hence it will be found advantageous to use tampons made by twisting cotton around the end of pieces of wood, a purpose for which the fine cylinders used in preparing matches are especially convenient. These may be cut into pieces six or eight inches long, and a number armed with the cotton are kept in readiness. In this way the loss of time and frequent loss of the field, unavoidable if the cotton must be changed in the ordinary holder, are avoided. The pencil is identical with that used in treating the throat, except that the holder is somewhat longer and straight. The ordinary laryngeal pen- cil can be adapted for endoscopic use if the shaft be thin and flexible. A tampon can of course be made to supply the place of a pencil. A caustic-holder for the application of bluestone and solid nitrate of sdver is a great convenience.. For purposes of medication the various agents commonly employed in the treatment of conjunctival affections may be used. Among these are : 6 82 DISEASES OF THE URINARY ORGANS. 1. Solutions of silver nitrate, the strength varying from one to forty grains to the ounce of water. These are especially valuable in granular and ulcerated conditions of the urethra, and are best applied by means of the pencil. 2. Iodine, either as the tincture or as a solution in glycerine with the iodide of potassium. The following formula is generally useful: Iodine, 1 ; iodide of potassium, 5 ; glycerine, 50. This is a useful application in cases of chronic urethritis. 3. Astringents, especially alum, sulphate of zinc, and tannin. The two former can be applied either as solution with a brush or can be blown in as powder; tannin is best applied as a solution in glycerine. Iodoform is an especially useful application in cases of chronic urethritis. For the medication of the deep urethra these and other remedies can be conveniently and advantageously applied through the endoscope by means of soluble gelatine bougies, such as are made by MitcheU in Phila- delphia. Cauterization of the urethra can be readdy made through the endo- scope, more advantageously, indeed, than by any other instrument em- ployed. A stick of the sulphate of copper or of lunar caustic, fixed in the caustic-holder, can be touched directly upon the spot requiring stimula- tion. For the removal of exuberant granulations of polyps, a wire snare can be employed. This answers the purpose satisfactorily in the anterior ure- thra, but is not so successful in the treatment of polyps in the posterior portion of the canal. For this latter purpose an instrument has been de- vised by Dr. Klotz, which is said to have been quite satisfactory in his hands. It consists of two concentric metallic tubes, the inner one revolv- ing readily within the outer. At the same point, near the visceral ends of the tubes, there is in each an elliptical window. The instrument is intro- duced so that the polyp projects into its lumen through the two openings; revolution of the interior tube (the edges of whose window are sharpened) then cuts cleanly through the base of the tumor. A full description of the instrument and its application is contained in the Medical Record, July 30, 1881. After this brief sketch of the capacity of the endoscope, I would again express my conviction that the instrument possesses far greater value for practical purposes than is generally believed. For the speciahst in the treatment of genito-urinary diseases, it is indispensable ; in general prac- tice the cases requiring its employment are comparatively few. The field in which the endoscope renders extremely valuable service and furnishes information inaccessible by other methods is quite limited, but includes nevertheless a class of cases which are by means of it readily cured and without it remain obstinate and even incurable. It is not asserted that every case of urethral difficulty which has re- sisted other means of diagnosis and treatment yields readily to the endo- scope ; nor is it true that all cases in which the diagnosis can be by the endoscope readily established are as readily cured. I have seen cases of gleet which had been treated with injections and sounds, in which, upon endoscopic examination, localized granular urethritis was detected ; and which, notwithstanding the use of topical applications applied through the instrument, have not resulted in a satisfactory cure. In such cases the discharge can often be arrested by a few applications, however obstinate it may have been toward injections and sounds ; but in the course of a few .months, either with or without provocation in the shape of excesses, it re- INSPECTION OF THE URETHRA---ENDOSCOPY. 83 appears. Again it is readily arrested, but is apt to return. In these cases of gleet (from granular urethritis) which resist topical applications through the endoscope, I have always found a constriction of the urethra, often of large calibre and detected only by the urethrometer or large bulbous sound ; indeed, my examination of the urethra in a case of gleet includes the use of both instruments, urethrometer and endoscope, unless a pro- nounced stricture is found. If a shght constriction and granular, urethritis are both discovered, I treat the latter condition for a time with topical ap- plications and resort to dilating urethrotomy only in those cases in which such treatment proves ineffectual. The Electric Endoscope.—Within the last few years instruments have been devised whereby the mucous membrane of the urethra and bladder can be inspected when illuminated by an incandescent platinum wire. The idea originated with Dr. Nitze, of Dresden, and was successfully reahzed by Leiter, a prominent instrument-maker of Vienna. The same principle has been applied, through modifications of instruments, to the Ulumination and inspection of various other cavities of the body—the larynx, the ear, the vagina, uterus, rectum, oesophagus, and stomach. In each of these instruments, including those for the inspection of the urethra and bladder, the wire whose incandescence (produced by an elec- tric current) furnishes the iUumination is carried into the cavity to be in- spected, thereby furnishing an intensity of illumination impracticable by any other means. Each instrument is, moreover, provided with a series of lenses—a microscope of low power, in fact—whereby objects brought within the range of vision appear magnified. This amplifying arrange- ment, rendered necessary by the construction of the instrument, confers certain disadvantages as weU as the one evident advantage of rendering visible objects which would escape the naked eye. The instrument is a marvel of mechanical conception and execution, but so complicated as to practically vitiate the value derived from the in- tensity of the illumination secured by it. Furthermore, it is so expensive (costing about $130 in Vienna) that it is beyond the reach of all except the favored few. Whether or not it is capable of affording information in the diagnosis of urethral and vesical diseases which cannot be secured by other means remains to be seen. As yet only very few surgeons have had the opportunity for testing its powers, and these few do not profess to have exhausted its resources. My own practical acquaintance with the instrument is limited to an observation of its use in the hands of Professor Dittel and Dr. Griinfeld, of Vienna, who, by the way, have been most prominently identified with the practical applications of the instrument (so far as its use in the urethra and bladder is concerned), and have devoted much attention to its employ- ment. Griinfeld, confessedly the most skilful and experienced of endo- scopists, was especially zealous in and had most ample opportunities for em- ploying the new instrument. In his hands, as weU as in those of Professor Dittel, it was barren of practical results ; for notwithstanding its perfection as an instrument, its employment was attended with most serious, and in many cases insuperable difficulties. For purposes of diagnosis and treat- ment it was indeed far inferior to the simple endoscope illuminated by re- flected light. We can indeed imagine certain conditions in which it might furnish valuable information unattainable by other means ; but, so far as I am aware, it has not as yet demonstrated such value in practice. Yet it is possible that further experience and a more general use of the instrument may entitle it to a place in the armament of the genito-urinary speciahst CHAPTER VILL DETERMINATION OF THE URETHRAL CALIBRE BY THE URETHROMETER. The sounds ordinarily used for the exploration of the urethra are capa- ble of detecting only strictures of small calibre, those which seriously en- croach upon the lumen of the canal. By means of the acorn-pointed bougies and sounds, strictures of larger calibre which escape detection by the conical and cylindrical sounds can be recognized. Yet even these fad to detect certain pronounced strictures. For the meatus is, as a rule, less capacious than the pendulous urethra, just as every other tube which na- ture designs for throwing a stream of hquid some httle distance is nar- rowed at its orifice. Now since the instrument which explores the urethra must be small enough to pass the meatus, it is evident that it is too small to detect a stricture of the pendulous portion so long as the calibre of this stricture exceeds that of the meatus. If, for example, the meatus, as often happens, admits only No. 22 or 23 French, while the general calibre of the pendulous urethra is 32, 34, or 36, a sound, even an olive-pointed bougie, necessarily no larger than the meatus, might fail to detect a strict- ure admitting 24 or 25. An examination with such instruments might therefore give a negative result as to stricture, whUe as a matter of fact a decided constriction of the urethra might exist at one or more points. The meatus therefore constitutes, in most cases of normal conformation, a barrier to the accurate exploration of the urethral cahbre. This obstacle can of course be overcome by enlarging the meatus, but is more readdy evaded by special instruments. In order to explore the calibre of the urethra independently of the mea- tus, Dr. F. N. Otis, of New York, devised an instrument which he calls the " urethra-meter," but which is generally designated urethrometer. This can be inserted through a narrow meatus and when within the urethra dilated at the will of the operator, the amount of dUatation being registered by an index at the handle. " When introduced into the urethra and expanded up to a point which is recognized by the patient as filling it completely— and yet easily moving back and forth—the index at the handle then shows the normal circumference of the urethra under examination. In withdraw- ing the instrument, contractions at any point may be exactly measured, and any want of correspondence between the calibre of the canal and the externa] orifice be readily appreciated. Among the advantages claimed for this instrument are : 1. Its capacity to measure the size of the urethra and to ascertain the locality and size of any strictures present, without reference to the size of the meatus. 2. It enables the surgeon to complete the ex- amination of several strictures by a single introduction of the instrument." An improvement in this instrument has been devised by Dr. Robert F. Weir, of New York. The improvement consists in the substitution of an DETERMINATION OF THE URETHRAL CALIBRE. 85 acorn-shaped bulb instead of the oval extremity, thereby increasing the dehcacy of the instrument in detecting slight contractions of calibre. Dr. Otis and others have made numerous measurements of urethre supposed to be normal, and have deduced therefrom va- rious conclusions as to the normal calibre of the urethra. Dr. Otis finds that the bulbous portion of the urethra, about an inch in length, is usually more capacious than the remainder of the pendulous urethra ; that when the urethrometer is introduced into the bulbous urethra, then ddated and gently withdrawn toward the meatus, it becomes necessary to diminish the calibre of the bulb 3 or 4 mm. in the first inch traversed ; the calibre of the canal then remains practicaUy unchanged untU the instrument reaches the immediate vicinity of the meatus, which is usually decidedly smaUer. He states that in 100 cases of supposed normal urethre, carefully measured ■with his urethrometer, the calibre of the ante-bulbous portion averaged 32.95 mm., the bulbous portion itself being on the average 35 mm. In 13 of these 100 cases he detected no variation at all in the calibre of the ure- thra from the bulb to the meatus. Dr. Weir, after numerous examinations, comes to somewhat different conclusions as follows : The urethral canal is, in the words of Jarjavay, "nar- row at the meatus, ddated in the glans, and very shghtly narrowed at the termination of the fossa navicularis; then it forms a cylinder nearly uniform to the prepubian angle, where a coarctation is found. It enlarges then to the bulb." The spongy portion of the urethra is the smallest (except the meatus) and least dilatable portion of the canal. Normal constrictions (or obstructions) are to be met with in this portion of the canal as small certainly as No. 29, and the means at present employed are insuf- ficient for the distinction of such from " strictures of large calibre." The healthy urethra in this portion can generaUy be readdy and safely dilated up to an average size of 32 mm. The normal size of the meatus is from No. 21 to 28. These conclusions of Dr. Weir are corroborated by Bumstead and Taylor. Otis, relying upon his measurements, is inclined to IGthrometer. regard any constriction of the urethra in the ante-bul- bous portion measuring decidedly less than the bulbous portion as an abnor- mality which calls for division in case the patient complains of obscure symptoms connected with the bladder, urethra, or genital functions. He has at different times, especially in his recent volume upon " Genito-Uri- nary Diseases and Syphilis," reported numerous cases in which the division of such constrictions has been followed by the relief of symptoms which had persisted in spite of other and ordinary measures of treatment. He maintains, furthermore, that there is a constant relation between the cir- cumference of the penis and that of the urethra. He says:1 "When the 1 Loc. cit., p. 441. 86 DISEASES OF THE URINARY ORGANS. urethral contractions are below the calibre of the closed bulb, or when they are numerous and close together, the normal calibre of the canal may be assumed from the circumference of the flaccid penis. When the circum- ference is 3 inches, the urethra has a normal calibre of at least 30 French ; if 3i it will be 32 ; if 3|, 34 ; if 3|, 36; if 4 inches, 38 ; if 4£ inches 40 or more. The correction " (correctness ?) " of this proportionate relation has been verified by the author's careful measurement in over one thousand consecutive cases, without meeting with a single exception in infancy, childhood, adult life, or old age." Combining these two propositions—first, that the calibre of the urethra is practicaUy uniform from the bidb to the meatus, and, second, that this calibre bears a definite ratio (as set forth in the preceding table) to the circumference of the flaccid penis, posterior to the glans—Otis formulates a simple plan of procedure : The calibre of the urethra from bulb to meatus should be made to bear this given relation to the circumference of the penis ; a constriction in any part of the pendulous urethra which con- stitutes a deviation from this ratio should be divided for the relief of ob- stinate symptoms. The fact that a large sound, even 28 Charriere (15 English), is admitted, does not, according to Otis, preclude the existence of a stricture which may be responsible for annoying symptoms. An instance of Dr. Otis' theory and practice is furnished in the foUowing case :] " T. W----, aged thirty-five, had gonorrhoea fifteen years ago ; has had it several times since—the last time, four years ago, coming on forty-eight hours from date of exposure. After the discharge had existed ten or twelve days, he states that he 'stopped it with a powerful quack injection.' Three or four days subsequent to this he began to suffer with a neuralgic pain in the left testicle, the scrotum became tender and red, testicles moved up and down alternately much of the time, and the penis was greatly con- tracted ; there was likewise pain in the groins, described as drawing and sickening, which extended down into his knees and the bottoms of his feet. This continued with varying severity almost without cessation up to Feb- ruary 22d, when he came to New York for treatment. He feU into the hands of an endoscopist, who discovered numerous granular spots deep in his urethra. Applications made at regular intervals for about three months without benefit. An application of carbolic acid to the scrotum gave some relief to his nervous feelings, but this caused vesication and the relief was but temporary. About May 1st he sought the advice of a surgeon skiUed in genito-urinary diseases. Slight stricture was discovered near the meatus and several indurated points farther down. A 28 French solid steel sound was introduced, and after some repetition during one month was given to the patient, to be regularly used once in three days until his trouble ceased. " Went back to his home, some eight hundred miles distant, and pursued the plan laid out for him, but received no benefit. The motion of his tes- ticles was almost constant, and the nervous feeling this induced drove him almost frantic. Compared with it the pains in his groins, knees, and feet were a positive relief. He became very low-spirited and despondent. Early in October his physician advised him to return to New York and put him- self under my care. My examination discovered a penis of normal size, three inches in circumference ; scrotum greatly relaxed and covered with ecze- matous scales produced by the carbolic acid ; testicles hanging very low. My attention was at once drawn by the patient to the rhythmical contraction of the cremaster muscles, through which a see-saw motion of the testicles 1 Loc. cit., p. 506. DETERMINATION OF THE URETHRAL CALIBRE. 87 was kept up, and which constituted his chief annoyance. Bulbous sound 30 French passed the meatus, but was arrested at half an inch, a point to which his greatest sensitiveness during passage of instruments had always been referred. Bulb 28 French passes through and detects another strict- ure at two inches and still another at two and a half. On Friday, October 17th, at my invitation, the patient was examined by Dr. Coldham, of Tole- do, and Drs. Woodruff and Howe, of New York, especially in reference to the spasmodic action of the cremasters. This was very marked and constant, and continued until the patient was placed under the influence of ether by Dr. Howe. I then demonstrated the size and locality of the strictures before mentioned, and divided them in succession with my large dilating urethrotome, after which I passed with ease a 30 French steel sound through aU and into the bladder. As the patient emerged from the in- fluence of the ether, it was observed that there was no longer any of the spasmodic action of the cremaster. When he became conscious he stated that he already felt less of his nervous feeling than for many months. He was certain that the right chord had been struck. " October 8th. Improvement continues. No return of spasmodic action. " October 20th. Examination with 30 French shows a slight clinging at one-fourth of an inch from the external orifice. Cut this at once and freely with straight bistoury and pass 31 French. The patient, on the foUowing day, expressed his belief that a complete cure had been effected ; that since the final division of the meatus he had not the slightest return of the ab- normal sensations and pain with which he had in some degree constantly suffered for the previous four years. Daily introduction of the bulb was kept up in this case untU all bleeding ceased, when the patient was dis- missed with the promise on his part to inform me by post if he had any return of this trouble. No such information was received." Dr. Otis' views on the normal calibre of the urethra, the morbid in- fluence of slight constrictions of that channel, as well as on the radical cure of stricture, have been before the profession for a number of years, but have not been very extensively adopted. The explanation appears to lie largely in the fact that comparatively few surgeons have taken the trouble to investigate the results obtained in practice by the applica- tion of these ideas. The opposition and hostile criticism so plentifully be- stowed seem to be based upon d priori theoretical deductions rather than upon failures in practice. In his recent work upon genito-urinary dis- eases, Dr. Otis mentions numerous surgeons who have given the subject a fair investigation, and who certify to the favorable results obtained in practice by the applications of the principles enunciated. It is difficult for one who has carefully investigated the anatomy of the urethra in numerous post-mortem examinations to accept the statement that the normal calibre of the urethra is practically uniform from the bulb to the meatus ; and measurements made during life with the urethrometer confirm the general experience of anatomists that the urethra normally and generally presents certain slight constrictions in the pendulous por- tion aside from that almost invariably found at the meatus. Indeed Dr. Otis' own measurements exhibit the same fact ; for in his table of "meas- urements of 100 cases of supposed normal urethra1 with the urethro- meter, the measured difference between the bulbous urethra and the part anterior to it was," in 6 cases, 4 mm.; in 2 cases, 5 mm.; in 2 cases, 6 mm. ; in 2 cases, 7 mm. ; in 1 case, 11 mm. Since in these cases, as well as in those measured by Dr. Weir and others, there were no symptoms whatever indicating an abnormal condi- 88 DISEASES OF THE URINARY ORGANS. tion of the genito-urinary functions, it must be inferred that these slight contractions are normal and, of themselves at least, incapable of originat- ing any disturbance of function. Even if there were possibilities for contention as to the relative calibre of the urethra at different portions, there can be no dispute as to the fact that in the vast majority of cases the meatus is decidedly smaUer than the average of the canal. It would seem that a contraction at the meatus ought to exert at least as much disturbing influence as a similar contrac- tion posterior to it. Dr. Otis furnishes1 a table showing the calibre of the urethral orifice in 100 cases in which no inflammatory condition had ex- isted. The circumference of these varied from 13 to 37.5 mm., the aver- age of the 100 being 24.72 mm. " In no case was the urethra, in the 100 cases, below a calibre of 26 mm.—ranging from this to 39—the average being 32.95." It would seem, therefore, demonstrated by Dr. Otis' own measure- ments, as well as those of others, that contractions in the calibre of the ure- thra as well as its orifice are perfectly normal; that they are found in cases where no inflammatory or other abnormal condition of the urethra has existed to originate them ; that they are in other words congenital and frequent; and that they occasion no disturbance of function so long as the urethra remains free from disease, notwithstanding the great disproportion of the calibre at these points of constriction to the general size of the ure- thra and to the circumference of the penis. When, however, the urethra has been the seat of inflammation, it is quite possible that these congenital and normal constrictions of its calibre, even when so slight as to escape detection by the ordinary instruments of exploration, may aggravate and prolong the affection and induce complica- tions which can be relieved only by the removal of the constriction. In support of this assumption there are certain analogous facts and direct demonstrations. It is a familiar and unquestioned observation that a decided constric- tion of the urethra or of the meatus originates complications in the course of urethral inflammation which can be relieved only by the removal of the constriction ; many a case of gleet, of dribbling after urination, of neural- gia of the urethra and bladder-neck, has been relieved by the dilatation of a narrow stricture or the division of a narrow meatus. It would seem, therefore, plausible to suppose that a constriction of the urethra, even though it admitted a larger sound than could pass the average meatus, might exert effects similar in kind if not in degree. Dr. Otis has certainly demonstrated that such constrictions, congenital or acquired, may exist and escape detection by any other instrument than one constructed upon the principle of his urethrometer. Yet the question must be decided, of course, not by d priori reason- ing, but by actual test in practice. As already stated, this test has not been made so extensively as is required to determine finaUy and definitely how far these " strictures of large calibre " are to be held responsible for geni- tal and urinary disorders. Dr. Otis himself has furnished a long list of cases in which the division of such constrictions, both in the course of the urethra and at the meatus, has been followed by relief from symptoms which had defied all other methods of treatment ; and several other sur- geons, notably Dr. S. W. Gross, of Philadelphia, have upon the basis of practical experience indorsed more or less completely Dr. Otis' assertions. 'Loc. cit., p. 421. DETERMINATION OF THE URETHRAL CALIBRE. 89 My own systematic investigation of this subject began only about four years ago ; and although opportunities for observation during that time have been rather extensive and have convinced me that strictures of large calibre are often responsible for morbid conditions, they have not enabled me to determine to what extent these constrictions are indirectly produc- tive of functional abnormalities of the urinary and genital organs, as main- tained by Otis. I have learned to regard the urethrometer as an essential means of diagnosis in many disorders of the genito-urinary apparatus ; indeed, I make it a part of every examination of these organs unless special circumstances forbid. Yet I do not regard every slight constriction which may be discovered as an indication for operation until other means of diagnosis have been employed and other possible abnormalities have been removed by less radical measures. Even cases of gleet are sometimes curable by topical applications without division of urethral constrictions which may be present; and I have repeatedly seen a gleet continue after the removal of such constrictions and the passage of large sounds, until such topical applications were made. A careful examination of the urethra in twenty-two men who had never had gonorrhoea nor other urethral difficulty has furnished the foUowing results : 1. The bulbous portion is the most capacious and gradually decreases in calibre from behind forward for about an inch or an inch and a half ; from this point to the meatus the calibre is sometimes practically uniform, but often exhibits slight constrictions which are not constant as to location or size. 2. The narrowest point of the channel (except the meatus) was found in more than half the cases at about the middle of the pendulous urethra. 3. The difference in capacity between the widest portion (the bulb) and the narrowest point (the middle of the pendulous urethra) may amount to five, ten, or even twelve mUlimetres. 4. There is no constant relation between the general urethral calibre and the size of the meatus ; the latter is sometimes almost as capacious as the urethra (in one instance admitting easUy a No. 36 bulb) but usually much smaller (by ten, fifteen, or even twenty miUimetres). In another series comprising sixteen cases I measured the urethra of individuals who had had gonorrhoea one or more times, but were entirely free from gleet and other abnormalities of the urinary organs. I was not enabled to satisfy myself that the urethra in these cases exhibited any marked and constant deviation from the features presented by the cases in the first series who had never had gonorrhoea. Slight contractions of the urethral channel seem, therefore, to be either congenital and natural or are frequently produced by other influences than gonorrhoea ; they may doubtless result from masturbation and probably from lithiasis also. In every case of urinary or sexual derangement, their existence should be noted; whether or not such constrictions should be divided is a question which must be decided by their probable relation to the morbid condition as well as by the results of other remedial measures. Like other methods of examination and treatment, this one has ac- quired much disrepute from its employment in cases to which it is not ap- plicable. It is unfortunate that the specialist in genito-urinary, as in other diseases, acquires a routine method in diagnosis as well as treatment; he is prone to the adoption of some one method to the exclusion of all others, and in his zealous application of one ignores others of equal value. The endoscope, for example, has a most valuable field in the diagnosis and 90 DISEASES OF THE URINARY ORGANS. treatment of urethral diseases, a field which can be occupied by no other means or instruments ; yet endoscopists have endeavored to crowd into that limited field classes of cases in which the endoscope is either useless, or at least far inferior to other instruments for diagnosis and treatment. The result has been that the profession practically ignores the endoscope ; for, having proven the faUacy of the claims made for it in many cases, we are disposed to regard it as equaUy useless in all—to reason that since it cannot do everything asserted for it, it can do nothing. A simUar miscon- ception prevaUs largely, as I think, with regard to the "strictures of large calibre " whose pathological importance Dr. Otis has been so instrumental in bringing before the profession. The clinical importance of these strict- ures has been much exaggerated ; that is, they have been held responsible not only for some but for all of those cases of obscure and obstinate affec- tions of the urethra and bladder which resist primitive treatment by sounds and injections. The result has been that enthusiastic supporters of Otis' plan of treatment have sought refuge in a real or imaginary stricture of large calibre upon slight provocation, and without a complete investigation as to other morbid factors; and the failure to relieve obstinate symptoms by the division of such stricture in cases where other pathological condi- tions were present, has brought undeserved discredit upon the entire sub- ject. There can be no doubt that a division of a stricture of large calibre, recognizable only by Otis' or a similar urethrometer, has effected the relief of symptoms which sounds, injections, and the endoscope were powerless to remove ; but it is equaUy certain that such division has been performed in many cases without benefit, simply because the morbid symptoms were dependent upon some other pathological condition. The discredit re- dounds, of course, not to the method but to the surgeon who insists upon curing aU cases of whatever nature by that one method ; just as the dis- credit into which the endoscope has fallen is to be ascribed, not to the in- strument itself, but to the folly of those who can see no other cause for urethral symptoms than a real or imaginary granular patch in the mucous membrane. My own experience has demonstrated the morbid influence of strictures of large calibre and the necessity for their complete division (by Otis' dilating urethrotome) in the foUowing conditions : 1. Gleet. That a gleety discharge which has made the usual round among physicians, and has for years resisted medication by injections and the passage of large sounds (12 to 16 English), is often maintained by a shght constriction of the urethral calibre and completely and immedi- ately relieved by the division of such constriction, I have repeatedly demon- strated ; in one of my cases which were promptly cured by this method, a No. 17 English sound passed readily into the bladder ; in another and unique case (narrated on a previous page) the urethra admitted a No. 22 sound. Yet with the greatest deference for the authority of Dr. Otis, to whom the credit of demonstrating this important relation is chiefly due, I must dissent from his assertion that gleet is always a proof of stricture, or as he states it, that " gleet is the signal which nature hangs out to notify the patient and his surgeon that the urethra is strictured at some point." For I have treated a few cases in which I was unable to detect even a slight stricture, and in several others I have seen a gleet continue after division of slight strictures and passage of fuU-sized sounds. One of these was the foUowing : A railway conductor, aged forty-one, had had three attacks of gonor- rhoea, the last ten months before he consulted me. He had been afflicted DETERMINATION OF THE URETHRAL CALIBRE. 91 since the last attack with a persistent gleet, which had resisted treatment by sounds and injections in the hands of his physician. After several months of this treatment, during which no abatement of the discharge had occurred, the physician explored the urethra with Otis' urethrometer. It was found that the general calibre was 34, while a constriction to 28 was detected about one and a half inch back of the meatus, the latter meas- uring 23. This constriction was by means of Otis' urethrotome enlarged to 32, the meatus being also incised to the same extent. The calibre of the urethra was maintained by the daily passage of a 32 sound. The gleet continued almost as profusely as before. Two months after the operation, the patient consulted me. At that time a 31 French sound passed without difficulty into the bladder, causing some pain at a point two inches behind the meatus. Upon examination with the endoscope, I found the mucous membrane just posterior to the former stricture quite red, slightly granular, and presenting near the median line on the floor of the canal a mass of flabby granulations more than an eighth of an inch in diameter. These were removed by means of the snare, the base touched with a forty per cent, solution of the nitrate of silver, and the surrounding red surface pencilled with bluestone. In less than two weeks the dis- charge ceased entirely, and up to the present time (about five months) has not returned. 2. Irritability of the bladder, manifested by frequent urination, with or without pain. In all of my cases of this category there has been more or less hyperesthesia of the urethra, and the sound has revealed very sensi- tive spots in this channel. 3. Various sexual disorders, especially those apparently due to hyperes- thesia of the prostate, and manifested by abnormally frequent poUutions and premature ejaculation. 4. Chronic inflammation of the prostate and bladder as a sequel of gonorrhoea. The division of constrictions of the meatus and urethra has occasionally transformed an obstinate into a tractable case. Doubtless the passage of a sound large enough to completely distend the urethra—possible only after the division of such constrictions—contrib- utes largely to the benefit conferred in many of these cases. In several other instances I have divided slight constrictions and thus rendered the pendulous urethra of uniform calibre throughout, without the slightest perceptible improvement or relief of symptoms which, after the faUure of other remedial measures, I had believed to be produced or at least maintained by urethral constrictions. Most of these cases have ex- hibited irritabUity and neuralgia of the bladder. The failure to relieve these patients does not disprove the morbid influence of slight urethral strictures in many other cases, but merely demonstrates my error in at- tributing the symptoms in these instances to such constrictions. How- ever, the operation has rarely produced any serious reaction, and usually permits the patient to resume his vocation in twenty-four hours ; I have repeatedly performed it without anesthesia. Hence in obscure or doubt- ful cases the division of strictures of large calibre is justifiable as a tenta- tive and diagnostic operation. My impression in regard to this matter is, then, that the presence of a stricture of large calibre may be the means of prolonging and aggravating various disorders originating in a urethritis ; that in every case in which urethral inflammation has occurred (perhaps in others also) which exhibits a refractory behavior toward ordinary therapeutic means, the urethra should be examined as to the possible existence of such constrictions, and 92 DISEASES OF THE URINARY ORGANS. that these, if detected, should be removed. On the other hand, it is doubt- less a mistake to suppose that these " strictures of large calibre " consti- tute the key to aU the obstinate and obscure affections of the genito-urinary organs. The exploration of the urethra with an instrument constructed on the same principle as Otis' urethrometer should be recognized as one of the means of diagnosis, but only one, and not a complete and thorough examination in itself. Moreover, the discovery of such a constriction is not of itself a sufficient warrant for urethrotomy, until the symptoms and the effects of treatment indicate strongly that the constriction is the cause of the difficulty. Catheteeization of the Ureter. This is a measure which might in exceptional cases possess extreme value in diagnosis, possibly in treatment also. The advantages are obvi- ous : it would be a regular preliminary to any operation which might in- terfere with the functions of a kidney, such as nephrectomy or nephrotomy. The introduction of a catheter into the opposite ureter would enable the surgeon to satisfy himself whether or not the second kidney was present and in a healthy condition ; for it has repeatedly happened that after the removal of one kidney the patient has died of uremia, because, as has been revealed post-mortem, the excised organ was the only kidney present in a condition to discharge its functions. The introduction of the catheter into the ureter might also solve a question in diagnosis which cannot always be decided by the present methods of examination : namely, whether a given fluctuating tumor of the abdomen is a hydronephrosis or an ovarian cyst. Possibly a hydronephrosis could be evacuated in this way. Such a meas- ure would give certainty to a diagnosis as to the presence of a calculus in the ureter ; it might even be useful in pushing back the calculus into the pelvis of the kidney, or at least of determining whether or not nephrec- tomy would be necessary. Such advantages would undoubtedly accrue from the introduction of the catheter into the ureter if this measure were generally practised. Up to the present time, however, but few have been able to overcome the ex- treme difficulties which oppose the execution of this plan. Indeed, it has been accomplished only in the female, where the anatomical relations are such as to oppose but little difficulty as compared with the situation in the male. Simon first practised catheterization of the ureter, after dilatation of the urethra. He performed this manipulation on seventeen women, and in aU but two cases succeeded in reaching the pelvis of the kidney. Others, however, who endeavored to repeat the operation found extra- ordinary difficulty even after the urethra was dilated up to 2 ctm. Thus Winckel and Rutenberg failed entirely, the former asserting that he could not even recognize the orifice of the ureter. Moreover, the preliminary dilatation of the urethra constitutes a serious objection to this method, not only because of the necessity for anesthesia, but also and especially because of the iU effects sometimes consequent thereupon—incontinence of urine, cellulitis, and fatal peritonitis. The next successful attempt to catheterize the ureter in the female was made by Griinfeld. By means of a short, wide endoscope, the inner ex- tremity of which was closed with glass, Griinfeld was enabled to bring into the field of vision the opening of the ureter, and then to introduce into this a sound of special construction. He has in this way passed a sound into the ureter to the depth of 15 ctm. This method I know by experience DETERMINATION OF THE URETHRAL CALIBRE. 93 to be extremely difficult; it requires, on the part of the operator, consider- able familiarity with the instrument, and much patience and practice in order to distinguish the opening of the ureter from the numerous folds and depressions presented by the mucous membrane. It is impracticable except when the bladder is distended, whereby these folds are obliterated ; and the opacity of the urine, aggravated by the cloud of mucus which soon appears as the result of the irritation caused by the instrument, renders this manipulation tedious and uncertain even after long practice. The simplest and most practicable method yet presented was demon- strated in September, 1881, to the "Versammlung Deutscher Natur- forscher " at Salzburg, by Dr. Carl Pawlik. This depends for its execu- tion upon the fact that the trigonum of the bladder in the female—at whose apices the ureters open into the bladder—is distinguishable by both eye and finger through the vagina. Pawlik happened upon this method of sounding the ureters by his observations in cases of vesico- vaginal fistula operated upon in Carl Braun's clinic, where he was assist- ant. He found that by introducing the finger through a fistula into the bladder, a catheter passed through the urethra could be readily directed into the ureter; subsequently he observed that the finger in the vagina afforded the necessary assistance for the same purpose. As originally practised, the patient was made to assume the knee-elbow position ; a Sims speculum retracted the posterior wall of the vagina, so that the oper- ator could both see and feel the projection in the anterior wall correspond- ing to the trigonum vesice. A sound introduced through the urethra was then guided by the finger into the ureter. Subsequently Pawlik found that inspection of the vagina was unnecessary ; by placing the woman upon her back in the ordinary attitude for vaginal examination, the finger in the vagina sufficed to direct the instrument in the bladder. Pawlik thus introduced sounds into the ureters in several cases in which Billroth performed the vaginal extirpation of the uterus, thereby affording the sur- geon better facilities for avoiding the ureters. In the summer of 1882 Pawlik informed me that he had successfully catheterized the ureter in more than forty cases, having failed Only once ; this failure was due to a decided prolapse of the uterus. However simple this method may appear, its successful execution re- quires, nevertheless, considerable practice and patience. I have performed it repeatedly on the cadaver, but have not always been successful. I use a flexible sound, its bulbous extremity having a calibre of not more than No. 4 Charriere. The instrument is straight except that the last half inch (at the bulbous extremity) is bent at a slight angle with the shaft. With the finger in the vagina the apex of the trigonum is recognized and slightly raised, so that the orifice of the ureter shaU rest on the inner side of the finger. The point of the instrument introduced into the bladder can readdy be detected, and should be guided so as to enter the orifice. The first attempt will probably be unsuccessful; the point engages in the mu- cous membrane in the vicinity of the ureter, and the mistake is discovered only when the effort to advance the instrument meets with decided resist- ance. When finally the instrument enters the ureter, the fact can be ascer- tained by observing that while it progresses readdy in the direction of the ureter, it cannot be moved lateraUy without decided resistance. A catheter of appropriate size—not larger than No. 4 or No. 5—can be slipped over the sound after the closed end has been cut off. If it enters the ureter, it usuaUy advances without much obstruction until it reaches the point where the ureter crosses the common iliac artery ; here a con- 94 DISEASES OF THE URINARY ORGANS. siderable, sometimes insurmountable, obstacle is offered by the change in direction of the ureter. While this method is by no means easy of execution, it is practicable, requires no preparation on the part of the patient, and no instruments of special construction. It should be undertaken in every case where its suc- cessful execution would be a matter of importance in diagnosis ; for even if unsuccessful, the attempt, when carefuUy and judiciously made, inflicts no injury upon the patient. The introduction of the catheter into the ureter in the male has not as yet been accomplished; the anatomical relations are such as to offer but little encouragement to the attempt. Various measures have been devised for the purpose of securing the urine from one or the other ureter as re- quired. These measures have consisted in the attempt to obstruct one ureter so as to prevent the escape of urine from it into the bladder; the liquid which then collects in the bladder, being derived from the opposite kidney, affords the means of estimating the condition of this organ. The first method devised for this purpose was contrived and executed on his own person by Teichmann. He constructed an instrument resembling a light lithotrite ; this was introduced into the bladder, the jaws separated and then approximated so as to compress the orifice of one ureter. Al- though the measure was carried into execution by Teichmann upon himself, apparently with success, it was not adopted by others, for obvious reasons. Other plans have been tried, based upon the occlusion of one ureter by the pressure exerted over its vesical orifice ; one of the most promising of these is that devised by Silbermann, of Breslau. A metallic catheter (No. 18 French) is provided with an opening one and a half inch long upon the side and with several small perforations at its extremity. After the instrument has been introduced, a smaUer catheter is passed into it. Over the end of this smaUer tube is fitted a rubber bag, which, when the smaller instrument is in position, fiUs the eye of the outer catheter. This instrument is so placed that the eye rests against the orifice of the ureter; mercury is then poured into the inner tube, dilating the rubber bag and compressing this orifice. It is said that this instrument has been success- fully employed in securing the urine from one kidney only ; yet there seems to be necessarily an element of uncertainty as to whether the ureter is completely occluded. In other cases the hand has been introduced into the rectum, the ureter sought out as it passes along the posterior surface of the bladder and compressed between the fingers. This is a tedious manoeuvre, not en- tirely devoid of danger to the patient; and after all it affords no certainty of accomplishing the desired object; for the fingers, which must compress the ureter for ten or fifteen minutes at least, require occasional change of position, during which movement the urine which has collected above the point of compression may possibly escape into the bladder. CHAPTER IX. PHYSIOLOGY OF THE URINE. The kidney is an aggregation of tubules, each of which secretes urine. The study of the process whereby the urine is secreted consists, therefore, in a study of the urinary tubule and its functions. The tubule is a microscopic canal which begins at the pelvis of the kidney (of which it is indeed a prolongation), extends through the entire breadth of the kidney, and terminates in an expanded extremity in the cortical portion of the organ. The tubule consists of an elastic cylinder, the inner (concave) surface of which is covered with cylindrical epithelial cells, whose broad bases rest upon the elastic basement, while their narrow ends point into the lumen. The various portions of the urinary tubule have been designated by different names: the first portion—that which proceeds in a straight course from the pelvis to the cortex—is termed the "straight tube of Bellini ;" the next segment—that which runs from the cortex into the meduUa and then curves back again into the cortex—is called the " loop of Henle;" the terminal segment of the tubule—that which presents a series of short, irregular curves—is designated the " convoluted tubule." The expanded blind extremity of the tubule is depressed ; that is, the blind end of the tube is pushed into its cavity, making a cup-shaped de- pression, just such as would be produced by pushing the end of a glove finger into its cavity. In this cup-shaped depression rests the bunch of capiUaries termed the " Malpighian tuft" or "glomerulus." The de- pressed, blind extremity of the tubule is closely adherent to the glom- erulus, which it almost completely encloses, leaving uncovered only a small space for the entrance of an artery and exit of a vein which carry the blood to and from the glomerulus. This portion of the tubule covering the glomerulus is accordingly termed the " capsule " of the glomerulus (Fig. 1). The ceUs hning the tubule differ in form and size in the different seg- ments of the canal. In the straight tube of BeUini and in Henle's loop, distinct cylindrical cells are distinguishable ; in the convoluted tubules, on the other hand, the epithelium consists of a jelly-like mass in which nuclei are imbedded at regular intervals, though no separation of the mass into distinct cells is possible. The ceUs constituting the blind extremity of the tubule—those cover- ing the glomerulus—are thin, flat scales, apparently identical in form with the endothehal cells which line the serous cavities of the body. They are therefore entirely different in appearance from those constituting the rest of the tubule. They appear to lie directly upon the capillaries of the glomerulus, there being no basement membrane interposed. The tubule is surrounded throughout almost its entire length by capil- lary meshes. The branches of the renal artery pass from the hilus of the 96 DISEASES OF THE URINARY ORGANS. kidney between the straight tubules, where they divide into two sets of vessels. One set divide at once into the capillaries which surround the straight tubules ; the other set of arteries proceed between the straight tubules to the cortex of the kidney, where each terminates as a glomerulus. The vein emerging from the glomerulus conducts the blood to the network of capiUaries surrounding the convoluted tubules. It is thus evident that while all the blood which enters the kidney passes through the inter- tubular capillaries, only a portion of it reaches the glomeruli. In this connection it is interesting to note that in certain amphibians there is a marked difference in the blood-supply to the glomeruli and to the tubules ; the former receive blood directly and only from the renal artery, while the capillaries surrounding the tubules are supplied also by a renal portal vein, which transfers blood from the alimentary canal to the kidney. Hence, in man as well as in the loAver animals, the tubules are supplied with more blood than reaches the glomeruli, since they receive the blood which has passed through these tufts plus an addi- tional quantity which is supplied directly from the renal artery, or from a renal portal vein. This increased blood-supply to the tubules would in- dicate that they perform a function different from that of the glomeruli— an inference whose correctness has been demonstrated by the researches of the last decade. The blood-supply of the human kidney is derived chiefly, though not entirely, from the renal artery ; for there is free anas- tomosis between the vessels of the kidney and those of its capsule, and this latter is largely supplied with blood by branches of the suprarenal, lumbar, and spermatic arteries. The supply of blood from these sources is quite considerable ; for Hermann has shown that the secretion of urine may continue in appreciable quantity even after the renal artery has been ligated, sufficient blood being derived from the suprarenal and spermatic arteries to maintain the function of the kidney. Litten has shown that the spermatic artery alone furnishes an appreciable amount of blood to the kidney; he found that after ligation of the renal artery and vein and of the suprarenal artery, there occurs a transient period of anemia of the kidney, which is, however, soon followed by decided congestion of the organ and even the formation of infarcts ; by ligating the ureter, includ- ing the spermatic artery (in addition to the vessels already named), perma- nent anemia of the kidney was secured. The Functions of the Tubule.—The lower portion of the tubule—the straight tube of Bellini—has, so far as known, only the mechanical function of a duct, a channel for the passage of the urine. This part of the tubule seems to be merely the continuation of the ureter. The remaining portion—the loop of Henle and the convoluted tube— effects the true secretion of the urine. The epithelial cells in this portion of the tubule perform the ordinary functions of a gland, in that they ab- stract from the blood which circulates around them certain ingredients which are then transferred to the lumen of the tubule.1 1 This secretory activity of the cells lining the convoluted tubules and loops of Henle was first satisfactorily demonstrated by Heidenhain, in 1875. He injected into the circulation a solution of the indigosulphate of sodium, and observed that in the course of a few minutes the urine acquired a blue color, indicating that the indigo was being excreted from the blood by the kidneys. To determine what part of the organ was instrumental in this excretion, Heidenhain killed the animals at various periods after the appearance of the blue tint in the urine, and examined the kidneys microscopically. He found particles of indigo blue in great numbers in the cells lining the convoluted tiurales, and in smaller quantity in the cells of Henle's loops, but never in those of the PHYSIOLOGY OF THE URINE. 97 That these secreting ceUs separate from the blood not only the solid constituents but also some of the water, must be admitted without actual demonstration, since excretion of solids without water is inconceivable. But Nussbaum has furnished in the foUowing way an elegant demonstra- tion of the fact that the cells of the tubule separate from the blood some of its watery constituents : in amphibians, the Malpighian tufts are sup- plied with blood by branches of the renal artery, while the capillaries sur- rounding the urinary tubules obtain an additional supply from the renal portal vein. Ligature of the renal artery, therefore, while cutting off the blood-supply of the Malpighian tufts, does not deprive the tubules entirely of blood. Nussbaum observed that ligature of the renal artery in amphib- ians was followed at once by a suppression of the urinary secretion ; but he found that this secretion commenced again in appreciable quantity after an injection of urea into the blood of the animal, even though the ligature on the artery remained undisturbed. It is evident, therefore, that the well-known diuretic effect of the urea was sufficient in this case to stimulate the cells of the tubules to a considerable excretion of water. The functional activity of these cells appears to be limited almost en- tirely to excretion, since nearly aU of the materials found in the urine are produced in the body without the intervention of the kidneys, and exist preformed in the blood of the systemic circulation. The kidneys, like other organs, produce urea and uric acid, but only in relatively small quantity. There is, however, one substance which is produced chiefly, if not entirely, by the secreting cells of the kidney—hippuric acid. The recent researches of Bunge and Schmiedeberg have demonstrated that benzoic acid is transformed into hippuric acid in the living animal by the kidneys ; indeed, they were able to secure this transformation in extirpated kidneys by passing through the excised organs blood containing benzoic acid.l straight tubules, nor in the capsules of the glomeruli. It was thus demonstrated that the cells of the convoluted tubules and of Henle's loops possess the power of separating one substance at least from the blood. Subsequent research showed that the urates and the biliary pigments also are excreted by these same epithelial cells ; and it is as- sumed that all the other solid ingredients of the urine are abstracted from the blood by the activity of these same cells. Since the publication of Heidenhain's researches, numerous investigators have con- firmed his results. It has been found, furthermore, that the injection of certain sub- stances, such as chromic acid and cantharides, is followed by necrosis of the cells in the convoluted tubules, while the remainder of the kidney remains unaffected. This fact also demonstrates the secretory activity of these cells, which abstract the chromic acid from the blood, and are thereby rendered necrotic ; while the cells lining the rest of the tubule, because they possess no secretory activity, experience no damage from the toxic agent. 1 Attempts have been made to ascertain whether or not this power of the kidney to transform benzoic acid into hippuric acid is impaired in various renal affections. Jaarsveld and Stokvis assert, as the result of both clinical and experimental observa- tion, that such impairment does occur, and can perhaps be made a factor of diagnostic importance in the recognition of kidney diseases. These observers induced hsemo- globinuria and nephritis in rabbits by the hrection of glycerine ; they found that such animals excreted no hippuric acid." Benzoic acid administered to these rabbits ap- peared in the urine unchanged ; while healthy rabbits to which benzoic acid was ad- ministered excreted in the urine none of this substance, but a corresponding quantity of hippuric acid. Extending their observations to the bedside, Jaarsveld and Stokvis found that the excretion of hippuric acid was diminished in certain cases of renal dis- ease as follows : In two cases of parenchymatous nephritis, one acute and one chronic, no hippuric acid was found in the urine ; benzoic acid administered by the mouth appeared in the urine unchanged. In two other cases of the same affection, the excre- tion of hippuric acid was markedly decreased ; also in two cases of amyloid degeneration 7 98 DISEASES OF THE URINARY ORGANS. The Functions of the Glomerulus.—The anatomical structure of the glomerulus indicates its physiological function ; it seems to be a purely mechanical apparatus for the separation of the watery constituents of the blood by filtration. It is so arranged that the blood exerts upon the walls of the capillaries composing the glomerulus much greater pressure than is exerted upon the capillaries elsewhere in the body. This arrangement consists merely in the division of the arteriole—the vas afferens—into a large number of capiUaries, which subsequently reunite into a single small vein—the vas efferens. Since the calibre of this efferent vein is much less than the combined calibre of the capillaries which empty into it, there must necessarily occur an unusuaUy great pressure on the walls of these capillaries. To favor the process of filtration still more, unusually slight resistance is offered to the escape of fluid from the capillaries of the glom- erulus, since the blood in them is separated from the lumen of the tubule only by the capillary wall and the layer of delicate cells covering the glomerulus. Under such conditions a much larger percentage of the watery elements of the blood must necessarily escape. In all the capillaries of the body a certain amount of the blood serum passes through the vas- cular walls ; from those of the kidney not less than fifty ounces of fluid usually escape during the twenty-four hours. The separation of the water (and of the salts which naturally accom- pany it) is generally regarded, therefore, as a process of purely mechanical nitration. Upon this assumption we can understand the variations in the quantity of urine observed in clinical and experimental cases. The quan- tity of water filtered through the glomeruli, and hence of the urine, will be increased by any one or more of the following factors : 1. Increase of blood-pressure in the glomeridi. This may be due either to increase of the general arterial pressure, or to obstruction to the return of blood through the renal vein. Digitalis, for example, causes an in- creased secretion of urine by raising the general blood-pressure in the arteries and hence in the glomeruli. Obstruction to the return of blood from the kidney rarely occurs clinically except as a result of enfeebled action of the heart; a few cases are, however, on record in which a local impediment existed which interfered with the circulation through the renal vein without affecting the general blood-pressure. In these cases an in- creased secretion of urine has been observed. 2. Increased rapidity of the blood-current through the glomeruli. This usuaUy occurs as an accompaniment of increased blood-pressure, since the influence which increases the pressure usuaUy increases also the rapidity of the circulation. Yet we know from the laws governing filtration of fluids, that the effect of increased rapidity is, cceteris paribus, to increase the rapidity of filtration. 3. Dilution of the filtering fluid. The ingestion of large quantities of water is followed by a profuse secretion of urine. This results not from an increase of blood-pressure (because no such increase occurs), but simply from the increased diffusibility of the circulating fluid. of the kidney. In three cases of cirrhosis and one of venous congestion, on the other hand, the excretion of hippuric acid was unimpaired, benzoic acid administered by the mouth undergoing the same transformation as occurs in healthy persons. Although the number of these observations is too small to justify a conclusion, they certainly afford a presumption that the excretion of hippuric acid by the kidneys may become an important item in determining whether or not the renal epithelium is affected in cases of kidney disease, or whether the affection is limited to the interstitial connective tissue and the blood-vessels—in other words, whether the nephritis is parenchymatous or interstitial. PHYSIOLOGY OF THE URINE. 99 4. Increased permeability of the capillary walls. Upon this point we have but little definite knowledge. It is known that an increased flow of urine often occurs in cases of pure amyloid degeneration of the kidney ; and it is also known that this degeneration affects especially the capillaries of the glomeruli ; hence the inference that these degenerated capillary walls offer less resistance to the escape of the contained fluid. That a thickening of the filtering membrane would retard the escape of water from the blood is not only plausible, but is actually demonstrated in the nephritis which follows scarlet fever. During this affection the quan- tity of urine excreted is much diminished ; indeed, temporary anuria may occur. The reason for this is apparent upon microscopic examination of the inflamed kidney, Avhich reveals a proliferation and thickening of the flat cells covering the glomerulus, and a thickening of the capillary waUs. There are cases in which variation in the quantity of urine secreted seems inexplicable by the laws of simple filtration. Thus in many in- stances an increased secretion of urine seems to result directly from ner- vous influence ; such is the polyuria which usually follows a hysterical at- tack or an epileptic convulsion. It seems highly probable, however, that the nervous influence affects the kidney not directly, but indirectly through the splanchnic nerves, whereby the calibre of the renal arteries is increased and a greater amount of blood circulates through the kidney. It is at any rate demonstrated that the amount of urine secreted can be increased by puncture of the floor of the fourth ventricle, whereby (through the agency of the splanchnic nerves) the circulation of blood through the kidney is increased.1 In the present state of our knowledge, therefore, we must regard the urine as the product of two distinct processes : 1, the specific activity of the cells lining the convoluted tubule and the loop of Henle, whereby the solid ingredients of the urine and some water are separated from the blood; and, 2, filtration through the glomeruli, whereby the liquid ingredients and certain salts escape from the blood. It seems with our present knowledge that the solid constituents of the urine—urea, uric acid, creatinin, etc.—never escape from the blood in ap- preciable quantity through the glomeruli ; their presence in the urine in- dicates and measures the functional activity and integrity of the epithelial ceUs of the tubules. The excretion of water from the blood, on the other hand, is not monopolized by the glomeruli; a certain amount is separated under ordinary circumstances by the secreting cells of the tubules, and this amount can be, under extraordinary circumstances, much increased. The experiment of Nussbaum, already related, shows that the presence of urea in the blood stimulates these ceUs to the secretion of considerable water; it is possible that the diuretic effect of certain salines is exerted in hke manner through the ceUs of the tubules, rather than through the glomeruli. 1 Heidenhain has recently argued upon theoretical grounds that the escape of water from the glomeruli is not a purely mechanical process, but is influenced largely by the activity of the cells covering the tufts. The considerations advanced in support of this view seem by no means convincing. CHAPTER X. PATHOLOGY OF THE URINE. The solid constituents of the urine comprise almost aU the products of decomposition of the albuminous substances contained in the tissues. So long as the kidneys perform their function properly, but little of these al- buminous products escapes through the skin, lungs, and intestine. The urine is therefore an index to the metamorphosis of the albuminous in- gredients of the tissues. Conversely, so long as the other organs of the body perform their functions normally, the solid constituents of the urine constitute an index to the activity of the kidneys. Yet not all of the solids found in the urine are to be regarded as the products of tissue metamorphosis ; for materials introduced by the mouth, such as egg albumen, are rapidly eliminated by the kidneys, and substances produced in the smaU intestine, such as indican and carbolic acid, are separated from the blood by the same organ. Even the excretion of urea —which is pre-eminently a product of tissue metamorphosis—varies largely according as much or little nitrogenous food is consumed. Hence a proper interpretation of the information derived from an analysis of the urine must be based upon a knowledge of the individual's general condition, diet, etc. Variations in the Normal Ingredients of the Urine. Normal urine may be regarded, for practical purposes, as a solution of urea and of the chloride of sodium. These three chief ingredients—water, urea, and chloride of sodium—are accompanied in their exit from the blood by certain other sohd ingredients of that fluid, organic and inor- ganic, as well as by various foreign matters which have been introduced into the organism. For clinical purposes the most important ingredients of normal urine are the following; the average amount excreted daily (according to Sal- kowski) is also given : Grammes. Urea.................................. 25.00 to 35.00 Carbolic acid........................... 0.02 to 0.05 Indican................................ 0.06 to 0.08 Urobilin...............................Undetermined. Chlorides............................... 10.00 to 15.00 Earthy phosphates....................... 0.80 to 1.40 Alkaline phosphates..................... 2.50 to 3.50 Sulphates.............................. 1.50 to 2.50 PATHOLOGY OF THE URINE. 101 Urea.—This, the chief solid ingredient of the urine, is derived exclu- sively from albumen. Whether or not it is formed directly from albumen, or indirectly after existing in the shape of other compounds, is still an un- settled question. The attempts to produce urea artificially by direct oxi- dation of albumen have failed, though .a substance very similar to urea— guanidine—has been produced by the action of the permanganate of potas- sium upon albumen (B^champ, Ritter). It seems probable that urea is formed in the body not directly from albumen, but from one of the sub- stances which arise from the decomposition of this. Schultzen and Nencki have shown that albumen is changed in the organism into fatty acids, and that these are transformed into urea ; yet it is by no means certain that most of the urea is produced in this manner. It has been shown by Fre- richs, Stokvis, and Neubauer, that uric acid introduced into the stomach is transformed and excreted as urea. Probably some of the uric acid pro- duced in the organism as the result of tissue change is likewise oxidized into urea. Leucin taken into the stomach is entirely converted into urea; hence it is considered certain that the leucin naturally produced in the tissues from the metamorphosis of albuminous substances is normally transformed and excreted as urea. This transformation seems to be effected by the liver. It is quite possible, and indeed probable, that urea originates in still other ways in the organism. Many attempts have been made to ascertain where and by what organs the transformation of these various intermediate albuminous substances into urea is accomplished. The classical and often-repeated experiment of Prevost and Dumas —the extirpation of the kidneys—shows that these or- gans have little if any agency in the production of urea ; for this substance is produced in the usual quantity after the kidneys have been removed. Urea is constantly found in certain tissues of the body, particularly in the liver, the lungs, and spleen ; it is also constantly present in the blood, lymph, aqueous humor, and serous fluid. There is, indeed, one reason for believing that the organs named are largely concerned in the production of urea: this reason is the generally admitted absence of urea from the muscles ; although one would suppose that the muscular sj^stem—so exten- sive and so rich in albuminous matters—would necessarily furnish much of the urea, yet no trustworthy observer has as yet been successful in de- tecting this substance in the muscles of healthy animals. Voit, it is true, found that the muscles of a dog from which the kidneys had been removed contained more than twice as much urea as the blood, and hence beheves that the muscles must, at least under these abnormal conditions, produce urea. So too it has been found that the muscles of patients dead from cholera contained urea in appreciable quantity—in fact, more than the blood. The absence of urea from the muscles and its constant presence in the liver and spleen indicate that the latter organs are instrumental in pro- ducing this substance. All observers have found the liver especiaUy rich in urea, and have usually observed that it contains a larger percentage of this substance than the blood. A fact first observed by Frerichs, and sub- sequently confirmed by others, points strongly to the same conclusion : he noticed that in a case of acute yellow atrophy of the liver, the urea found in the urine was much decreased in quantity and even disappeared entirely, while on the other hand certain intermediate products in the de- composition of albumen—leucin and tyrosin particularly—were excreted. Ratio between Tissue Metamorphosis and Urea.—The quantity of urea 102 DISEASES OF THE URINARY ORGANS. excreted in the urine varies in different conditions of health and disease ; and since it is a product of the decomposition of albumen, many efforts have been made to discover and determine for pathological purposes a quantitative relation between the amount of this substance found in the urine and the decomposition of the nitrogenous elements of the tissues. The actual amount of urea excreted in the urine cannot, of course, repre- sent accurately the albuminous decomposition, because, first, only a part of the urea formed in the body is excreted by the kidneys, the remainder being eliminated by the skin, intestine, and lungs; second, urea is only one of several substances into which the nitrogenous elements of the tis- sues are decomposed ; hence its quantity does not fully represent the amount of such decomposition ; third, much of the urea excreted is de- rived directly from the food and not at aU from tissue waste. Yet it has been found by Voit that an approximately accurate index to the decomposition of albuminous substances in the body is furnished by the urea and other nitrogenous matters excreted in the urine. It has been ascertained that 100 grins, of muscular tissue separated from its fat and connective tissue contain about 3.4 grms. of nitrogen, corresponding to 7.28 grms. of urea. Every gramme of urea found in the urine would therefore represent a decomposition of 13.72 grms. of muscular tissue (or its equivalent of other tissue). Nitrogen Equilibrium.—Urea is excreted so long as life persists ; in starving animals there is an appreciable excretion even until death. If a fasting animal be supplied with nitrogenous food, an unexpectedly large excretion of urea is observed. For it is found that the urea excreted rep- resents not only the albuminous substances of the food, but also almost as much body waste as occurred during the period of fasting. The latter quantity is, however, a trifle less than formerly, and thus there occurs a gradual accumulation of albuminous materials, and hence increase of weight in the body. This repair continues until the body weight is re- stored to its normal figure, after which the quantity of urea excreted cor- responds exactly to the amount of albuminous materials in the food.' 1 Thus a fasting dog excretes, say, 10 grms. of urea per day ; since each gramme of urea results from the decomposition of 13.72 grms. of albuminous tissue, the animal is losing 137 (10 x 13.72) grms. of flesh per day. Now if this amount—137 grms. — of meat be administered to the dog daily, we would expect that it would be used to supply the loss, and that as a result the body waste would cease at once, while the daily excretion of urea would remain 10 grms. Such is, however, not the case ; the excretion of urea becomes almost vthough not quite) double what it was during fasting—say 18 grms ; this represents the urea formed from the food (10 grms ) plus that derived Irom the tissues (8 grms). The daily loss of flesh is diminished, but does not cease entirely. If now the quantity of food be doubled, that is, if 274 grms. of meat be given, the amount of urea excreted becomes about twenty-five grammes—that is, 20 grms. from the food and 5 grms. from the tissues. This amount of food is therefore not sufficient to replace the albumen consumed in the tissues—the animal continues to emaciate. When the amount of food is increased so that it alone furnishes about four times as much urea as the fasting animal excretes, the dog ceases to emaciate, and it is found that the urea excreted now corresponds exactly to the amount consumed with the food. The ani- mal's weight remains unchanged from day to day. This is '' nitrogen equilibrium." By still further increasing the amount of food, it is found that during the first few days the quantity of urea excreted is less than that contained in the food—in other words, some of the albuminous constituents of the nourishment are stored away in the body. After some days, however, the equilibrium is again restored—i.e., the amount of urea excreted equals exactly the quantity supplied by the food. If, on the other hand, the quantity of food administered to a well-nourished animal be suddenly diminished, it is at first observed that the urea excreted represents more albuminous matter than the food contains ; in other words, the tissues lose a certain PATHOLOGY OF THE URINE. 103 It follows from these facts that the healthy organism possesses a certain accommodative power, by virtue of which it is enabled within certain limits to adapt its consumption of albumen to the amount supplied, whether this be large or smaU ; so long as the bodily functions are normally performed, the amount of albuminous constituents excreted is just equal to that supplied by the food. The minimum amount of nourish- ment required to sustain this " nitrogen equilibrium" must contain much more nitrogen than is actually consumed by the tissues—probably about four times as much. It is further evident that the quantity of urea con- tained in the urine affords no clue to the amount of tissue metamorphosis, unless the quantity of albumen contained in the food is also known. Quantity of Urea Excreted.—From what has been said, it is evident that the excretion of urea may vary in the same healthy individual from day to day according to the kind and amount of food consumed. Hence obser- vations made upon different classes of people have given divergent results. Voit and Rubner found that the average daily excretion of urea in well- nourished German laborers was 30 to 35 grins. This was at the rate of .5 to .6 grms. for each kilogramme of body weight. In corpulent individ- uals the percentage is somewhat small, since the excess of body weight in such persons represents an accumulation of fat rather than albuminous tissues. The percentage is less in females than in males, but much higher in clhldren than in adults. Clinical Estimation of Urea.—For clinical purposes the determination of the quantity of urea excreted in the urine has seldom much value as an index to the amount of tissue metamorphosU. For since the urea is fur- nished not only by the decomposition of tissues but also directly by the food, the quantity derived from the tissues can be ascertained only when that furnished by the food is estimated. Such procedure is too compli- cated for clinical purposes ; hence the determination of urea is practically valuable only under certain circumstances. Thus in acute febrile diseases the patient rarely receives any consider- able quantity of nitrogenous food ; hence the amount of urea excreted— being derived almost exclusively from tissue waste—represents fairly the amount of this waste. Yet even here we are not sure that all the urea produced is excreted ; in fact, we know some circumstances which retard the elimination of urea through the kidneys. Among these are the re- tention of water in the blood—a usual occurrence in febrile conditions ; the formation of transudations in the subcutaneous tissue and in the serous cavities (for these transudations contain urea and albumen) ; ab- normally low arterial pressure, as occurs in typhoid and typhus fevers ; profuse perspiration, copious diarrhoea, inflammation of the kidney—all divert urea from the urine. On the other hand, there are various circum- stances which may cause an increased amount of urea to appear in the urine, without any increase in tissue metamorphosis ; thus active diuresis, whether from the ingestion of water or from a rise of blood-pressure, may result in washing out of the blood urea which had accumulated in this fluid. So, too, the resorption of transudations brings into the blood a con- siderable amount of albumen contained in the transuded fluid. This al- bumen is at once transformed into urea, and being excreted by the kidneys, raises considerably the amount of urea contained in the urine, portion of their nitrogenous constituents. This relation lasts, however, but a few days, after which period the urea excreted corresponds to the diminished amount of nour- ishment. 104 DISEASES OF THE URINARY ORGANS. though there has been no increase in tissue metamorphosis nor in the quantity of nitrogenous food ingested. If therefore we are to derive accurate and reliable information as to the amount of tissue change from the quantity of urea excreted by the kidneys, we must eliminate the possible sources of error already enumerated by taking into account the influences other than tissue waste whereby the ex- cretion of urea is affected ; but this is practically impossible.' It is as an index to the secretory activity of the kidneys that the deter- mination of the urea often furnished important information ; for, since the excretion of urea is performed by the renal epithelium, the deficit in the amount excreted in cases of renal disease indicates in a general icay the degree of impairment of the renal function. Yet only in a general way ; to secure even approximate accuracy, it is necessary to compare the urea excreted by the patient with that excreted by a healthy individual nour- ished upon the same diet and exposed to the same conditions of exercise, clothing, temperature, etc. Such comparison is in private practice at least usually impossible. Hence the determination of urea as an index to the condition of the kidney is practically valuable only when the quantity is found upon repeated examination to be markedly less or more than the average amount excreted by healthy persons.2 Factors ichicli Influence the Production and Excretion of Urea.—The quantity of urea which appears in the urine can be perceptibly increased without augmenting the amount of albumen in the food, by various measures which increase tissue change. The administration of phosphorus —in doses sufficient to cause death in eight or ten days—augments the quantity of urea excreted to three or four times its normal amount. Other 1 Fortunately we may often derive valuable information by comparing the quantity of urea with that of the common salt excreted by the kidneys. For it is found in healthy individuals the salt excreted amounts to about one-half by weight of the urea in the same urine. Now since the salt is derived chiefly from the food, a comparison of the two shows whether the urea is derived largely from the food or from the tissues ; for if an increase in the quantity of urea excreted is accompanied by a corresponding in- crease in the quantity of salt eliminated, the inference is that the urea is derived largely from the food; if the quantity of salt be, on the contrary, much less than normal, an excess of urea indicates an excessive tissue change. In fever the quantity of salt excreted in the urine is very small, partly because but little salt is contained in the food, and partly because there is an actual retention of salt in the tissues during fever. Since during convalescence from fever a considerable portion of the albumen of the food is retained in the tissues for restoring them to the normal condition, while the chloride of sodium is not thus needed nor retained, it often happens that during convalescence the quantity of salt in the urine may closely approximate or even equal that of the urea. 2 Here too an estimation of tlie cMorvles in the urine may afford valuable informa- tion. These salts probably escape from the blood by simple filtration with the water through the glomeruli-and not by the secretory activity of the cells ; at any rate it is well established that the chlorides are excreted quite as freely in the various forms of chronic nephritis as by healthy kidneys. Now in health the quantity of chlorides in the urine is usually about half that of the urea ; hence if, in a case of chronic Bright's disease, the quantity of chlorides in the urine is constantly more than one-half that of the urea, we may infer that the latter substance is not completely excreted—in other words, that the integrity of the kidneys is impaired. It is interesting to note that variations in the excretion of urea in Bright's disease are accompanied by similar variations in the excretion of phosphoric and carbonic acid. Fleischer found furthermore that phosphoric acid administered by the mouth was ex- creted less readily by diseased than by healthy kidneys, though no such difference was observed in the excretion of other salts—bromide and iodide of potassium, for example. The quantitative estimation of phosphoric acid in the urine is, however, so complicated a process that the fact mentioned has but little clinical value. PATHOLOGY OF THE URINE. 105 substances, among them arsenic and alcohol, exert a similar though less pronounced effect. Limitation of the oxygen inspired increases also the excretion of urea. This has been demonstrated by Fraenkel, who diminished the quantity of air inspired by constricting the trachea in dogs. He found that the urea excreted rose to three or four times the normal amount. Pathological states accompanied with dyspnoea in the human subject also exhibit in- creased excretion of urea. Poisoning with carbonic acid also augments the amount of urea excreted —probably, as Fraenkel suggests, by diminishing the quantity of oxygen supplied to the tissues. Loss of blood induces the same result, apparently because it decreases the amount of oxygen distributed to the tissues. Artificial elevation of temperature, by exposure to a warm bath or warm air, has been observed to increase the amount of urea excreted. Schleih found that after one hour's immersion in a hot bath whereby his tempera- ture rose to 39.5° O, ths quantity of urea excreted was increased more than thirty-three per cent. Diuresis favors, of course, the excretion of urea ; the increase does not, however, appear to be the result of an augmented tissue change, but occurs simply from the more thorough removal of the urea from the tissues. The consumption of animal food naturally increases the amount of urea formed as well as excreted. Diverse results have been obtained in the effort to answer the question whether or not excessive muscular action causes an increased production and excretion of urea. Voit, Fick, Wislicenus, and Vrietzke were unable to find any increase of the urea in the urine after prolonged and excessive exercise. Flint, Parkes, Schenck, and recently North, on the other hand, observed a marked increase under similar circumstances. The diversity of these results seems to be explained by later observations. Kellner ob- served that the urea excreted by horses fed upon a diet rich in nitrogen increased decidedly after prolonged exercise ; but that when the diet con- sisted chiefly of hydrocarbons, but shght increase was observed. The ex- planation appears to be that muscular activity requires the consumption of fats and hydrocarbons ; so long as these are supplied in sufficient quantity the nitrogenous tissues are not consumed ; when, however, there is a dearth of hydro-carbonaceous materials, the albuminous substances in the tissues are consumed, and a corresponding increase occurs in the urea produced and excreted. A second moment serves to reconcile the conflicting results above mentioned. Oppenheim found that muscular activity, accompanied with dyspnoea, was foUowed by decided increase in the excretion of urea, while the same amount of work performed so deliberately as not to embarrass the respiration, did not increase the excretion of urea. Hence he infers that the excessive production of urea observed during muscular activity is the result, not of this activity, but of the imperfect supply of oxygen accom- panying it, which, as already stated, is known to be a sufficient cause for an increase in the production and excretion of urea. The observations of Senator and of Bauer upon cases of tetanus, and of Fleischer upon a case of mercurial convulsions, show that in these con- ditions, notwithstanding the enormous amount of muscular exertion, no increase in the excretion of urea occurs. No agent, physiological or medicinal, is known, whereby the amount of urea produced in the body can be much decreased. Fraenkel found that the respiration of condensed air decreased slightly the production of 106 DISEASES OF THE URINARY ORGANS. urea, while the substitution of rarefied air had, as might be expected, the same effect as the abstraction of oxygen—a slight increase in the amount of urea produced. Excretion of Urea in Disease.—In febrile conditions, from whatsoever cause, the excretion of urea is almost invariably increased. This increase is observed during the height of the fever in most instances, but is some- times noticed before the rise of temperature begins. In many cases this increased excretion continues also for some time after the critical faU of temperature ; this is especially often noticed in cases of croupous pneumonia. It has been observed that after the administration of quinine, in cases of continued fevers, the interval of reduced temperature is accompanied by an excessive excretion of urea. It is further found that fever induced artificially by the injection of putrid materials is (like the clinical septi- caemia and pyaemia), accompanied also by an increased excretion. Sur- gical operations do not per se affect the production of urea ; but the oc- currence of fever, even if it be only the aseptic wound fever, is accompanied by an increased production. The only acute febrile condition, aside from renal disease, in which the urea excreted is less than normal, is acute yellow atrophy of the liver ; in this disease the urea may entirely disappear from the urine. In non feb- rile conditions there is great diversity in the behavior of urea ; in many cases accompanied by anaemia there is an increased production, corre- sponding to the observation that a similar increase occurs after artificial or natural hemorrhage. In pernicious anaemia and leucocythaemia the excre- tion of urea is often excessive. The greatest excretion occurs in diabetes meUitus; here there is not only an unusually large consumption of albu- minous food, but also an excessive metamorphosis of the albuminous con- stituents of the tissues. The result of this double production of urea is the excretion of an enormous amount, sometimes 125 or even 150 grammes per day. Epileptic attacks are also followed by an increased excretion of urea—due doubtless in part to the diminished supply of oxygen which occurs as a feature of the attack. Resorption of exudates and transudates, such as dropsical fluids, brings into the blood a quantity of albumen, which is transformed into urea and excreted, thus increasing the total amount found in the urine. An in- crease in the excretion of urea by a dropsical patient with Bright's disease does not therefore necessarUy indicate an improvement in the renal func- tions. In cases of gout, chronic rheumatism, biliary colic, and various diseases of the liver, the excretion of urea is diminished. In various hepatic dis- eases this diminution in the urea excreted is accompanied by an increased excretion of intermediate products, particularly uric acid. In such dis- orders, therefore—of the hver, bile-ducts and duodenum—the urine is often loaded with urates. It has been repeatedly noticed that the development of cancer is ac- companied by a decided fall in the excretion of urea ; in one case the amount feU from 29 to 7 grammes in twenty-four hours. It has been proposed to utilize this observation for diagnosis in cases of suspected cancer of internal organs. It is evident from the considerations mentioned in the earlier part of this chapter, that but little value can be attached to many observations on record as to the excretion of urea, since in but few cases have the condi- tions necessary to accuracy of observation been fulfilled. PATHOLOGY OF THE URINE. 107 While in the conditions already mentioned the diminished excretion seems to depend upon a diminished production of urea, there are others in which there appears to be the usual production, but a failure to ex- crete ; these are especiaUy cases of renal disease. Sir Andrew Clark has recently described under the name "renal inadequacy" a class of cases in which the excretion of urea is habitually less than normal, though there is no evidence of kidney disease. Uric acid and urates are also deficient, the urine having a low specific gravity. This condition is usually observed in high livers and is corrected by regulation of the diet. Hippuric Acid is also .", constant ingredient of the urine in man, though it occurs in much smaller quantity than in that of herbivorous animals. It is produced, in part at least, by the decomposition of albumen ; under the influence of pancreatic juice there is produced in the alimentary canal a substance which is absorbed and in the circulation is oxidized to benzoic acid; this is subsequently transformed (by a combination with glycocoll) into hippuric acid. The benzoic acid which is contained in vegetables and fruits, such as cranberries and plums, or administered by the mouth, is similarly changed into hippuric acid.1 Carbolic Acid.—The putrid decomposition of albuminous bodies—pu- trefaction—produces numerous aromatic substances. This decomposition is constantly occurring in the lower portion of the small intestine ; the pu- trid products are in great part expelled with the feces, yet a smaU portion is absorbed by the intestine. Among the products of this albuminous decomposition in the bowel are two substances which are subsequently eliminated by the kidney, and sometimes possess great clinical significance. These are phenol (carbolic acid) and indol (the source of indican). Although normal urine contains no trace of carbolic acid, either free or combined directly with an alkali, yet there is present in every urine a certain quantity (.01 to .05 gramme) of the acid derived from the intestine, and combined with sulphuric acid as a sulphocarbolate of potassium. Car- bolic acid taken into the stomach or injected under the skin also appears in this form in the urine. Circumstances which favor the decomposition of albuminous substances in the intestines, as weU as those which impede the evacuation of the faeces, must, of course, favor an increased absorption of carbolic acid. Accord- ingly it has been observed that ligature of the intestine in dogs and intes- tinal obstruction in the human subject is followed by an increased elimi- nation of carbolic acid (in combination) in the urine. Carbolic acid is, as is weU known, a toxic agent; the combination in which it appears in the urine—the sulphocarbolate of potassium—is, on the other hand, innocuous. So long as the blood supplies sufficient sulphuric acid for the formation of the sulphocarbolates, the carbolic acid which may 1 One of the most Interesting physiological facts established in recent years is the dem- onstration by Bunge and Schmiedeberg, that this formation of hippuric from benzoic acid is accomplished by the cells of the kidney. They found that after the extirpation of the kidneys or the ligature of the renal vessels in dogs, these animals lost the power of converting benzoic into hippuric acid; ligation of the ureters only, on the other hand, did not interfere with the production of this acid. The same transformation was effected by passing blood containing benzoic acid through freshly excised kidney. After the lapse of some hours the excised kidneys lost this power. It is therefore de- monstrated that the kidney cells are the agents whereby benzoic is converted into hip- puric acid. These observers found that the addition of quinine to the blood prevented this transformation (probably by destroying the protoplasm of the renal cells) ; carbonic acid had a similar effect. 108 DISEASES OF THE URINARY ORGANS. be absorbed, either from the intestine or from the surface of a wound, is neutralized by a combination into the harmless sulphocarbolate. So soon, however, as the amount of carbolic acid absorbed is more than enough to combine with the sulphuric acid contained in the blood, an excess of the former must remain as free acid, and exert its injurious effects. It is hence evident that an examination of the urine reveals the approach of danger from carbolic acid poisoning in those who are employing this agent either internally as a medicine, or externally as a dressing. So long as the urine contains an appreciable amount of sulphuric acid (and sulphates) it may be assumed that there is no danger from the carbolic acid ; while the disappearance of the sulphates from the urine indicates that the blood is saturated with carbolic acid, and that no more of this substance can be absorbed without danger to the patient. Baumann ascertained that the amount of available sulphuric acid in the blood can be materiaUy increased by the administration of the sulphate of sodium ; hence this salt may be properly administered as an antidote to carbolic acid poisoning, present or prospective. Excretion in Disease.—As yet but few observations on the pathological significance of carbolic acid in the urine have been made. An increased excretion has been observed in cases of inactivity and obstruction of the intestine, intussusception, peritonitis, perityphlitis, atony of the bowel. Since, moreover, the absorption into the blood of the products of albumi- nous decomposition from whatever source is followed by the excretion of the acid by the kidneys, there occurs an increased ehmination in cases of pulmonary gangrene, putrid bronchitis, empyaema, dilatation of the stom- ach with fermentation, cancer of the womb, rectum, breast, etc.] Indican.—Normal urine contains a substance which, upon the addition of hydrochloric acid, exhibits a blue color identical with that of indigo. This indigo-producing substance has long been known and has been termed indican. Only recently, however, has its origin and composition been ascertained (by Baumann and Brieger). Indican is derived from indol, which, like carbolic acid, is a regular product of the decomposition of albumen. Indol is, therefore, constantly produced in the small intestine ; some of it is evacuated with the faeces, while a portion is absorbed by the intestine, and arriving in the blood, it combines (like carbohc acid) with sulphuric acid and potassium, making the indoxylsulphate of potassium, or indican. The amount is increased by an exclusively flesh diet, but it does not disappear entirely during fasting. Possibly indican is formed in smaU quantity by normal tissue metamor- phosis. Excretion in Disease.—Indican is an ingredient of normal urine, derived by absorption from the intestine. In all pathological conditions in which the evacuation of the faeces is retarded, the quantity of indican in the urine 1 A fact which possesses great pathological interest, though but little clinical impor- tance, was established by Brieger. He found that while the amount of carbolic acid excreted in the urine*is decreased in febrile conditions in general, such as pneumonia, acute rheumatism, and meningitis, yet in four infectious diseases an excessive amount of phenol is thus excreted ; these diseases are diphtheria, scarlet fever, erysipelas, and pyaemia. In other infectious diseases, even though the temperature be equally high— small-pox, typhoid and intermittent fever—the amount of carbolic acid is less than in health. Brieger therefore infers that the four diseases named have a common etiolog- ical factor—the absorption of putrid products—and he terms them " putrefactive dis- eases." This observation accords perfectly with the recent investigations into the eti- ology of the septic diseases, which show that the introduction into the body of putrid products induce diphtheria, erysipelas, pyaemia, and septicaemia. PATHOLOGY OF THE URINE. 109 is increased. Jaffe observed an enormous amount in a fatal case of incar- ceration of the small intestine, and achieved the same result experimentaUy by ligating the intestine in dogs. In a case of incarcerated hernia, reduced twenty-four hours later, a similar increase of the indican in the urine was observed. In cases of diarrhoea, purulent peritonitis, and in habitual constipation, an excessive excretion has been noted ; and it has long been known that in cholera the urine contains an excess of the same substance. The excretion of indican, like that of carbolic acid, is increased in cases of pulmonary gangrene, cancer of the stomach, and similar conditions wherein putrid products gain access to the blood ; yet Brieger found that indican and the acid are not always increased in the same degree. Senator found that the urine of new-born children contains no indican —a fact quite in accordance with the observation that putrefaction does not occur in the foetal intestine, and that no indol is discoverable in the meconium. He asserts that the granular atrophy of the kidneys is marked by an increased excretion of indican, while other forms of nephritis and the amyloid degeneration of the kidneys are not so accompanied. In rare cases the indican becomes oxidized to indigo in the urinary passages, so that the urine is blue when evacuated. In other cases a spontaneous transformation into indigo occurs soon after emission. Ford reports a case in which a stone consisting of blood-clots, phosphates, and indigo was found in the pelvis in a case of sarcoma of the kidney. In addition to its occurrence in cases where decomposition products of albumen are present in the blood, indican has been observed in several pathological conditions where its presence cannot as yet be explained. It has been found in cases of cancer of various organs, especially of the liver ; also in a case of melanotic cancer of the orbit. Rosenstein observed an increase in eleven out of twelve cases of Addison's disease. Robin has usually found an increase of indican in the urine of typhoid fever patients, and considers this a valuable item in differential diagnosis from conditions presenting similar symptoms, such as acute miliary tuberculosis. Urines containing much indican, when heated with nitric acid, exhibit a bluish, greenish, or reddish tinge—a fact which doubtless explains the existence of these tints in the urine of disease ; for urines containing much indican are strongly acid, deposit uric acid, and decompose copper salts. Urobilin.—This pigment (variously termed hydrobilirubin, urophain, and urohaematin) is contained in normal urine in small quantity, and ap- pears in larger amount during febrile conditions ; it is also found in the bile. That which appears in the urine is obtained by absorption of the bile from the intestine ; the greater part of the coloring matter remains in the alimentary canal, and colors the faeces. Urobilin is derived indirectly from the coloring matter of the red cor- puscles ; indeed Hoppe-Seyler has obtained this pigment directly from haemoglobin by treatment with hydrochloric acid and tin. It is therefore increased in all those pathological conditions which are accompanied by destruction of red corpuscles, such as fever. It has also been found in the urine in large quantity in cases of jaundice from intestinal catarrh. Inorganic Constituents of the Urine. All the soluble and some of the insoluble salts contained in the nour- ishment appear in the urine ; the quantity varies naturally with that con- sumed. Yet the system evidently stores away a certain portion of the salts, since it is found that an animal fed upon a diet containing but little 110 DISEASES OF THE URINARY ORGANS. of these salts excretes nevertheless a considerable quantity more than is contained in the food. That they constitute an essential part of the food is shown by the impairment of health and even fatal result which attend their absence from the diet. Ordinary food contains an abundance of such salts; it is only under special conditions (such as the transition from nursing to eating), that some of the salts—lime especially—may be present in insufficient quantity. The Chlorides are for clinical purposes the most important of the in- organic constituents of the urine. They are derived chiefly from the food, and in health the quantity excreted in the urine varies with the amount consumed. In febrile conditions the chlorides are retained in the tissues ; the amount contained in the urine constitutes an index to the course of the disease, since this amount decreases and increases according as the patho- logical process is more or less aggravated. The quantity of chlorides in the urine is increased by the absorption of dropsical fluids and inflammatory exudates. In diabetes insipidus there is, according to Vogel, an excessive excretion, while in diabetes mel- litus the quantity is normal. In cases of Bright's disease the estimation of the chlorides in the urine often furnishes information of much diagnostic value, as has been already explained. The Phosphates excreted in the urine amount ordinarily to two or three grammes. Since the bones contain large quantities of phosphates, it would be expected that diseases involving disintegration of bone sub- stance would be accompanied by an increased excretion of phosphates. Yet in most cases of rachitis and osteomalacia the amount of phosphates is found to be less than normal. In gout and chronic rheumatism the amount is also decreased.1 The term phosphaturia has been applied to an excessive excretion of the earthy phosphates, the amount being sometimes increased to three times the normal quantity. The amount of urea and the quantity of urine are also much increased, so that the condition has been termed " phosphatic diabetes." Notwithstanding the large amount of phosphates present, there may occur no precipitation of these salts, since the urine remains acid. At some period of the disease, however, the urine usually becomes alka- line, and then heavy white sediments of amorphous calcium phosphate are precipitated. This excessive elimination of the phosphates may be only temporary ; or it may persist, in which case phthisis is sometimes devel- oped. The cause of this peculiar excretion is unknown ; it is observed almost exclusively in individuals suffering from general or sexual exhaus- tion, and sometimes appears suddenly after the patient has undergone a severe mental strain. An excessive excretion of the alkaline phosphates of sodium and potas- sium is observed more frequently ; it is usuaU}r accompanied with some 1 There occurs a marked and constant diminution of the phosphates in all forms of parenchymatous nephritis—acute and chronic, with and without amyloid degener- ation ; the diminished excretion of phosphoric acid in these affections seems to run parallel with the decreased elimination of urea. Fleischer has shown that phosphoric acid administered to patients suffering from nephritis is not excreted in the urine, as it is by healthy individuals. It is probable, therefore, that in these renal affections there is more or less retention of the phosphates in the body. This fact is important in re- lation to the etiology of uraemia, since recent experiments make it probable that these retained phosphates play an important part in the production of uraemic poisoning. PATHOLOGY OF THE URINE. Ill polyuria. In many cases these phosphates are deposited as an amorphous sediment, the urine being persistently alkaline. This condition of the urine is commonly observed in connection with acute inflammations of the brain and spinal cord or their membranes, after acute mania and injuries to the head, and in many nervous individuals where none of these morbid conditions exist; it is a frequent symptom of neurasthenia and of sexual derangements. This persistent alkalinity of the urine and excessive de- posit of the alkaline phosphates—often improperly called phosphaturia— is frequently accompanied with irritability of the bladder. The Sulphates.—The decomposition of albumen furnishes a consider- able quantity of sulphuric acid—from two to two and a half grammes of strong acid daily. The amount of the sulphates is therefore increased by animal diet. The sulphuric acid formed in the tissues is neutralized in carnivorous animals and in man by combination with ammonia. It is fouud that by administering free sulphuric acid to dogs a large increase in the ammonia salts of the urine is produced, the animal meanwhile suffer- ing no impairment of health. Herbivorous animals, on the other hand, obtain but little ammonia from their non-nitrogenous food, and cannot supply it in sufficient quantity to neutralize free acid which may be ad- ministered to them ; such acid is neutralized by the fixed alkalies ab- stracted from the tissues, and these suffer a corresponding impairment of function. A comparatively small amount of free sulphuric acid is there- fore sufficient to destroy a herbivorous animal. Walter found that by neutralizing the acid with carbonate of sodium injections, the life of a rabbit could be saved even when the animal lay at the point of death from poisoning by acids. Herein is the explanation of the fact that herbivo- rous animals cannot exist upon a flesh diet unless it be accompanied with sufficient alkali to neutralize the sulphuric acid derived from such food. Herbivorous animals ordinarily excrete an alkaline urine ; when fast- ing, however, their urine becomes acid. They are, therefore, evidently de- pendent upon their food for the alkalies necessary to neutralize the acid formed by their own tissue metamorphosis. The excretion of the sulphates has but little clinical significance ; it is usually parallel with that of urea, since the sulphuric acid and urea are derived from a common source—albumen. Ammonia.—The ammonia found in combination in the urine is derived in smaU part only from the food ; the greater part proceeds from the de- composition of albumen. Much of it appears in the shape of urea; the amount which is excreted as a simple salt of ammonia is always small, the quantity varying with the amount of acid which is to be neutralized. If an excess of acid be contained in the blood, a large amount of ammonia is required (in man and the carnivora) to neutralize it; if but a small amount of acid be present, a limited quantity of ammonia may appear in the urine. CHAPTEE XL PATHOLOGY OF THE URINE (Continued). Abnormal Ingredients of the Urine. The following substances appear in the urine chiefly or exclusively in pathological conditions : The albumens: serum albumen, serum globulin (paraglobulin), pep- tone, p"ropeptone. Sugars: grape sugar, milk sugar, inosite. Biliary pigments, biliary acids, haemoglobin, fat, sulphuretted hydrogen. Albumen.—Since the urine is obtained by filtration from the blood, the most apparent and frequent sources for albumen in it are the albuminous constituents of the blood. The term albuminuria is, indeed, properly re- stricted to that admixture of albumen with the urine which occurs in the kidney—renal albuminuria. The admixture of pus, blood, or mucus brings albumen into the urine, a condition designated for convenience " false al- buminuria." Two albuminous constituents are constantly present in the blood—se- rum albumen and serum globulin. Yet these are not the only forms found in the blood, nor are they the only albuminous substances which filter into the urine. The two usual tests, heat and nitric acid, detect the presence of these two only ; hence a negative result with these tests does not neces- sarily prove the absence of all forms of albumen from the urine. For there is contained in the blood-corpuscles an albuminous substance, haemo- globin, which is under certain conditions liberated from them, dissolved in the serum, and then immediately filters into the urine. In addition to these regular constituents of the blood there are certain albuminous matters which under special circumstances are found in the circulating fluid, and hence in the urine also. Foremost among these is peptone, and a substance intermediate between albumen and peptone, called pro- peptone. Bechamp has further described as a constant ingredient in nor- mal urine an albuminous substance called nephrozymase ; this is, according to Leube, a mixture of two substances, an albumen and a ferment. In addition to these soluble forms of albumen there is occasionally found in the urine a solid albuminous substance, fibrin, as weU as the coagidated masses of albumen known as " tube-casts." Serum albumen is more commonly found in urine than any of the other varieties; indeed, we have come to regard albuminuria as signifying the presence of this substance in the urine. That the other varieties have been so seldom observed is doubtless due in large part to the fact that the tests generally employed for detecting albumen do not reveal them. Since the blood contains globulin, and since this substance is more diffusible than serum albumen, we would expect that it would also be present where the albumen is found in the urine ; it is, in fact, actually demonstrated PATHOLOGY OF THE URINE. 113 that in most cases in which serum albumen can be detected, globulin is also present. Heat and nitric acid coagulate both of them, and do not therefore differentiate between them. Estelle has devised a method for separating globulin from serum albumen; the application of this method to the examination of albuminous urine shows that sometimes one, some- times the other form is present, though usually both are found in the same specimen. Indeed in many instances the coagulum produced by heat and nitric acid is found to consist chiefly of globulin—an observation quite in accordance with the fact that globulin exists in the blood in larger quan- tity than serum albumen. In certain pathological cases globulin alone is found in the urine ; this is true, according to. Senator, in cases of amyloid degeneration of the kid- ney, though this statement needs revision.1 Whether or not the distinction between these two forms of albumen in the urine may possess diagnostic value, has not as yet been determined. It has been shown that heat and nitric acid are by no means delicate tests for globulin, since they often fail to reveal minute quantities of it. Since, moreover, globulin is more diffusible than serum albumen, it seems quite probable that it may be often present undetected in urine which seems to be free from albumen. Within recent years it has been demonstrated that peptone frequently appears in the urine during pathological conditions, and that it sometimes possesses diagnostic importance. Peptone escapes detection by the ordi- nary clinical tests, since it is not coagulated by heat or nitric acid. In some instances it is associated with serum albumen, while in others the latter substance is absent. That there need be no association of the two is evident from a consid- eration of its source. Peptone is produced in the alimentary canal during digestion, but is transformed into albumen before it reaches the circula- tion. Hence the blood contains no peptone ; even the portal blood exhib- its only a trace of it for a short time after digestion. This fact explains its absence from the urine under ordinary conditions, since there is nothing to prevent its escape through the kidney when it is present in the blood. For it has been often demonstrated that peptone injected directly into the circulation or into the subcutaneous tissue, reappears in the urine at once. It may therefore be laid down as a general principle that peptone which gains access to the circulation by any other route than the alimentary canal, will appear in the urine. Now there is at least one other source for peptone beside digestion. It has been ascertained that peptone is a constant product in the putrefac- tion of albuminous substances, and is moreover contained in every speci- men of pus. Every collection of pus in the body is, therefore, a depot for the formation and absorption of peptone, which immediately appears in the urine. This fact has been already employed for recognizing deep- seated suppuration inaccessible to the trocar or hypodermic needle. Thus v. Jaksch detected the bursting of an ovarian cyst by the appearance in the urine of peptone derived from the pus of the consequent inflamma- tion. It is highly probable that suppuration is not the only pathological pro- cess whereby albuminous substances are transformed into peptone ; for this substance is produced by the action of acids and alkalies upon albumen, '' A case of globulinuria during acute nephritis is reported in the New York Medical Record, No. 8, 1884. 8 114 DISEASES OF THE URINARY ORGANS. and also by the influence of pancreatic juice. It seems plausible to suppose that various pathological states can so modify tissue metamorphosis as to change albumen into peptone in the body. While this assumption is not as yet demonstrated, yet it is a well-established fact that fever is usually accompanied by the appearance of peptone in the urine, without regard to the origin of the febrile condition. Furthermore, different agents which cause a pronounced alteration in tissue change are also productive of pep- tonuria. Thus peptone has been observed in the urine in cases of phos- phorus poisoning, diphtheria, pneumonia, typhoid fever, and acute yellow atrophy ; and it appears to be almost constantly jn'esent in cases of acute and chronic Bright's disease. Lassar recently made an observation indicating the probable origin of peptone in the tissues under special circumstances. Having observed that serum albumen appeared in the urine in consequence of inunctions of petroleum for scabies, he experimented with rabbits to ascertain the effect of the same substance upon them. He found that inunctions of petroleum regularly induced in rabbits the appearance of peptone, foUowed after a short interval by albumen, in the urine. Propeptone is one of the intermediate products in the transformation of albumen into peptone in the stomach. It is found in the blood during digestion and in pus; also in the medullary substance of bone in the healthy condition and in osteomalacia. Leube detected it in the albumi- nous urine of a patient suffering from urticaria, and Neale observed it in a case of haemoglobinuria. Senator maintains that the presence of propeptone in urine is much more frequent than has been supposed by writers and investigators. Within four years he detected this substance in seven different cases— tertiary syphilis, haemiplegia, diphtheria, cancer of the oesophagus, pneu- monia, and muscular atrophy respectively. The last case was remarkable ; the patient had four years previously suffered from hemorrhagic nephritis, after recovery from which the urine for a long time contained albumen. Eighteen months later the albumen disappeared, but occasionally reap- peared transiently ; the subsequent discovery of propeptone was quite ac- cidental. The patient had never had oedema, and exhibited no cardiac hypertrophy. Since propeptone is not coagulated by heat, it is usuaUy overlooked ; indeed since propeptone is albumen at a certain stage of transformation into peptone, it would not be strange if it were found in urine in many of those conditions which induce peptonuria. Lassar, in his experiments with petroleum above referred to, found propeptone in the urine at a cer- tain stage of the inunction. CHAPTER XII. ALBUMINURIA. Physiological Albuminuria. In order to determine the importance to be attached to the presence of serum albumen in the urine in pathological cases, it must be decided under what if any circumstances, independent of diseased conditions, albu- men is present. It was formerly supposed that albuminuria was neces- sarily indicative of disease of the kidney ; further investigation showed that it occurred in various pathological conditions other than renal disease. In course of time it was discovered that albumen is occasionaUy present in the urine of apparently healthy individuals ; this occurrence, at first regarded as a physiological curiosity, was soon found to be by no means rare. It became further apparent that the urine of the same individual was at different times, even at different hours of the same day, sometimes free from and sometimes mixed with albumen. Thus Leube examined the urine of 119 soldiers. He found that in the morning 5 individuals (1.2 per cent.) had albuminuria; at noon, after the mUitary exercises of the morning, 19 (16 per cent.); in the evening, after resting for several hours, the number was decreased to the original 5 indi- viduals. Munn found among 200 apparently healthy applicants for life insurance, 21 cases (12 per cent.) of albuminuria. Furbringer found albu- men in the urine of 7 out of 61 healthy children (11.5 per cent.); Kleudgen in 11 out of 32 healthy persons (44 per cent.). Chateaubourg has recently reported numerous examinations of the urine from apparently healthy persons ; he found albumen in the urine of 44 out of 98 soldiers, the specimen being passed three hours after dinner. Another test of the urine passed five hours after eating, revealed albumi- nuria in 76 out of 91 soldiers. In stUl another examination, he found albu- minuria in 201 out of 231 cases, the specimen having been obtained after the performance of fatigue duty. These tests were made with especiaUy delicate reagents. Senator made an extensive series of observations upon himself ami three assistants, all in the enjoyment of perfect health. Care was taken to obtain unmixed urine, by using for the examination only that last voided at each evacuation ; in this-way the urine was obtained free from the se- cretions of the urethra, which always contain albumen. In each of these healthy individuals, albuminuria was occasionally detected, usually during digestion. In recent years this fact—that albumen is often present in the urine of perfectly healthy individuals, without exposure to unusual influences— has been established by numerous observers, among them Frerichs, Ultz- 116 DISEASES OF THE URINARY ORGANS. mann, De Mussy, Vogel, Gull, Moxon, Lepine. In such cases the amount of albumen is rarely more and usually less than 0.1 per cent. In a still larger number of cases, transient albuminuria is observed as a consequence of certain special influences. Thus it often occurs after cold baths, severe muscular effort, and the combination of these two factors, prolonged sea-bathing ; after profuse perspiration, intense emotion. Fiir- bringer observed most carefully for a long period a healthy young physician who, under the influence of mental excitement, repeatedly evacuated urine of high specific gravity, containing as much as 0.6 per cent, of albumen ; at such times he experienced dull pain in the region of the kidney. No casts nor other indications of renal disease were discovered ; in the intervals be- tween these periods the urine was quite free from albumen, and at the end of a year's observation the health was unimpaired. The observations of Virchow, Ruge, and Martin show that in a large percentage of cases the urine of infants is albuminous during the first days of life. Assuming that some of these apparently healthy individuals in whom temporary or persistent albuminuria has been observed are the subjects of unrecognized renal disease, it must be admitted that there remains a large contingent in whom the presence of albumen in the urine must be ex- plained upon some other ground. Senator argues that by the use of more delicate reagents a much larger percentage of cases of albuminuria in healthy persons would be revealed. But assuming that the results obtained by the ordinary tests represent a fair average, it follows that one out of every seven or eight individuals has at least now and then albumen in the urine. To explain this we must assume either that albumen is present in every urine, or that it may occur in every healthy person under special physiological circumstances. In the former case we must beheve that the amount of albumen varies, being sometimes recognizable by our ordinary tests, and at other times too slight to be thus detected. Senator concludes that this is actuaUy the case, namely, that the urine always contains albumen, though oftentimes in such smaU quantity as to escape detection by the reagents commonly employed. The epithelial ceUs covering the capUlaries of the glomeruli are similar to the endothelial ceUs of serous membranes ; hence it is rea- sonable to assume (in the absence of demonstrations to the contrary) that the fluid which passes from the blood through the cells, covering the glomeruli, has the same qualitative composition as that which escapes from the blood into serous cavities. Now it is well known that these serous fluids contain albumen ; the cerebro-spinal fluid contains, for example, from one to three-tenths per cent, of albumen, as weU as a due proportion of the salts of the blood. Analogy would therefore suggest that the liquid which escapes from the glomeruli into the renal tubules would also con- tain not only water and salts, but also albumen. The percentage of albu- men would of course be less than that contained in the serous fluids, since the blood-pressure is greater in the glomeruli than in any other capiUary system of the body ; and it is well established that the greater the press- ure during filtration, the larger is the amount of filtrate and the smaller the percentage of albumen. Hence the liquid filtered under great pressure through the glomeruli, while having the same qualitative composition as other transudations, would contain a smaller percentage of albumen. The objections to the assumption that the urine, like other transudates, contains albumen normally, are chiefly three : first, that the ordinary clin- ical tests usually fail to reveal albumen in the urine of healthy persons ; ALBUMINURIA. 117 second, that the observations of Posner, who coagulated the albumen in fresh kidneys by boiling, would seem to indicate that albumen is not found in the Malpighian capsules of the normal kidney ; third, that the glomeruli are the only capillaries in the body directly covered with epithelium ; hence the inference that these epithelial ceUs have some special function, possi- bly the power of preventing the escape of serum albumen from the cap- iUaries.1 As to the first—the failure to detect albumen in normal urine by the ordinary tests—the answer is plain ; there is ample proof that these tests are incapable of revealing minute traces of albumen, which may therefore be present in many cases unsuspected. In fact, observations made with especially delicate methods, such as the potassio-mercuric iodide, reveal, as has been already stated, the frequent presence of albumen in healthy per- sons, in cases where heat and nitric acid show none. Posner, by boiling pieces of fresh kidney, coagulated the albumen, and was thus enabled to demonstrate that in cases of albuminuria the albumen escapes into the tubules from the glomeruli—a fact which had been previ- ously assumed, but not demonstrated. Inasmuch as Posner failed to find albumen in the capsules of normal kidneys treated in this way, he asserts that in normal kidneys no albumen escapes from the blood-vessels of the glomeruli. His conclusion is not, however, warranted by his observation ; for minute quantities of albumen can be present in the capsules without being discoverable by the microscope, even after coagulation by boiling. Albuminuria can be induced in rabbits very easily by rapid elevation of temperature, or by the injection of smaU quantities of phosphorus dis- solved in ohve oil. Such albuminuria is accompanied by granular tube- casts and by renal epithelium in the urine ; yet sections of the boiled kid- ney frequently show no albumen whatsoever in the capsules or tubules. A series of experiments conducted under Cohnheim's direction gave a sim- Uar absence of albumen in the capsules in cases of albuminuria induced by the injection of egg albumen into the circulation. The explanation is simply that the amount of albumen in these cases is so small that even when coagulated it is indistinguishable by the microscope.2 It is therefore demonstrated that normal urine may and frequently does contain serum albumen ; indeed, the recent extensive employment of delicate reagents (especially the potassio-mercuric iodide) furnish results which tend to support Senator's belief that albumen is just as normal a constituent of the urine as many of the ordinary ingredients. The re- searches of recent years have shown that several substances, formerly sup- posed to be occasional and accidental constituents of the urine, are con- 1 Heidenhain, Cohnheim. 4 Heidenhain and Cohnheim have recently urged the hypothesis, already very pop- ular in Germany, that the epithelial covering of the glomeruli possesses the power of preventing the escape of serum albumen from the blood, and that the appearance of albumen in the urine usually indicates an impairment of function of these cells. When- ever from any cause these cells are imperfectly nourished—as occurs in anaemia of the kidney, slowness of the circulation, ischaemia, etc.—they permit albumen to escape from the blood into the tubules. This theory lacks, as yet, experimental foundation ; but it is extremely convenient for explaining the albuminuria of many clinical cases. Some of its advocates have even assumed a congenital malformation of these epithelial cells for the explanation of cases of persistent albuminuria in apparently healthy in- dividuals. This hypothesis fails to explain satisfactorily the well-known fact that other forms of albumen closely allied to that of the serum—egg albumen and peptone, for instance—meet no impediment in escaping from the glomeruli, but are at once ex- creted by normal kidneys whenever introduced into the blood. 118 DISEASES OF THE URINARY ORGANS. stant and normal ingredients ; this has been proven, for example, of indi> can, carbohc acid, hippuric and oxalic acid ; and after much controversy it has been established that grape-sugar is frequently excreted in minute quantities by normal kidneys, and may even be present in appreciable amount in the urine of healthy individuals. The time has certainly arrived when the simple presence of albumen in the urine cannot be regarded as proof of any morbid condition of the kidneys; the question is no longer, Does the urine contain albumen ? but, How much albumen is present, is it persistent, and are there any other indications, mi- croscopical or clinical, of renal disease ? Albuminuria from Pathological Conditions other than Renal Disease. Many investigations, clinical and experimental, have been made to de- termine the various influences other than disease of the kidney which cause the escape of albumen into the urine. To enumerate these would exceed the scope of this chapter, which shaU aim merely at summarizing the re- sults already obtained. It must be admitted that the subject is but partially elucidated ; the explanation of the albuminuria observed in many clinical cases is still uncertain and must so remain until the physiological relations of the kidney to the general bodily functions are more thoroughly ascertained. At present we are often unable to trace satisfactordy the effects upon the kidney of different disturbing factors involved in the same clinical or experimental condition. It is, however, definitely established that albuminuria may result from any one of several influences ; these will be briefly discussed. 1. Increase of arterial pressure. There are various methods for in- creasing general arterial pressure without inflicting injury upon the ani- mal. First among these is muscular activity. It has been amply shown through observations with the kymograph that every muscular contraction tends to increase the general arterial pressure, and that violent muscular exercise may easily raise this pressure forty or fifty per cent. Now it is established by clinical observations that albuminuria occurs in healthy in- dividuals with especial frequency after muscular effort. The observation of Leube already referred to, in which the percentage of cases of albumi- nuria in healthy persons rose from four to sixteen per cent, during muscular exertion, is an instance. It is also known that convulsions, tetanic and epileptic especiaUy, are followed by albuminuria in persons whose urine is at other times free from albumen. Experimentally it has been observed that the struggles of animals while being bound upon the operating-table are followed by the excretion of albuminous urine, even though the urine evacuated just before this muscular action was quite free from albumen. Another method for increasing arterial pressure experimentaUy without interfering directly with the activity of the kidneys, is artificial elevation of temperature, graduaUy induced. An increase of temperature of one or two degrees Centigrade causes an appreciable rise of arterial pressure and with it the appearance of albumen in the urine. Examination of the kidneys immediately afterward, by means of Posner's method of boding, shows that the albumen has escaped as usual from the glomeruli. The injection of strychnine or of potassium nitrate causes a marked rise of blood-pressure and the appearance of albumen in the urine. The latter seems to be the result of the increased pressure. 2. Decrease of arterial pressure is a frequent condition, which results ALBUMINURIA. 119 in general venous hypersemia. It obtains sooner or later in most febrile conditions, in cases of coUapse from pain or hemorrhage, and in valvular heart disease before compensatory hypertrophy ; in all of these albumi- nuria is a frequent occurrence. From an experimental investigation into the condition of the renal cir- culation during febrile conditions, Mendelson arrives at the following conclusions.1 1. That in dogs with fever the kidney undergoes a diminution in its bulk. 2. That this diminution is due to a contraction of the walls of the blood-vessels. 3. That it is constant and progressive, being proportionate to the intensity of the fever. These observations afford a demonstration of the fact that the albu- minuria as well as the oliguria usuaUy attendant upon febrile conditions is attributable, in part at least, to the decrease of arterial pressure in the glomeruli. It is probable that a very large number of clinical cases of albuminuria, aside from febrile conditions, are to be explained by the diminished ar- terial pressure in the kidney. For many subjects of anaemia and nervous exhaustion, especially during youth when the physical development is very rapid, exhibit slight albuminuria, which may be transient and temporary or may occur intermittently for years. Such patients often complain of headache and listlessness, are frequently nervous and sometimes suffer from dyspepsia and even diarrhoea. Owing to the prevalent negligence in examining urine, the albumen usuaUy remains undiscovered ; if detected, however, it usually arouses the gravest apprehensions. Such anxiety is needless (unless indeed there be evidences of renal disease) ; for the al- buminuria seems to result merely from the diminished blood-pressure in the kidney as a part of the general anaemia ; and it disappears so soon as the patient's general health is improved. To the same cause must be referred the albuminuria often seen in wasting constitutional diseases, leukaemia, and conditions of general marasmus; also after profuse hemorrhage, in collapse and in the last days of life during exhausting diseases. The albuminuria which frequently appears during a febrile diarrhoea, may be in part due to the accompa- nying debdity, though largely caused, doubtless, by the abstraction of water from the blood. 3. Increase of venous pressure occurs either ii om decrease of the arte- rial pressure or from impediment to the return or blood from the kidney. It has been found that simple pressure upon the renal vein of a dog pro- duces albuminuria ; the same result is caused by placing a ligature around the vein for ten or twelve minutes. If the kidneys be at once removed and boiled after Posner's method, coagulated albumen is found, not in the capsules, but in the tubules, especiaUy those of the medullary portion. It appears, therefore, that the medullary part of the kidney suffers especially during venous hyperaemia. This is readily explained by the observations of Ludwig, who found that this temporary occlusion of the renal vein (the arterial pressure remaining unchanged) caused such distention of the veins in the medullary portion of the kidney as to compress and close completely the tubules surrounded by these veins. In short, venous hyperaemia causes—in the kidney, as elsewhere—oedema, i.e., the transudation of 1 Cartwright Prize Essay, American Journal of the Medical Sciences, October, 1883. 120 DISEASES OF THE URINARY ORGANS. water, salts, and albumen from the smaUer veins into the surrounding tis- sue. Since the tissue surrounding the veins in the kidney is composed of tubules, the transuded fluid must evidently escape into them, where it is mixed with the urine ; the latter, therefore, becomes albuminous. Venous hyperaemia of the kidney occurs chnicaUy in numerous cases. Valvular disease and fatty degeneration of the heart, impairment of the respiratory function, such as occurs in asthma, emphysema, and consump- tion—are familiar examples. In such cases the diagnosis of " Bright's disease"—based upon the presence of albumen and hyaline casts in the urine—is often erroneously made ; the writer has repeatedly seen such so- called Bright's disease—due to valvular disease of the heart—cured by digitalis. The effect of venous hyperaemia from local mechanical obstruction was demonstrated in the familiar case reported by Bartels. This patient, suffering from visceral syphilis, had oedema of the lower extremities and enormous dilatation of the superficial veins of the abdomen. The autopsy showed thrombosis of the inferior vena cava above the entrance of the renal vein. In this case the patient evacuated more than the usual amount of urine, which was highly albuminous. 4. Disease and injury of the nervous system are directly responsible for albuminuria in many cases. Some of these are traceable to injuries in or near the fourth ventricle. Claude Bernard discovered that puncture of the floor of the fourth ven- tricle was followed by albuminuria, and it has been since demonstrated that injury to certain portions of the cerebeUum and of the crura cerebri induce the same result. Subsequent research has shown that the albumi- nuria in these cases of injury to the brain results from the consequent paralysis of the splanchnic nerves, whereby the general arterial pressure (including that in the renal artery) is much reduced. In such cases the albuminuria is to be referred, therefore, directly to the decreased arterial pressure, induced (through the agency of the splanchnic nerves) by the injury to the brain. Clinically, such cases are not infrequent; thus Frerichs reports four- teen cases of albuminuria without renal disease, in which post-mortem ex- amination showed hemorrhage or inflammation involving the floor of the fourth ventricle, the cerebellum, or the crura cerebri. In aU of these cases sugar was also found in the urine. Various diseases affecting the nervous system are accompanied by al- buminuria whose origin is obscure—tetanus, epilepsy, chorea, meningitis; so are psychical disturbances, emotional excess, and nervous exhaustion. The observation of Fiirstner, Weinberg, and Bummhave shown the es- pecial frequency of albuminuria in cases of delirium tremens ; these ob- servers noticed that the quantity of albumen rose and fell with the violence of the delirium, while the kidneys were apparently normal in several fatal cases. Various transient nervous disturbances, such as intense emotion, shock, and pain, may also produce albuminuria; paroxysms of pain, renal or bil- iary colic, and the " gastric crises " of tabes are frequently accompanied and followed for a few days by slight albuminuria. 5. Changes in the Composition of the Blood.—Egg albumen injected into the circulation of an animal, soon appears in the urine. In most cases the albuminuria thus induced ceases so soon as the quantity of albumen ex- creted by the kidneys equals that introduced into the circulation. In other instances the injection of egg albumen into the blood is followed by ALBUMINURIA. 121 a prolonged excretion of albumen by the kidneys ; thus Stokvis observed in one case that four times as much albumen was excreted as had been in- jected. This excess of albumen must have been derived from the blood- serum ; hence it is demonstrated that the simple presence of egg albumen in the blood can induce albuminuria. It has also been shown that the injection of the serum albumen of dogs into the circulation of rabbits causes prolonged albuminuria in these ani- mals. That the albumen excreted is derived chiefly from the rabbit's blood is shown by the fact that far more albumen is excreted than is in- jected, and furthermore that a destruction of the red blood-corpuscles oc- curs, evidenced by the appearance of haemaglobin in the urine. It is, therefore, well established that albuminuria can be induced by the presence in the blood of foreign substances—even though so nearly allied as the blood-serum of other animals—without any appreciable lesion of the kidney. It has been assumed that certain modifications of tissue metamorphosis in the body may result in the production of albuminous materials which may act like egg albumen or the serum albumen of other animals, and produce albuminuria. An analogy for this assumption is found in the fact that peptone, though normally absent from the blood, is produced in the tissues in certain pathological states—suppuration, acute yellow atrophy of the hver, and osteomalacia—and is then excreted in the urine. It has also been assumed that disorders of digestion may result in the production of unusual forms of albumen in the stomach, which when taken into the circulation may cause the same effect as egg albumen—that is, al- buminuria. This idea has been a favorite one among English authors since the time of Prout. Sir Andrew Clark is a believer in what is termed " hepatic albuminuria," i.e., the escape of albumen in consequence of the presence in the blood of albuminoids intermediate between the peptones taken from the stomach and the fuUy metamorphosed serum albumen ; since the liver is largely concerned in effecting these transformations, the presence of the intermediate albuminoids in the blood (and the consequent albumi- nuria) are attributed to disorders of this organ. It is certain that albumi- nuria is observed during many hepatic disorders ; that the urine is at the same time loaded with urates and uric acid ; and that a persistence of such hepatic derangement may be followed by Bright's disease. While these are possible causes of albuminuria, it must be admitted that we have as yet no demonstration of these theories. AU attempts to prove that albuminuria can be of hematogenous origin—i.e., can result from a change in the albuminous constituents of the blood (except in those cases already mentioned, in which albumen is introduced into the body from without)—have failed. So, too, it has been assumed that Bright's disease was consequent upon the presence in the blood of abnormal forms of albumen ; but thus far no observer has been able to demonstrate the existence of such unusual forms of albumen in the blood of patients suffering from Bright's disease. The only known qualitative change in the composition of the blood, therefore, sufficient to induce albuminuria (without causing disease of the kidney) is the presence of albuminous substances derived from foreign sources. There are, however, quantitative changes in the relative propor- tion of the different ingredients of the blood, which may doubtless play a considerable role in causing albuminuria. For it is a well-established principle that the amount of albumen which filters through a membrane in- creases, ceteris paribus, as the albumen and the salts in the filtering fluid are 122 DISEASES OF THE URINARY ORGANS. increased. In those conditions, therefore, in which the blood contains an unusual amount of albumen or of salts or of both, or a deficiency of water, albumen is apt to appear in the urine. Now, there are several physiological conditions in which the percentage of albumen and of salts in the blood is unusually high ; foremost among these is the process of digestion. For during this process the albuminous and saline constituents of the blood are augmented from the food and, as a result, the filtration of albumen through the membrane of the glomeru- lus is facilitated. Now, as a matter of fact, it has been often observed that, in those healthy persons who exhibit albuminuria, the albumen occurs with especial frequency and in greatest quantity during the process of digestion ; indeed, for these cases the term "digestion albuminuria" has been created. Furthermore, it has been ascertained that, in cases of patho- logical albuminuria, the amount of albumen excreted is greatest during the process of digestion. This digestion albuminuria is also most marked after the ingestion of highly albuminous food, such as meat and cheese. The withdrawal of water from the blood effects of course the same re- sult as an increase of the albumen and salts, namely, a relative augmenta- tion of the latter. Hence an excessive excretion of water may be of itself sufficient to induce albuminuria. This has been amply demonstrated ; profuse perspiration, even when induced by pilocarpine, whereby the blood- pressure remains essentially unchanged, is foUowed frequently by albumi- nuria ; doubtless it is, in part at least, the loss of water from the blood which induces albuminuria so frequently in cases of afebrde diarrhoea.1 Albuminuria from Renal Disease. Serum albumen can reach the tubules either from the capillary net- work surrounding them, or from the capillaries composing the glomerulus. In the former case there is disease of the epithelial ceUs hning the tubules, in the latter there is found degeneration of the capiUary waUs in the glomerulus. In most, though not all cases of renal disease both the tubules and the glomeruli exhibit pathological changes. Albuminuria from Degeneration of the Tubal Epithelium.—The greater number of the true secretions of the body contain albumen furnished by the cast-off epithelial ceUs of the respective glands which are min- gled with the secretions. A certain number of secreting glands—the liver, the sweat- and tear-glands—furnish a secretion which is, in the nor- mal condition, free from albumen. The secreting ceUs of the kidney— those of the convoluted tubules—also furnish a product free from albu- men. Now it has been ascertained that in abnormal conditions of the 1 It is quite possible that variations in the alkalinity of the blood may be a factor in favoring the escape of albumen with the urine. For it is well known that the injec- tion of alkaline liquids into the circulation induce augmented contractions of the heart and arteries ; while dilute acid solutions, on the other hand, diminish these contrac- tions (Gaskell). Now the escape of albumen (as well as of sugar) is favored by dilatation of the vascular area supplied by the splanchnic nerves ; and it is certainly possible that a diminished alkalinity of the blood may favor such dilatation, and hence albu- minuria. Such relative acidity of the blood occurs in gout and acute rheumatism, where transient albuminuria is a frequent phenomenon ; it doubtless exists also in disorders of the liver and pancreas whereby the alkaline secretions of these organs are repressed ; in these conditions, too, albuminuria is frequent. Possibly the value of alkaline mineral waters in diminishing the albuminuria of Bright's disease, is partly due to their influence in increasing the alkalinity of the blood. ALBUMINURIA. 123 hver, whereby the nutrition of the epithelial cells is impaired, the bile contains a certain amount of albumen ; this has been observed by Frerichs in cases of hepatic congestion, by Thenard in cases of fatty liver, and by Lehmann in cases of granular and fatty liver. We might assume by analogy that fatty degeneration of the secreting ceUs of the kidney would also be accompanied by the escape of albumen into the secretion ; but we are not compelled to rely upon analogy, since there is ample clinical and experimental proof that such is the case. Albuminuria can be induced by the administration of certain sub- stances, especiaUy chromic acid, cantharides, phosphorus, and petroleum. Now it is established by the observations of WTeigert and Lassar that these various poisons, administered in doses sufficient to cause pronounced albuminuria, produce merely a degeneration of the epithelial cells in the convoluted tubules, while the remaining elements of the kidney—the glomeruli, the interstitial tissue and the epithelium of the straight tubes— remain intact. The ceUs in the convoluted tubules present the peculiar condition caUed "coagulation necrosis ;" that is, the outhnes of the ceUs are lost, they coalesce into masses, lose their nuclei and their ability to absorb the ordinary staining agents. It is found, moreover, that the ceUs in this condition are unable to separate from the blood particles of the in- digosulphate of sodium, which, as Heidenhain has shown, is always accom- plished by these ceUs in their normal condition. Examination of these kidneys by the method of Posner (coagulation of albumen by boding) shows that the convoluted tubules contain albumen, and that there is, moreover, a layer of this substance between the epithelial cells of these tubules and the basement membrane upon which they previously rested. The albumen is found only in those portions of the tubules where the epithehum is necrotic. This constitutes, therefore, an admirable demonstration that serious interference with the nutrition of the epithelial cells in the convoluted tu- bules is sufficient to cause albuminuria. ClinicaUy it is also established that albuminuria is a frequent accompaniment of phosphorus poisoning and of pernicious anaemia, in both of which conditions fatty degeneration of the epithelial ceUs in the tubules occurs. The excretion of highly acid urine, of urates and uric acid in excess, is sufficient to cause temporary al- buminuria, probably from irritation of these cells. In the so-caUed idiopathic cases of nephritis—Bright's disease proper— it is a familiar clinical experience that albuminuria is most constant and pronounced in that variety (chronic parenchymatous nephritis) in which degeneration of the epithelium is the most prominent morbid change in the kidney ; in cirrhosis of the kidney, on the other hand, in which degen- eration of the epithelium seems to be secondary to increase of connective tissue, albumen is found in the urine in comparatively smaU quantity, or may even be absent altogether. Albuminuria from Degeneration of the Glomeruli.—It has become popu- lar in recent years to ascribe to the epithelial cells covering the glomeruli the power to prevent the escape of albumen from the capiUaries composing the tufts, and to assume that impairment of the nutrition of these cells is sufficient to permit albuminuria. However that may be, it is certainly es- tablished that a degeneration affecting the capiUary waUs of the glomeru- lus permits the escape of albumen into the tubules. The most familiar example of this condition is the amyloid degenera- tion of the capdlaries composing the glomeruli. WhUe such amyloid change is, in the majority of cases, an accompaniment of nephritis, yet 124 DISEASES OF THE URINARY ORGANS. cases of uncomplicated amyloid degeneration occur in which there is no nephritis, the cells of the tubules appear intact, while the glomeruli and their vasa afferentia alone exhibit the amyloid change. The pronounced albuminuria which almost invariably accompanies these cases of uncom- plicated amyloid degeneration must be attributed to the abnormal perme- ability of the glomeruli. Obstructive Albuminuria.—It is to be remembered that albuminuria may be produced by a purely mechanical impediment to the evacuation of urine, provided this causes an increased pressure of urine in the renal tu- bules. Partial occlusion of the pelvis or ureter, the pressure of an enlarged or displaced uterus, prostatic hypertrophy, urethral stricture, vesical spasm, tumor or calculus, even a tight phimosis (in infants)—in short, any condition capable of inducing hydronephrosis may also cause albuminuria ; the latter symptom may long precede the development of a recognizable tumor of the kidney. The pathology of albuminuria is by no means comprised in our pres- ent knowledge of the subject; many cases in which albumen appears in the urine remain still unexplained, while many others, in which albumi- nuria does not occur, are equally perplexing. Thus whUe albuminuria results from disorganization of the tubular epithelium and from amyloid degeneration of the glomeruli, yet cases are known in which, in spite of such disorganization and degeneration, no albumen has been discoverable in the urine. CHAPTER XIII. GLYCOSURIA. Physiological Glycosuria. Grape-sugar is constantly found in various tissues of the body, and is a normal ingredient of the blood. Since it is very diffusible, it would be expected that some of it would constantly filter through the glomeruli and appear in the urine. Mosler showed in 1853 that an exclusive diet of sugar and starch produced glycosuria in a healthy person ; Eichhorst ob- served the same phenomenon after an exclusively milk diet, Helfreich after vegetable nourishment. In 1858 Briicke announced that normal urine usually contains a trace of sugar. Subsequent investigations have shown that this occurrence is by no means constant, though frequent. Glycosuria is, therefore, per se, no proof of an organic lesion, if it be but shght and transient; indeed, persistent glycosuria without any indication of a pathological condition is occasionally observed, especiaUy in persons of nervous temperament, and in neurasthenic conditions. The increased production of sugar during pregnancy and lactation is naturaUy accompanied by the circulation of an increased amount of this substance in the blood. In 1856 Blot discovered the frequent presence of sugar in the urine of pregnant and nursing women, a statement which has been often corroborated. It has also been ascertained that an arrest of the lacteal secretion, such as weaning, is followed by an increased excre- tion of sugar in the urine—a fact which has been explained by the recent investigations of Hofmeister and Kaltenbach, who found that the substance excreted under these conditions was not grape- but milk-sugar. This form of glycosuria has been accordingly termed " lactosuria." As might be expected, the urine of infants nourished exclusively by mother's milk has been found to contain an appreciable quantity of milk- sugar (Eichhorst). Glycosuria Independent of Diabetes. Aside from the conditions mentioned in the previous paragraph—in which the increased quantity of sugar in the urine is the direct and natural result of an increased production or consumption of saccharine substances —there are numerous conditions in which glycosuria occurs without the other complex of symptoms designated " diabetes." Thus sugar has been observed in the urine—transiently and in comparatively small quantity— in cases of intermittent fever, tetanus, typhoid fever, gout, cardiac, and pulmonary inflammations ; also after large doses of chloral, chloroform, ether, morphine, curara, and other poisons. In order to appreciate the 126 DISEASES OF THE URINARY ORGANS. significance of such glycosuria, it is necessary to recall the formation and function of sugar in the animal economy. Glycogen is produced from the various saccharine and starchy ingredi- ents of the food by the action of the liver-cells. In the liver it undergoes a further transformation into grape-sugar, probably induced by a ferment which results from the breaking up of the red blood-corpuscles; at any rate, normal blood contains a ferment capable of transforming glycogen into grape-sugar. Under ordinary circumstances this transformation occurs in such a limited degree that the sugar appears in the blood in only small quantity and in the urine merely as traces ; under special circumstances, on the other hand, this production of grape-sugar is so rapid that the blood con- tains a comparatively large amount; hence the sugar filters through the glomeruli and appears in the urine in appreciable quantity. After Bernard's discovery that lesion of the floor of the fourth ventricle causes glycosuria, it was ascertained that the liver is an active agent in this process ; for if this organ be deprived of glycogen—by starving the animal or by the long-continued administration of arsenic (whereby the glycogenic function of the liver is arrested)—puncture of the floor of the fourth ven- tricle is not followed by glycosuria. Sugar introduced into the stomach of such animals appears at once in the urine (showing the abolition of the glycogenic function of the liver). It was at first supposed, in explanation of the fact discovered by Ber- nard, that the brain exercised some direct and peculiar influence over the secretory activity of the liver-cells, but it was subsequently ascertained that lesions in other parts of the cerebro-spinal axis—the thalamus opticus and spinal cord—produced glycosuria ; indeed, sugar appears in the urine without any other injury to the nervous system than simple section of the cervical and dorsal sympathetic. Since the only feature common to all these lesions is a dilatation of the abdominal blood-vessels and consequent increase in the quantity of blood circulating through the liver, it seems certain that the appearance of sugar in the urine after these various lesions results simply from the increased circulation through the liver; in conse- quence of this increased circulation, more sugar is carried to the liver than can be transformed into glycogen by the ceUs of this organ; hence some of the sugar passes through the liver unchanged into the general cir- culation and filters out of the glomeruli. The glycosuria which foUows the administration of certain drugs, curara for example, is apparently caused in the same way, since these drugs are known to induce dilatation of the abdominal blood-vessels. Numerous lesions of the nervous system have been found experiment- ally to induce glycosuria; among these are irritation of the first dorsal nerves, faradization of the central end of the divided vagus, as well as of the central end of the divided depressor nerve. Of far greater moment for clinical purposes is the fact that section or irritation of many spinal nerves has the same effect—glycosuria—as irritation of the abdominal sympathetic. Thus it has been amply demonstrated that section of the sciatic nerve causes glycosuria in animals—a fact of especial interest since transient glycosuria has been observed accompanying sciatica in the human subject (Eulenberg, Froning, Braun). Possibly the glycosuria which is observed in many cases of peripheral irritation, such as burns and inflam- mations of the skin, are to be explained in the same way. In the majority of cases in which sugar appears in the urine in smaU quantity, its presence can be explained by the increased flow of blood to GLYCOSURIA. 127 the liver such as occurs after injury to the floor of the fourth ventricle. Such cases comprise the numerous instances of disease or injury to the brain and spinal cord; meningitis, cerebral and spinal, encephalitis, cerebral hemorrhage, tumors at the base of the brain, epilepsy, tetanus, rabies, tabes dorsalis, emotion, and psychical affections are examples; and it is probable that various drugs which are known to produce temporary glyco- suria cause this effect in the same way—curara, morphine, nitrite of amyl, turpentine, ether, alcohol, chloroform, etc. Yet there remain numerous cases in which the explanation of the ac- companying glycosuria is not so apparent; such are gout, typhoid, recur- rent and intermittent fevers, and diseases of the pancreas, in all of which sugar frequently appears in the urine temporarily. Sugar is also usually found in the urine in cases of chyluria of non-parasitic origin. Glycosuria in Diabetes. Until the pathology of diabetes shall be definitely ascertained, it must remain, as it is now, impossible to explain the presence of sugar in the urine as a symptom of this affection. According to our present knowledge the complex of symptoms desig- nated " diabetes" may be induced by any one of several causes; chief among these are, 1. Disease of the cerebro-spinal axis ; 2. A perversion of ceU-nutrition. The autopsy usuaUy shows some disease of the central nervous axis; these lesions vary extremely as to both nature and locality, tumors and in- flammations of the brain and its membranes being the most frequent. In such cases there is usually observed polyuria and albuminuria intra-vitam and enlargement and congestion of the liver post-mortem. These clinical and anatomical features justify the assumption that the glycosuria is of analogous origin to that induced by Bernard's puncture of the fourth ven- tricle. Yet cases of diabetes occur in which the autopsy fads to reveal such lesions in the nervous system as would explain the glycosuria. While these lesions are therefore by no means constant, there is another impor- tant and constant departure from the normal economy in the diabetic pa- tient : the increased and perverted tissue metamorphosis. In every case of diabetes there occurs an increased excretion of urea, phosphoric acid, and carbonic acid, and a decreased consumption of oxygen. Gathgens, Fre- richs, and Kiilx have shown beyond doubt that the diabetic patient ex- cretes far more urea than a healthy person consuming the same diet, and more than can be furnished by the food ; there is, therefore, evidently an increased decomposition of albuminous matters in his body. Further- more, it is ascertained that the urine of a diabetic patient contains more sugar than is furnished by his food ; and since glycogen can be produced in the body from albumen, it seems probable that a part at least of the sugar excreted is derived from the decomposition of the albuminous con- stituents of the tissues. Inosituria.—Inosite is isomeric with grape-sugar, and occurs in small quantities in many organs of the body—the muscles, liver, spleen, kid- neys, brain, and lungs. It is not, however, found in normal urine except after the ingestion of large quantities of water, which apparently wash the sugar out of the tissues before it has undergone the usual decomposition. Many attempts have been made to trace a relation between the excre- 128 DISEASES OF THE URINARY ORGANS. tion of inosite and of grape-sugar in cases of diabetes. Bernard and Gallois found that the piqure occasionally caused the appearance, not of grape-sugar, but of inosite in the urine ; Schultzen observed inosituria in two patients suffering from tumors in the vicinity of the fourth ventricle ; Ebstein found both grape-sugar and inosite in the urine of a patient suffer- ing from disease of the medulla. On the other hand, Pribram observed a case of inflammation extending to the fourth ventricle in which neither grape-sugar nor inosite was discoverable in the urine, notwithstanding de- cided polyuria. Inosite has been repeatedly observed associated with grape- sugar in the urine of diabetics, and Vohl saw a remarkable case of diabetes in which the grape-sugar graduaUy disappeared and was replaced by inosite, 18 to 20 grammes of which were excreted per day. Gallois subsequently observed a similar case. Yet there appears to be no definite etiological relation between glyco- suria and inosituria. Kiilx found that after a six days' fast (whereby the glycogen of the liver was exhausted) the administration of inosite to rabbits did not cause glycosuria; he also found that the ingestion of inosite did not increase the quantity of sugar excreted by diabetic patients ; indeed, in one case of diabetes he was enabled, by an exclusively nitrogenous diet, to cause the sugar to disappear from the urine completely, yet even then the administration of inosite was not followed by glycosuria. For clinical purposes, therefore, the presence of inosite in the urine has no especial significance. CHAPTER XIV. EFFECT OF ACIDS AND PIGMENTS ON THE BLOOD. Choluria. The important constituents of the bile are the two acids, glycocholic and taurocholic, bilirubin and cholesterine. Both the acids and the bil- iary pigment are found occasionaUy in normal urine in minute quantity ; their appearance in appreciable amount indicates an abnormal condition.' Biliary pigment is formed from the haemoglobin, the coloring matter of the blood-corpuscles. The transformation of haemoglobin into bilirubin takes place normally in the liver, and abnormally in the circulating blood. Jaundice and the appearance of biliary pigment in the urine may, there- fore, be due to, 1. Disorders of the liver, and 2. Disturbances in the cir- culating fluid ; in the former case the jaundice is termed hepatogenous, in the latter haematogenous. The bile which is discharged into the intestine is largely reabsorbed and returned by the portal vein to the liver, where it is again separated from the blood, only a trace passing into the general circulation to be ex- creted by the kidneys. Whenever, from any cause, an accumulation of bile occurs in the liver, its constituents are taken into the circulation and ^ ehminated with the urine. The most frequent cause of such accumulation is an impediment to the passage of bile through the biliary duct—occlusion by gall-stones, by swelling of the mucous membrane, by cancerous, syphilitic or cirrhotic new formations, by abdominal tumors, especially enlargements of the pan- creas. Transformation of haemoglobin into bilirubin may occur in the blood without participation of the liver. It has been in recent years demon- strated that jaundice and the excretion of bilirubin in the urine can be readily induced by the injection of various agents into the blood by which blood-corpuscles are destroyed and their coloring matter converted into bilirubin. Chlor&form, injected or inhaled, produces this effect—a result sometimes transiently observed after anaesthesia ; injections of biliary salts, of haemoglobin, and even of pure water can induce jaundice. Such haematogenous jaundice is observed clinically in cases of septic infection—pyaemia and septicaemia—typhoid fever, malarial infection, as well as after poisoning by arsenic, chloroform, ether, etc. In such cases the biliary pigment appears in the urine before the skin is jaundiced ; in- 1 The appearance of the biliary acids in urine has no practical clinical value, because the process for their detection is too complicated for clinical use. It is only the biliary pigment which can be detected so readily as to come within the reach of clinical ex- amination. 9 130 DISEASES OF THE URINARY ORGANS. deed, the formation of bilirubin in the blood may be so slight that no jaundice occurs, although the pigment can be detected in the urine. Choluria is usually accompanied with albuminuria. Hemoglobinuria. Aside from the numerous cases in which blood is found mixed with the urine (in consequence of rupture of blood-vessels) there are frequent in- stances in which the urine exhibits the dark color characteristic of blood, and yet is found upon microscopic examination to contain no blood-cor- puscles. The peculiar color in these cases is due to the haemoglobin, which has been separated from the corpuscles in the blood and has es- caped into the urine without any rupture of blood-vessels. It has been established that haemoglobin is one of those albuminous substances which leave the blood and escape through the kidney without restraint. It is excreted largely through the glomeruli by simple filtra- tion, but appears to be in part also abstracted from the blood by the epi- thelial cells of the convoluted tubules. Under ordinary conditions haemo- globin is of course retained in the blood-corpuscles, and thus prevented from passing out through the kidneys ; but so soon as it is separated from these corpuscles and dissolved in the serum, it escapes from the kidneys quite as readily as egg-albumen or peptone. Haemoglobinuria is therefore evidence that the blood-corpuscles have been exposed to some unusual condition whereby the haemoglobin is sepa- rated from the rest of the corpuscle. Such separation occurs upon the introduction of certain substances into the blood. It has been experi- mentally ascertained that the injection of glycerine, mineral acids, chlorate of potassium, biliary salts, pyrogallic acid, naphthol, and even of pure water, is sufficient to cause such breaking up of the blood-corpuscles, and hence the appearance of haemoglobin in the urine. The same effect often follows transfusion with the blood of a different animal, and extensive burns; even a cold foot-bath is sometimes sufficient to induce hsemoglo- binuria (Rosenbach). Clinically haemoglobinuria has been observed chiefly in conditions sim- Uar to those which are found to produce it experimentally; in poisoning by chlorate of potassium, sulphuric, hydrochloric, carbolic, pyrogallic, and arsenious acids, naphthol, iodine, and nitro-benzole; in burns and scalds, transfusion of lamb's blood, sunstroke, and fatty embolus. Extreme care should be taken in the administration of chlorate of potash, since remark- ably small quantities of it have produced dangerous symptoms. Even after the ingestion of three drachms (in divided doses) of the chlorate, there have been seen dyspnoea, a small, weak pulse, cyanosis, icterus, haemoglobinuria, and grave cerebral symptoms ; partial or complete sup- pression of the urine and death may follow within one or two days. Many of the infectious diseases are occasionally accompanied by haemo- globinuria—septic infection, intermittent and other malarial fevers, scar- latina, diphtheria, typhoid fever and hemorrhagic small-pox; it has also been seen in scurvy and purpura, as well as after exposure to cold. Idiopathic Hcemoglobinuria.—In the cases already mentioned the ap- pearance of haemoglobin in the urine is explained by the evident presence of a foreign agent in the blood, whereby the haemoglobin is separated from the blood-corpuscles ; it occurs, however, where no such explanation is apparent, the patients apparently enjoying perfect health. In these EFFECT OF ACIDS AND PIGMENTS ON THE BLOOD. 131 cases the haemoglobin appears in the urine only at intervals, usually of se\-< eral weeks or months, and is found for a few hours or days at a time. The attack is preceded by signs of constitutional disturbance—prick- ling sensations in the skin, pains in the head, back, and limbs, a chilly sensation, or even a decided chill foUowed by fever and sweating ; in the latter stage the urine exhibits the haemoglobin ; the skin often becomes nomewhat jaundiced, apparently from the transformation of haemoglobin into bihrubin ; transient enlargement and sensitiveness of the liver and spleen are usual features of the attack. The etiology of this paroxysmal, intermittent hemoglobinuria is un- certain. The swelling and sensitiveness of the liver and spleen, together with the jaundice, indicate a derangement of one or both of these organs. Now since one of the numerous functions of the liver is doubtless the con- version of the haemoglobin of the disintegrated blood-corpuscles into bili- rubin, it has been assumed that a derangement of the liver might consti- tute the origin of the attack. Ponfick has shown that haemoglobin ma}' exist dissolved in the blood-serum -without appearing in the urine ; ex- cessive disintegration of corpuscles causes first a swelling of the spleen and next enlargement of the liver ; if both organs together are unable to remove the haemoglobin, the excess filters out of the blood into the urine. It is only when one-sixtieth of the entire amount of haemoglobin in the blood is dissolved out of the corpuscles, that haemoglobinuria appears. If the amount be even greater than can be disposed of by spleen, liver, and kidneys, jaundice occurs. The attack often occurs after exposure to cold, and has been repeatedly induced artificiaUy, in cases predisposed to the affection, by placing the hands or feet in cold Avater. The complaint is most frequent in winter and spring and rare in summer; and patients have themselves observed that the attack occurs only when they leave warm rooms. In other instances haemoglobinuria is induced by either physical exer- tion in general, or by some particular exercise ; it has also been observed to follow regularly upon emotional excitement, such as accompanies vene- real excesses. A case reported by Fleischer is especiaUy noteworthy. In this instance a robust soldier observed that the urine became bloody in appearance after he had been on the march for an hour or two ; the intensity and' duration of this color was proportional to the time spent in marching. It was found that the urine contained no blood-corpuscles, but simply haemo- globin ; and curiously enough no other form of exercise, no matter how violent, was foUowed by haemoglobinuria, nor was it induced by cold foot- baths ; yet it invariably followed after a march. In this case the patient had no fever nor other disturbance of the general health. In some cases haemoglobinuria is said to have occurred as a result of syphilis, and to have ceased under the employment of anti-syphilitic rem- edies ; in other instances it has appeared as one of the incidents in an at- tack of rheumatism, and has disappeared when the rheumatic pains ceased. That the haemoglobin is actually dissolved in the blood-serum in these cases has been demonstrated in several instances : Kiissner found that the blood removed from a patient during an attack of haemoglobinuria by leeches furnished serum of a ruby red color ; and Ehrlich observed a sim- ilar color in the serum of blood taken from the finger during an attack ; he also noticed that the red blood-corpuscles were decolorized, many of them disorganized, and that those which retained their haemoglobin showed a great diversity in size and shape. 132 DISEASES OF THE URINARY ORGANS. In the majority of cases of haemoglobinuria, serum albumen is found more or less constantly in the urine, accompanied naturally by hyaline casts. Masses of amorphous haemoglobin in the form of casts, and (if jaundice exist) of biliary pigment, are also found. The epithelial cells of the kidney which may be present sometimes contain crystals of haematoidin. The few cases in which post-mortem examination of the kidneys has been made show in these organs nothing abnormal except hyperaemia and the presence of pigment in the epithelial cells, and in the lumen of the tubules. In this situation the hemoglobin appears as an amorphous, brown mass, or as yellowish brown balls. In cases of artificial haemo- globinuria, these balls are often present in such quantity in the tubules as to present a radiating appearance. Haemoglobinuria seems to occur almost or quite exclusively in males. The fresh urine contains, as a rule, only methaemoglobin, which is oxidized to oxyhemoglobin only after standing for some time. In some cases the urine contains chiefly haematin, which gives an especiaUy dark color ; this has been observed in cases of diphtheria by Salkowski and Kiister. Chyluria. A trace of fat is found in normal urine. In various abnormal condi- tions fat is excreted in considerable quantity. In one class of cases it is found thoroughly mixed with the urine, making an emulsion—chyluria ; in another class the fat is not mixed with the urine, but floats as drops upon the surface—lipuria. Chyluria occurs in two distinct classes of cases ; in the one variety, which occurs exclusively in tropical climates, the patient's blood is found to contain a nematode worm in embryo form—the filaria sanguinis homi- nis ; in the other class, comprising but few cases, various (mostly undis- covered) factors are involved. As to the source of the fat in the urine, it is certain that it is derived from the food ; for Brieger and others have shown that by withholding fatty articles from the diet, all fat disappears from the urine in cases of chyluria ; and that it reappears again so soon as the food again comprises fatty articles. As to the manner in which the fat escapes into the urine, no definite information has been obtained. It has been supposed that an obstruction to the thoracic duct might result in dilatation of the intestinal lymphatics and the establishment of abnormal communication with the urinary chan- nels ; this supposition is supported by the fact that chylous fluids occa- sionally collect in the peritoneal cavity, yet no demonstration to this effect has as yet been furnished. Experimentally chyluria has been induced by the injection of olive-oil into the blood-vessels. In one clinical case ob- served by Eggel the blood was found to contain an excessive quantity of fat, so that in this case at least the fat found in the urine may have es- caped through the kidneys. It is highly probable that the fat usually escapes through the kidneys, because the urine contains in all cases albumen, globulin, and often pep- tone ; moreover, Brieger found that while the fat disappeared from the urine upon withdrawing fatty food, yet the albumen persisted. The fat also increased upon movement. In those cases of tropical chyluria, where the filaria is present in the patient's blood, the urine constantly contains blood and occasional worms. In these cases there is present also fibrin o- EFFECT OF ACIDS AND PIGMENTS ON THE BLOOD. 133 gen, whereby clots are produced in the urine, even before it leaves the bladder.' The few post-mortem examinations which have been made upon cases of chyluria have usually failed to furnish any plausible explanation of this phenomenon. In a few instances there appears to have been a fistulous opening between the radicles of the thoracic duct and the urinary tract; in one case cancer of the stomach was observed, in another tuberculosis of the lungs. Even in those cases in which the filaria is present in the blood, post-mortem examination has faded to explain the appearance of fat in the urine. Lipuria. It is demonstrated that fat can be eliminated from the blood by per- fectly healthy kidneys. Bernard found that fat appeared in the urine of a dog which had been fed for a week upon mutton fat exclusively. Wiener and Scriba further observed that injections of oil and fat into the blood were followed by its appearance in the urine, and that the fat escaped through the glomeruli. The appearance of fat as drops upon the surface of the urine is termed lipuria ; in such cases albumen is either absent or present only in small quantity, while in chyluria there is usually a large percentage of albumen as well as globulin and peptone. Clinically lipuria is observed either with or without disease of the kidney. In the latter case it has been noticed after the ingestion of fats and ods ; in diseases of the pancreas ; in cases of poisoning by phos- phorus, carbonic acid, and turpentine ; in acute yellow atrophy of the liver, in obstruction of the bile-duct by gall-stones, and in yellow fever. A most interesting observation is the occurrence of fat in the urine in cases of fatty embolus (Scriba) and in ordinary fractures (Riedel). It has also been seen in chronic diseases and tumors of bones, and in long-con- tinued suppuration. In the latter case the fat seems to be derived from degeneration of the pus-ceUs ; for Ebstein recently observed a case of lipuria following pyonephrosis. The appearance of fat in the urine is said to be a frequent occurrence during pregnancy. In this condition as well as in diabetes, which is also accompanied by lipuria, the blood contains an unusual percentage of fat. Chronic parenchymatous nephritis is often accompanied by extensive 1 While attached to the medical staff of the London Hospital, I had the rare oppor- tunity of carefully observing, for several months, a case of chyluria with filaria in the blood. (For a full report of the case see Path. Soc. Transactions, vol. xxxiii., p. 394.) In this case, as in all others on record, the worms were to be found only at night, at which time a drop of blood taken anywhere from the surface contained from fifty to one hundred of them. It is quite possible that the filaria has been repeatedly over- looked, because examinations of the blood were made only by day. The urine con- tained so much fibrin that it frequently coagulated in the bladder, causing retention and requiring the use of a catheter. The worms were to be found in the urinary sedi- ment by day as well as by night, yet so entangled and hidden in masses of fibrin that they were often overlooked. In this case a reversal of the ordinary daily programme —the patient sleeping by day and remaining awake at night—caused a revolution in the habits of the worms, which were now found in the blood only during the day. This patient—a healthy young soldier, just arrived from India—remained quite well for several months, but ultimately developed abscesses in the joints, and finally died of pysemia, about eleven months after the chyluria was first noticed. At the post- mortem examination the adult worm was not discovered. 134 DISEASES OF THE URINARY ORGANS. fatty degeneration of the kidney ; in a few instances of this affection, fat has been observed in the urine ; lipuria has also been seen in cases of cystitis, presumably from fatty degeneration of pus. Fibrinuria. In rare cases the urine coagulates some time after emission into a jelly- like mass. The coagulation is not dependent upon admixture of blood, since blood-corpuscles are few in number or may be absent entirely. This condition is said to be endemic in Brazil, Madagascar, and the Isle of France ; as to its etiology nothing is known, though the occurrence of fibrinuria with the filaria sanguinis in tropical regions suggests the possi- bility that such endemic fibrinuria 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 the use of cantharides. Hydrothionuria. Sulphuretted hydrogen is evolved during the decomposition of urine containing cystine ; but it has also been observed in fresh urine, chiefly in cases of cystitis, where it is produced by decomposition of pus. In a few cases of abscesses in the vicinity of the intestine, it has also been found. Emminghaus has described two cases of hydrothionuria after suppurative peritonitis foUowing perforation, and Betz observed it in a case of prostatic hypertrophy with dilatation of the rectum. In these and other cases the sulphuretted hydrogen appears to have been absorbed from the intestine or adjacent abscesses. In one case Dittel observed an escape of gas with the urine, the autopsy showing a vesico-intestinal fistula. CHAPTER XV. DAILY AMOUNT OF URINE. While the average daily quantity excreted by an adult is usuaUy be- tween thirty and sixty ounces (1,000 and 2,000 c.c), it may be diminished to 500 or increased to 3,000 c.c. for a day or two during perfect health ; for such variations may be occasioned by temporary changes in the quantity of liquid consumed as well as in the activity of other excretory organs, especially the skin and the bowels. There are also other influences which induce increased or diminished excretion of urine ; the quantity is increased by 1. An abundant supply of animal food. Ranke observed in one case the daily excretion of over 3,000 c.c, while during a period of starvation the amount passed by the same patient was reduced to 750 c.c. Seegen saw the quantity decreased even to 125 c.c. per day. This increased ex- cretion is due in large part to the excessive production of urea upon an animal diet, the diuretic effect of which is well known. 2. Psychical influences. Beneke observed during conditions of physio- logical exaltation an increase from 60 to 200 c.c. per hour, and during physical and mental depression, a decrease from 60 to 15 c.c. per hour. 3. Increase of arterial pressure. This results in increased rapidity of filtration through the glomeruli, and hence polyuria ; digitalis increases the renal excretion in this way. A decrease in the force and rapidity with which the blood circulates through the glomeruli causes, on the other hand, a diminished excretion of urine. 4. The presence in the blood of some substance which excites the secreting cells of the kidney to increased activity. Jaborandi, saltpetre, and urea in- crease the urinary excretion. The diuretic effect of urea is often observed in the polyuria which occurs at the beginning of convalescence from febrile affections, constituting an important feature in the so-caUed " crisis " of the case. This critical diuresis appears to be due to the effect of the ac- cumulated urea upon the kidney cells. The quantity of urine excreted is influenced in disease, and doubtless in health, by the nervous system. Bernard observed that injury to a cer- tain locality in the floor of the fourth ventricle causes marked increase in the quantity of urine excreted ; the same effect follows section of the splanchnic nerves, and it has been demonstrated that the diuresis which follows Bernard's piqure is due to the consequent paralysis of the renal artery, supplied by the splanchnic nerves. Section of the cervical cord or irritation of the dorsal cord induces an arrest of the urinary excretion by irritating the splanchnic nerves, whereby contraction of the renal arteries is produced ; indeed, direct irritation of 136 DISEASES OF THE URINARY ORGANS. these nerves has also a marked effect in decreasing or even arresting the urinary excretion. Many clinical cases of polyuria are caused by disease or injury in and around the fourth ventricle. In cases in which the symptoms have indi- cated and the autopsy has proven disease, hemorrhages and tumors of the central nervous system, the medulla, the cerebellum, and the spinal cord, polyuria has been a constant symptom. Injuries to the brain and to the skull have been accompanied by this same symptom. In another class of cases the influence of the nervous system is equally apparent though less intelligible. Examples are seen in the excessive ex- cretion of urine after a hysterical attack ; in some cases of hysteria poly- uria is not a transient but a persistent symptom. In epilepsy, too, a per- sistent increase in the excretion of urine has been observed. It has been already stated that the quantity of urine excreted is dimin- ished by irritation of the splanchnic nerves whereby contraction of the renal arteries is induced. It would seem that such irritation of these nerves occurs in cases of lead poisoning. Riegel observed that in lead colic the amount of urine decreased as the pain and arterial tension in- creased ; this relation was especially apparent where the attacks of colic recurred at intervals of several days. The quantity of urine is mechanically decreased by obstruction in the urinary channel—a result which is to be attributed to the increase of pressure on the outer side of the glomeruli, and consequent decrease in the rapidity of filtration. Renal calculi, tumors compressing the ureters, the swelling of the bladder mucous membrane in cystitis, paresis of the bladder, hypertrophy of the prostate, stricture, may all decrease the quantity of urine excreted. Reaction of the Urine. The reaction of the urine varies considerably in health even in the same person, and at different hours in the same day. It is dependent upon the degree of alkalinity of the blood, and this in turn largely upon the diet of the animal; thus carnivorous animals have a markedly acid urine, while the herbivora excrete a constantly alkaline urine. In man the urine is generally slightly acid ; the degree of acidity is much increased by an excess of animal food, and diminished by vegetable food. The alkalinity induced by vegetable food seems to be due to the vege- table acids therein contained—citric, tartaric, acetic, etc. ; for these are oxidized into carbonic acid in the organism, producing alkaline carbon- ates. It is found also clinically that the administration of these acids or salts containing them—citrate, tartrate, or acetate of potassium, for instance —induces alkalinity of the urine. The alkalinity of the blood (and therefore of the urine) is increased not only by the addition of alkalies, as occurs upon vegetable diet, but also by the abstraction of acids, which takes place during digestion. For the separation of hydrochloric acid by the gastric glands increases the alkalinity of the blood. It has been found both experimentally and clini- cally that there is a constant and direct relation between the secretion and deposition of the gastric juice on the one hand, and the acidity of the urine on the other. It has been shown by experiment that when the gastric juice of a dog is permitted to escape through a fistula, the urine (normally acid) becomes alkaline and so remains until the escape of gastric juice is pre- DAILY AMOUNT OF URINE. 137 vented. The same result was obtained by Quincke, by removing the gastric juice through a stomach-pump. Clinically it has been often ob- served that patients suffering from persistent vomiting excrete alkaline urine. The explanation of this alkalinity, observed in experiment as well as clinically, is evidently that the removal of the gastric juice from the body prevents its resorption into the blood and thus increases the alkalinity of this fluid and therefore of the urine derived from it. The alkalinity of the urine (absolute or relative) which is physiologically observed soon after the ingestion of food is therefore most plausibly explained by the forma- tion of hydrochloric acid in the stomach ; for the formation of this acid seems to be accomplished by the separation of hydrogen from the acid phosphate of sodium, whiah becomes the neutral phosphate ; and since the acidity of the urine depends largely upon the presence of this acid phosphate, the disappearance of this salt results in diminished acidity of the urine. Dr. Ralfe suggests that there may be another factor in the production of this alkalinity during digestion, namely, the increased exhalation of car- bonic acid by the lungs. Edward Smith has shown that during digestion this exhalation is increased, while it is diminished by fasting and by sleep. The acidity of the urine is inversely proportional to this exhalation, being- least during digestion and greatest during sleep. The reaction of the urine is affected in many derangements of the di- gestive and of the respiratory organs. Any interference with the elimi- nation of carbonic acid, or excessive production of the same, may be fol- lowed by an excessive excretion of alkaline carbonates, and consequent alkalinity of the urine ; such is often the case during convalescence from acute diseases. The failure to secrete normal gastric juice, as in certain forms of dyspepsia, or its removal from the stomach by persistent vomiting, may cause alkalinity of the urine. Any condition such as duodenal catarrh, which prevents the discharge of bile into the intestine, causes an accumu- lation in the blood of alkaline carbonates which would otherwise escape with the bile and, in part at least, be discharged with the feces; hence such condition may thus indirectly produce alkalinity of the urine. Probably a suppression or retention of the pancreatic secretion occasions the same re- sult in a similar way. Fermentation in the small intestine causes the pro- duction of certain fatty acids which are oxidized in the blood into carbonic acid, resulting in the excretion of alkaline carbonates in excess and conse- quent alkalescence of the urine (Ralfe). Such fermentation produces the symptoms of dyspepsia with constipation and flatulence, usually associated with alkaline urine. If these acids (lactic, butyric, etc.) are produced in the small intestine in excess, the oxidation is incomplete, producing oxalic acid, whereby the urine is rendered acid and the condition termed " oxa- luria " may be developed—dyspepsia, flatulence, and a copious precipitate of calcium oxalate crystals. CHAPTER XVI. URINARY SEDIMENTS. From Acid Urine. From Alkaline Urine. A. UNORGANIZED. 1. Amorphous. Urates of sodium and potassium. Phosphate and carbonate of calcium. 1. Uric acid. 2. Oxalate of calcium. 3. Cystin. 4. Tyrosin. 2. Crystalline. 1. Triple phosphate (ammonio-mag- nesium phosphate). 2. Urate of ammonium. 3. Phosphate of magnesium. 4. Phosphate of calcium. B. ORGANIZED. 1. Epithelial cells. 2. Blood-corpuscles. 3. Pus-corpuscles. 4. Tube-casts. 5. Spermatozoa. 6. Fragments of morbid growths. 7. Entozoa. 8. Fungi. 9. Bacteria. 1. Uric Acids and Urates.—The neutral urates of sodium and potassium are contained in every normal urine in perfect solution ; through the ac- tion of the acid phosphate of sodium contained in the urine, these neutral urates are, in the course of a few hours, decomposed into the acid urates and free uric acid ; since these substances are far less soluble than the neutral urates excreted by the kidneys, a precipitate occurs. Although such precipitation of the acid urates of sodium and potas- sium as well as of uric acid usually occurs only some hours after the urine has been voided, yet in certain states, normal as well as pathological, it oc- curs before the urine has left the body ; it is favored by : URINARY SEDIMENTS. 139 (1.) Excessive acidity of the urine. This occurs especially when the diet contains an undue proportion of nitrogenous (animal) food, since the decomposition of albumen in the body is accompanied by the formation of free acids. In cases of gout and of the so-called " uric acid diathesis," the urine is usually decidedly acid, and furnishes an abundant sediment of urates. That the precipitation of the urates may be quite independent of the actual production in the body, and entirely dependent upon the reaction of the urine, is shown in examples mentioned by Bartels: In a case of capillary bronchitis the patient excreted in twenty-four hours 920 c.c. of urine, containing 4.5 per cent, of urea and 0.123 per cent, of uric acid; the reaction was alkaline and the urine contained no sediment. In a case of typhoid fever there was excreted in twenty-four hours, 920 c.c. of urine, containing 4.4 per cent, of urea and 0.098 per cent, of uric acid ; the reaction was acid, and as a consequence a heavy sediment was precipitated. (2.) Scantiness of the urine. This occurs especiaUy when the watery ele- ments of the blood are largely excreted by the skin, the bowels, and the lungs, as in cases of profuse perspiration, diarrhea, etc.; also in febrile conditions. (3.) Excessive excretion of uric acid, such as happens at the so-caUed " crisis " of many febrile affections. (4.) Cooling of the urine, since the urates and uric acid are less soluble in cold than in warm water. Clinically the occurrence of a uric acid deposit is an important item in diagnosis only when in freshly voided urine and persistent. In such cases it will be found that the urine is highly acid, and that the crystals of uric acid are rough, pointed, and often arranged in rosettes. The detection of such forms suggests the suspicion that the deposit of uric acid and urates is occurring in the urinary passages, and should therefore stimulate further examination of the urine as weU as of the patient. In such cases albumen, blood, pus, and epithelial cells from the kidney and from the pelvis con- firm the suspicion that uric acid concretions may be forming in some por- tion of the urinary tract; in other cases the chief symptom noticed is a scalding upon urination suggestive of incipient gonorrhoea. Even though none of these conditions can he detected, a patient who habitually passes very acid urine, in which rough and pointed crystals of uric acid are soon precipitated, perhaps even whde the urine is still warm, should receive alkalies in order to avert pyehtis and nephritis. After the administration of alkaline carbonates or vegetable acids, it will be found that the uric acid is precipitated not as rough, pointed crystals, but in the usual whet- stone shapes. In certain conditions, especiaUy gout and the so-called uric acid dia- thesis, the acid and its compounds accumulate in the blood and may even form concretions in the skin and around the joints. It has been custom- ary to regard these phenomena as indications of an over-production of uric acid in the tissues ; recent researches make it, however, probable that this accumidation in the tissues results not from excessive production, but from deficient excretion ; that this imperfect excretion is due to diminished alkalinity of the blood, which in its turn is the result of addiction to nitro- genous food, whereby an undue amount of acid is produced. It was formerly supposed that the accumulation of uric acid in the tissues was favored by insufficient oxygenation of the blood; this idea 110 DISEASES OF THE URINARY ORGANS. rested chiefly upon the hypothesis that urea was produced by the oxida- tion of uric acid, and that a deficiency of oxygen would therefore prevent the usual oxidation of the acid. Subsequent researches have, however, shown, first that urea is produced chiefly in other ways than by the oxida- tion of uric acid ; and second that deficient oxygenation of the blood does not, as a matter of fact, clinically or experimentally, favor the increased production and excretion of uric acid. 2. Oxalate of Calcium.—This is usuaUy found in acid urine in com- pany, therefore, with uric acid and the urates ; it is not, however, die-solved by a slightly alkaline reaction of the urine. The octahedral crystals of the oxalate usually appear in greater quantity after the urine has stood for several hours ; indeed, in some cases none of these crystals can be detected in the freshly voided urine, while they are found in abundance after the lapse of some hours. The reason for this subsequent appearance of the oxalate of calcium crystals in the urine is the disappearance of the acid phosphate of sodium. Neubauer showed that the oxalate is held in solution by the acid phos- phate ; since the latter gradually combines with the urates, the oxalate of calcium is gradually thrown out of solution and appears in the sediment. The important inference from this fact is that the quantity of oxalate of calcium found in the sediment is determined not by the quantity ex- creted, but by the reaction of the urine. Even though the sediment con- tains no crystals of the oxalate, the urine may hold Ian excessive quantity of this salt in solution ; and conversely the appearance of numerous crys- tals of the oxalate in the sediment does not prove that an abnormally large amount of the salt is excreted by the kidneys. Furbringer's investigations show most clearly that there is no definite ratio between the amount of the oxalate actually contained in the urine on the one hand and the num- ber of crystals found in the sediment on the other; thus he found in some cases with a total excretion of ten miUigrammes a greater number of oxalate crystals in the sediment than occurred in other cases with an excretion of nearly twenty milligrammes. Oxaluria.—Many of the English authors have recognized, under this name, a distinct pathological condition, indicated by mental depression, dyspepsia, pain in the epigastrium and in the loins, emaciation and diu- resis ; since, in such cases, numerous oxalate of calcium crystals have been found in the sediment of the urine, it has .been supposed that the symp- toms originated in an increased production of oxalic acid in the body. Since it is now known, as has been stated, that there is no constant rela- tion between the amount of oxalic acid excreted, and the number of oxa- late crystals in the sediment, it is evident that there is no ground for ascribing the symptoms enumerated to the presence of oxahc acid in the blood. ClinicaUy the appearance of oxalic acid in the urine is not associated especially with any pathological condition ; an increase has been frequently observed in cases of diabetes, and Cantani has recently recorded a case in which sugar and oxalic acid were alternately excreted in large quantity. Fiirbringer detected oxalic acid in the sputum of a diabetic patient. Cal- cium oxalate crystals are sometimes found in excess in cases of fermenta- tion in the small intestine, whereby fatty acids are produced ; if these are only partially oxidized in the blood, oxalic acid is formed. The quantity of the acid excreted is of course increased by the inges- tion of vegetables containing it—beets, turnips, spinach, cabbage, apples, oranges, tomatoes, grapes, etc., rhubarb, squills, valerian. URINARY SEDIMENTS. Ill 3. Cystin.—This is a rare sediment, usually found in individuals who suffer from cystin stones; yet it may occur dissolved in the urine with- out the formation of vesical calculi and even without the precipitation of crystals in the sediment. The fact that cystin contains sulphur and nitrogen indicates its ori- gin in the albuminous constituents of the body. Many efforts have been made to ascertain whether the excretion of cystin is accompanied by a diminution in the other urinary ingredients containing nitrogen and sul- phur ; it has been determined that there is usually, in such cases, a de- crease in the excretion of uric acid and of the sulphates ; further than this no constant deviation has been observed. In one case Marowsky observed cystinuria associated with a dimin- ished activity of the liver (acholia) ; Ebstein and Salisbury have noticed cystinuria during acute rheumatism, the cystin disappearing after conva- lescence from the disease. Ebstein's case was especially noteworthy from the fact that albumen was associated with cystin, both disappearing from the urine at the same time. In another case Ebstein observed cys- tinuria in a syphilitic patient; after the employment of mercurials the cystin disappeared. Only one observation as yet indicates a direct influence of the diet upon the production of cystin : Ebstein observed that the quantity ex- creted was tripled after the ingestion of peas. Clinically, therefore, the occurrence of cystin in the urine—cystinuria —has as yet no especial significance. As yet only sixty-one cases have been observed, of which forty-five (seventy-five per cent.) occurred in males. Cystinuria has been noticed most frequently in youth, occasionally dur- ing middle age, but with extreme rarity after the fiftieth year. It has been repeatedly observed in different members of the same family, though whether from a common predisposition or as the result of common sur- roundings is not known. Thus Toel saw cystinuria in three members of the same family, mother and daughters, and Ebstein detected it in two brothers. Most of these individuals enjoy apparently perfect health. 4. Leucin and Tyrosin.—Leucin is found normally in small quantity in the spleen, the pancreas, the liver, and lymph glands ; also in the seeds of certain plants. It is produced in larger quantity during the putrefaction of the glands above named, as well as by the action of pancreatic juice upon albuminous substances ; it is therefore evidently constantly produced in the alimentary canal. Since, moreover, it is formed by the action of acids and alkalies upon albumen it seems probable that it may be formed in the body as a part of normal tissue metamorphosis. At any rate it has been discovered that during the germination of plants leucin and tyrosin are produced out of albuminous substances. Though a certain amount of leucin must therefore be present in the body, yet it appears to undergo further change before elimination, since it is never found in urine during health. Even the administration of con- siderable quantities of leucin by the mouth does not cause its appearance in the urine ; there does occur, however, a decided increase in the amount of urea excreted, whence it is inferred that some of the leucin at least is transformed into urea in the body. In plants it is known that leucin combines with hydrocarbons, producing albumen ; since the increased ex- cretion of urea which follows the administration of leucin by the mouth does not account for all of this substance administered, it is quite possible that a similar combination occurs in the animal. As yet leucin is known to occur in the urine only in two pathological 142 DISEASES OF THE URINARY ORGANS. conditions—acute yellow atrophy of the liver and acute phosphorus-poi- soning ; its reported occurrence in cases of small-pox, typhoid fever, and glanders is rare or altogether doubtful. Since in the two diseases named the liver is disorganized, and little or no urea excreted, it seems plausible to infer that the metamorphosis of leucin into urea and albumen occurs normally in this organ. In acute yellow atrophy of the liver leucin and tyrosin appear in the urine in large quantity ; in acute phosphorus-poisoning, on the other hand, in small quantity. This fact has been employed for differential diagnosis between the two affections (Schultzen and Riess). It must be remembered, however, that cases of undoubted acute liver atrophy have been observed in which neither leucin nor tyrosin could be found in the urine. Tyrosin seems to be formed in the human subject under precisely the same conditions which give rise to the production of leucin ; at any rate, they appear together in the urine. The normal acidity of the urine is sometimes replaced by a neutral or acid reaction. This occurs chiefly after, 1. Digestion ; 2. The ingestion of alkalies or of vegetable acids (which are transformed in the blood into carbonates) ; 3. Ammoniacal fermentation of urea; 4. Admixture of blood or pus. Alkahnity of the urine has been observed, though not con- stantly, in various conditions—anemia, disease of the central nervous sys- tem, after muscular exercise and warm baths. The sediments peculiar to alkaline urine are the salts of calcium, magnesium, and ammonium, which are comparatively insoluble in alkaline liquids. Litmus paper reveals not only the alkaline reaction, but also distinguishes between the salts of calcium and magnesium on the one hand and of ammonium on the other ; for red litmus paper, turned blue by am- moniacal urine, soon regains its red color upon exposure to the air in con- sequence of the volatility of the ammonia ; while if the alkalinity of the urine be due to other bases than ammonium, the litmus retains its blue color. These salts appear to be retained in solution largely by the carbonic acid contained in the urine ; upon the application of heat, whereby this acid is expelled, the sediment is much increased. Another phenomenon manifested by alkaline urine appears to be also due to the escape of car- bonic acid, namely, the production of a variegated scum upon the surface. This scum is found to consist chiefly of phosphate of calcium, precipitated on the surface by the escape of carbonic acid. The appearance of the phosphates of magnesium and calcium in the sediment has no especial significance in alkaline urine ; their persistent occurrence in neutral or slightly acid urine is sometimes observed in various neuroses. The appearance in fresh urine of the triple phosphate (ammonio- magnesium phosphate) and the urate of ammonium, on the other hand, has great clinical significance, since these two salts occur almost exclusively in cases where urea is transformed into carbonate of ammonium in the bladder, i.e., cases of cystitis. Normal urine contains comparatively little ammonium, and it is only when an excess of this base is produced by the fermentation of urea that the formation of its salts in considerable quantity is possible. It must, however, be remembered that the triple phosphate is not found exclusively in cases of cystitis ; occasional crystals are observed in normal alkaline urine. URINARY SEDIMENTS. 113 Organized Sediments. 1. Epithelial Cells.—The epithelium lining the urinary and genital tract presents chiefly three varieties of ceUs : 1. Flat ceUs ; 2. Columnar and caudate cells ; 3. Round cells. Columnar and caudate cells are found in various sections of the urinary mucous membrane—the urethra, the bladder, the ureters, and the pelvis of the kidney ; hence their appearance in the urine cannot be traced to any particular portion of the tract unless attendant circumstances furnish a clew. In most cases fortunately such circumstances are present, either as characteristic features of the urine or as symptoms presented by the patient. It is rarely difficult to decide upon the origin of these columnar cells, except when the diagnosis rests between prostatitis and pyelitis, since in each condition these cells may appear accompanied by threads composed of pus-corpuscles. In pyelitis, the urine is found to contain albumen, more than the pus present should furnish, while in prostatitis albuminuria is not a symptom ; in pyelitis, furthermore, the urine is usually quite acid and often contains pointed rough crystals of uric acid. The fiat cells are derived either from the bladder or from the vagina. These cells from the bladder occur singly or in a single layer, while those from the vagina are larger, usually grouped, and in several layers. The round cells are derived either from the tubules of the kidney or from the deeper layers of the pelvis. Their original form in the tubules is not circular but polygonal; sometimes such cells are found in the urine, but in most cases the angles have been obliterated by the absorption of water. These round cells are often confused with the young, half de- veloped flat cells from the bladder ; in fact, it is practically impossible even for an expert to distinguish individual cells from these two sources ; it is only when the kidney cells occur in groups, thus presenting their polyg- onal form, that the recognition can be made with perfect confidence. Variations from the typical form of the epithelial cells are frequently seen ; this is especially true of the columnar cells, which often exhibit long caudate extremities on one or both sides. Such cells are often re- garded as indications of malignant new formation—" cancer cells." These unipolar and bipolar caudate ceUs are, however, normally produced in the pelvis of the kidney, in the bladder and urethra ; occurring individually they do not alone indicate a morbid growth. 2. Blood.—The admixture of blood with the urine is a frequent and often a perplexing symptom ; for it may be derived from any portion of the urinary tract as well as from the seminal vesicles or even the epididymis. In most cases hematuria is an evidence of a ruptured blood-vessel or of an ulcerated surface in the urinary tract; though in some few cases the blood- corpuscles seem to escape into the urinary channels by diapedesis, without any rupture of vascular walls. Clinically it is extremely important, though sometimes difficult, to de- termine the source and the cause of hematuria. Blood may escape into the urine— (1) From the urethra ; (2.) From the neck of the bladder (prostatic urethra); (3.) From the bladder ; (4.) From the ureter ; (5.) From the pelvis of the kidney; (6.) From the kidney; 144 DISEASES OF THE URINARY ORGANS. (7.) From the entire urinary tract; (8.) From the genital tract; (9.) From sources external to the urinary and genital mucous mem- branes. (1.) Bleeding from the urethra is a frequent occurrence during the course of gonorrhoea, and is occasionally observed in gleet, and from stricture. The diagnosis as to source and cause is easy, since the blood is mixed with pus. If the blood escape from some portion of the mucous mem- brane anterior to the membranous urethra, it escapes constantly and can be pressed out; if the source of the blood be in or posterior to the mem- branous portion, on the other hand, blood escapes only during the act of micturition, since the circular muscular fibres of the membranous urethra by their tonic contraction occlude the urinary channel. Bleeding may also occur from injuries by instruments, from forced coitus, and from polyps in the urethra. These tumors are probably re- sponsible for urethral hemorrhage more frequently than is generally sup- posed ; for the existence is seldom ascertained or even suspected during life, though post-mortem examination shows that they are not extremely rare. The writer observed a case of urethral hemorrhage which ceased entirely after the removal of four vascular polyps from the floor of the pendulous urethra. In a few cases bleeding from the urethra has occurred from the lodg- ment of urinary calculi and of foreign bodies, such as hairpins, in the channel. (2.) Bleeding from the neck of the bladder and the prostatic urethra usually occurs only at the end of micturition, and is seldom profuse. It occurs chiefly during catarrh of the prostate, a condition which is often observed in the fifth or sixth week of gonorrhoea, and is indicated by the necessity for frequent urination ; prostatitis and prostatic hemorrhage may also occur in those cases of paresis or dilatation of the bladder in which the constant use of the catheter is necessary. In cases of chronic prostatitis following gonorrhoea, blood sometimes escapes spontaneously at the end of urination, but is especially apt to follow the introduction of any instrument into the bladder. Another cause of hemorrhage from the bladder-neck is the existence of varicosities or "bladder-piles "in this locality. This condition is some- what infrequent, and is usually found in individuals who suffer also from rectal hemorrhoids. In a few cases it has been noticed that hemorrhage occurred alternately from the rectal and vesical varicosities (Ultzmann). Another unusual source of bleeding from the bladder-neck is the exist- ence of fissures at the vesical orifice. In one such case observed by Ultz- mann, the fissure was plainly visible upon endoscopic examination. Urinary concretions in the prostatic sinus, new growths and calculi at the neck of the bladder, may also induce hemorrhage from the prostatic urethra. (3.) Hemorrhage from the bladder occurs in cases of neoplasms, vesical calculi, parasites (bilharzia hemotobia and filaria sanguinis), cystitis, tuber- culous and diphtheritic ulcerations. (4) and (5.) Bleeding from the pelvis of the kidney occurs most fre- quently from the presence of kidney stones, tubercular inflammation, new growths, and parasites. (6.) Bleeding from the kidney is doubtless the most frequent source of hematuria. Foremost among the causes are the various forms of nephritis, and the renal congestion which occurs in so many infectious and constitu- URINARY SEDIMENTS. 145 tional diseases—smaU-pox, scarlet fever, measles, intermittent and recur- rent fevers, erysipelas, scurvy, purpura, etc. ; in fact, hematuria seems a possible result of a febrile condition from whatever cause. Obstruction to the renal circulation, venous congestion of the kidney, thrombosis of the renal vein, embolus of the renal artery are all known causes. Tuberculosis, cancer, abscess, and echinococcus of the kidney have been observed to produce hemorrhage from this organ. Renal hematuria has been observed after the ingestion of irritant sub- stances, such as cantharides, turpentine, mustard, and even quinine. In other cases it occurs in diseases of organs which are not intimately associ- ated with the kidney ; thus it has been observed in cirrhosis of the liver. Finally a few cases occur in which blood appears in the urine as the result of exposure to cold; this is a not infrequent cause of hemoglobinuria, though the cases in which blood-corpuscles escape from the kidney as a result of taking cold are as yet few. Greenhow observed four cases of paroxysmal hematuria with simultaneous rheumatic pains and a large amount of oxalate of calcium in the urine. Socoloff reports the case of a Russian officer who during eight years had occasional hematuria, which almost invariably foUowed exposure to cold; the case was especially in- teresting because the patient exhibited during the hematuria paresis and diminished sensibility of the left side, and complained of pain over the left kidney ; the sediment contained blood-corpuscles, blood-casts, and renal epithelial ceUs. Hematuria, perhaps with pain in the bladder and groin, is occasionaUy observed in hot weather, especially in persons not yet ac- climated in a given locality. Possibly this is caused by the concentration of urine from excessive perspiration, and consequent formation of smaU concretions. It is usuaUy relieved by alkalies. In a few cases renal hemorrhage is reported occurring apparently as vicarious menstruation; in one case a woman seventy-five years of age is said to have had irregular hematuria subsequent to the menopause, twenty- six years previously. (7.) Hemorrhage from the entire unnary tract occurs usually in cases ex- hibiting anomalies of the blood or blood-vessels. In most of these cases hemoglobin only escapes into the urine, while in some the sediment is found to contain not only the amorphous masses of hemoglobin but also distinct corpuscles. A more important class of cases is that in which hemorrhage foUows the complete evacuation of a dilated bladder; cases in which hypertrophy of the prostate, stricture, or paresis of the bladder has resulted in perma- nent distention of this organ with incomplete evacuation of urine. Such a condition is sooner or later followed by dilatation of the ureters, pelves, and tubules of the kidney ; this condition usuaUy exists for years before it becomes necessary to employ the catheter; if catheterization be in- cautiously performed, if the bladder be completely evacuated at one sit- ting, there occurs a congestion of the blood-vessels in the urinary mucous membrane in consequence of the removal of the accustomed pressure. This congestion often results in cysto-pyelitis and even nephritis ; in other cases severe capiUary hemorrhage occurs in the different portions of the urinary tract. (8.) Bleeding from the genital tract in the male is usually discovered by the admixture of blood with semen ; in some cases tuberculous or calcu- lous inflammation of the seminal vesicles causes an escape of blood which may appear in the urine. 10 146 DISEASES OF THE URINARY ORGANS. The urine of females often contains blood derived from the uterus or vagina, not only during the menstrual period, but also in the intervals. (9.) Blood is frequently mixed with the urine from sources external to the genito-urinary organs. In such cases there is usually inflammation or ab- scess in the vicinity of the urinary tract, such as perinephritis or psoas abscess. To determine the source of the blood which may be mixed with the urine, reliance must be placed chiefly upon the symptoms, and upon the microscopic examination of the sediment; the reaction, color, and specific gravity of the urine furnish presumptive though not conclusive evidence. The reaction of the urine is usually acid in hemorrhage from the kid- ney and pelvis, and alkaline in vesical hemorrhage, provided the latter proceed from an inflamed bladder. The color of the urine in cases of hematuria is usually either bright red, dark red, or nearly black. This difference in color indicates merely the length of time during which the blood has been in intimate contact with the urine in the body. For at the temperature of the body the bright red hemoglobin becomes oxidized by contact with the urine into the brown methemoglobin, causing a corresponding change in the color of the urine. This brown tint indicates, therefore, that the blood has been mixed with the urine quite intimately for some time ; since this mixture occurs in the kidney, and in parenchymatous hemorrhages, the brown color is usually found in cases of renal bleeding. Blood which escapes from the bladder-wall is retained such a short time that this change of color does not occur. In cases of parenchymatous hemorrhage from the bladder, such as results sometimes from cancer and stone, the blood may be so intimately mixed with the urine as to exhibit the change of color to brown. The specific gravity may also have some diagnostic value in determin- ing the source of a hemorrhage ; for in inflammation of the kidney and of the pelvis there is often polyuria with a correspondingly low specific gravity. Blood-clots are sometimes present and often indicate the source of the hemorrhage ; fresh clots are usually formed in the bladder or urethra, while clots of a brown or yeUowish color are of less recent origin and may have been formed in the pelvis or ureter. Long, rod-shaped clots of smaU calibre are formed in the ureters, indicating that the hemorrhage has oc- curred above these channels. The microscopic examination of the sediment enables us to distinguish parenchymatous (capillary) hemorrhage from that following rupture of larger vessels with comparative certainty, and since hemorrhage from the kidney is usually capillary, we can usuaUy distinguish renal hemorrhage from that from other sources. Capillary or parenchymatous hemorrhage is detected microscopicaUy chiefly by one characteristic feature—the varying size and color of the red corpuscles. In hemorrhage from a larger vessel, the blood-corpuscles ap- pear in the urine without greater variations in diameter than we are ac- customed to observe in freshly drawn blood ; after capiUary hemorrhage, on the other hand, the greatest diversity in size of the red corpuscles is observed, varying from the ordinary diameter down to mere granules. These smaller forms appear to be fragments of corpuscles disorganized by the long-continued contact of the urine. Many of the corpuscles have lost their color and are visible only by refraction at the periphery ; indeed by applying a weak solution of iodine we can in such cases often bring into URINARY SEDIMENTS. 147 view red corpuscles which had previously escaped notice. Friedreich first pointed out the fact that in cases of capiUary hemorrhage, the red cor- puscles in the sediment frequently exhibit amoeboid movements such as are often manifested by the white blood-corpuscles. It has been found that these movements are excited by contact with urea ; hence they are more frequently observed in concentrated than in dilute urines. Since capillary hemorrhage occurs more frequently from the kidney than elsewhere in the urinary tract, these amoeboid movements of the red corpuscles are most frequently if not exclusively observed in cases of renal hemorrhage. The most important characteristics for determining the source and cause of blood in the urine are, however, as already stated, not based upon the appearances of the blood itself, but upon the symptoms presented by the patient and upon the elements other than blood contained in the sediment. Thus in cases of hemorrhage from the kidney there are usually found blood-casts from the tubules as weU as renal epithelium. In such cases it can sometimes be determined that the urine contains a greater amount of albumen than should be furnished by the blood present. If the hemorrhage be caused by parasites—filaria sanguinis, echino- coccus, or bdharzia—evidence of their existence will be found upon careful search in the sediment. Hemorrhage from the pelvis, if due to renal stones, will usually be ac- companied by rough, pointed crystals of uric acid, and sooner or later by pus; if due to tuberculosis, the characteristic baciUi may possibly be found. Hemorrhage from the bladder is often accompanied by crystals of triple phosphate and urate of ammonia; if from the bladder neck, there may be found mucous casts from the prostatic glands containing pus-cor- puscles. In many cases assistance in diagnosis can be derived from the presence of peculiar epithelial ceUs. In cases of malignant formation, particles of the growth are often discoverable in the urine. 3. Pus.—The urine may contain pus derived from any part of the genito- urinary tract as weU as from abscesses external to this tract; thus ab- scesses around the bladder, the womb, the rectum, the kidney, in the psoas muscle, in the abdominal waU, in the hver and in the spleen, have been known to break into the pelvis of the kidney, the ureter, or the blad- der, and discharge their contents into the urine. The symptoms of the patient and the other elements present in the sediment must be relied upon to determine the seat of suppuration. The pus itself affords but little information in this regard ; if the pus-corpuscles are imbedded in mucus so as to make plugs or strings, it may be inferred that the pus is derived from the urethra or from the prostate as a sequel of gonorrhoea, though such threads are occasionaUy observed in cases of pyelitis. The form of the epithehal ceUs accompanying the pus may distinguish between the two sources. In ammoniacal urine pus is converted into a slimy, jelly- like mass, usuaUy miscaUed mucus. Tube-casts. Since the discovery by Henle (1842) that casts of the urinary tubules appear in the urine in various renal diseases, these cylinders have been the object of much study and attention. It was at first supposed that they consisted always of fibrin which had escaped from the blood-vessels during the inflammatory process and coagulated in the tubules; the different ob- 148 DISEASES OF THE URINARY ORGANS. Fig. 5.—Hyaline Casts, from Renal Congestion (Furbringer). jects often observed upon casts—blood-corpuscles, epithelial cells, and granules—were supposed to be merely entangled in the coagulating fibrin. The casts were regard- ed as positive proof of renal inflammation. Recent investiga- tions have, however, shown that casts arise in different ways, and that some varieties are formed and expeUed with the urine even when the kidneys are entirely free from in- flammatory action. Etiologically consid- ered, there are three varieties of cylinders: 1, blood-casts; 2, hya- line casts; 3, epithelial casts. 1. Blood-casts con- sist simply of blood which has escaped in- to the tubules and there coagulated; they are found only in cases where free blood-corpuscles are present in the urine ; hematuria of renal origin and acute nephritis usuaUy furnish these casts (Fig. 6). 2. Hyaline Casts.— Of these there are two varieties, the very deli- cate and transparent cyl- inders (Fig. 5) and the thicker and more opaque casts (Fig. 7). The lat- ter originate in the epi- thelial cells. The delicate trans- parent hyaline casts are homogeneous and glas- sy, sometimes contain- ing a few granules or epithelial cells, and usu- ally very narrow (.01 to 1 mm. in breadth). When studded with granules they may be mistaken by a careless observer for " granu- lar " casts—an error to be avoided, since the lat- ter are found only during renal inflammation. The true hyaline are readily distinguished from the granular casts by their extreme delicacy and transparency. Fig. 6.—Epithelial, Blood, and Granular Casts, from Acute Scarlatinal Nephritis. URINARY SEDIMENTS. 149 Fig. 7.—Epithelial, Amyloid, and Fatty Casts and Swollen Epithe- lial Cells, from Chronic Parenchymatous Nephritis. 3. Epithelial casts appear under three different and distinct forms, which have received different names, but whose significance depends upon the fact that they orig- inate in the epithelial ceUs. These are : sim- ple epithelial casts (Fig. 6); granular casts (Figs. 6 and 8); opaque hya- line and waxy casts (Fig. 7). WhUe these repre- sent the three types of epithelial cylinders, there are found numer- ous transitional and mixed forms (Fig. 7). The simple epithelial casts are composed of epithelial cells which have been detached from the basement membrane of the tu- bule and expeUed un- changed, so that the outlines of the individ- ual ceUs and often their nuclei are distinguishable The granular casts are formed by a metamorphosis of the epithelium, whereby the outlines of the ceUs and their nu- clei are but indistinctly if at all visible, the cells being replaced by mass- es of granules. These casts are often of irreg- ular outline, fissured, of a dark brown color, and thickly studded with dark granules. A still further meta- morphosis of the epithe- lium results in the pro- duction of the opaque hyaline casts. These are readily distinguished from the transparent hyaline casts (which are of different origin) by their thickness, opacity, strong refractive power, and frequently by a yel- lowish color. In a few cases they produce the amyloid reaction with iodine. These thick casts of waxy appearance are often fissured and frequently accompanied by masses of swollen epithelial cells. Fig. 8.—Finely Granular Casts and a " Cylindroid," from Acute Nephritis. 150 DISEASES OF THE URINARY ORGANS. Casts of all varieties may contain, entangled in their substance, various foreign elements, such as blood-corpuscles, individual epithelial ceUs, fat- granules and drops, bacteria, and various urinary salts, amorphous or crys- talline (urates, uric acid, calcium oxalate, etc.). The term cylindroid has been applied (Thomas) to very long and nar- row casts, which are, however, really mere modifications of the delicate hyaline casts (Fig. 8). Origin of Tube-casts.—The transparent hyaline casts are composed sim- ply of coagulated albumen which has undergone some as yet unknown modification, since they exhibit reactions different from those shown by serum albumen, globulin, and fibrin. They are formed entirely from the serum of the blood, and may therefore appear in the urine in any case in which serum albumen is found, even though there be no disease of the kidney whatsoever. Weissgerber and Ribbert have produced hyahne casts experimentally by simple pressure upon the renal vein or occlusion of the renal artery; they are also produced by such artificial elevation of temper^ ature as suffices to cause albuminuria. Under these circumstances the epithelium of the tubules exhibits no abnormal appearance, but their lumina become fiUed with finely granular albumen, which after a time is transformed into perfectly hyaline casts of the tubules. These experimental researches are in perfect accord with the clinical observation that hyaline casts may appear in the urine during any of those conditions already enumerated which induce albuminuria independent of renal disease ; hence alone they do not constitute the slightest evidence of Bright's disease. The epithelial, granular, and opaque hyaline casts are composed of the epithelial cells of the tubules, either unchanged or (in the two latter va- rieties) metamorphosed. In the first-named variety the outlines of the cells and nuclei are distinctly visible. In many casts of epithelial origin, however, the ceUs coalesce into a finely granular mass in which the con- tours of cells and nuclei are nearly or quite obliterated (granular casts). At a later stage the mass becomes hyaline from the periphery and may ultimately appear homogeneous and glassy throughout (opaque hyaline casts). Indeed, the transformation from distinct epithelial cells to a glassy, homogeneous mass appears to occur directly in some instances. This meta- morphosis of the epithelial ceUs in the urinary tubules during inflammation is analogous to the transformation which occurs in the epithehum of mu- cous surfaces during croupous inflammation. Epithelial casts, properly speaking—those which originate in detach- ment of the tubular epithelium during inflammation—comprise, therefore, not only those in which epithelial cells can be distinctly outlined, but also those which are commonly termed granular and waxy cylinders. Since different casts even of the same variety vary much in diameter and in shape, it has been supposed that they could be traced to different por- tions of the tubules by these features; that the broad casts were formed in the wider portions of the tubules and the spiral casts in the convoluted tubules. There is, however, no ground for such assumption ; there is, in- deed, no means for identifying the particular portion of the tubule from which a given cast has been derived, unless distinct epithelial ceUs are at- tached. Probably most casts are formed originally in the convoluted tubules. It has been asserted that so-called " secretion casts " are produced in normal kidneys by the exudation of plasma from the tubular epithelium. This certainly occurs in certain non-inflammatory conditions of the kidney, URINARY SEDIMENTS. 151 where the urine contains an excess of urates or has a high specific gravity (1030 or more) but no albumen ; possibly this exudation is caused by ir- ritation of the tubular epithelium. These cylinders are generaUy included under the name "mucous casts," though most of the objects so caUed are casts of the spermatic tubules. Amyloid casts seem to arise either from hyaline or from epithelial cylin- ders ; they are found in cases of nephritis as well as in pure amyloid de- generation of the kidney. They do not, therefore, necessarily indicate a degeneration of the epithelium, though found also, as already stated, in cases where such degeneration has occurred. Fatty casts are either hyaline or epithelial casts which are studded with oil-globules produced by fatty degeneration of the renal epithelium ; they are usually derived from the cells of the tubules, and hence are properly included in the group of epithelial casts. Mucous casts is a term applied to objects derived from several sources. Under this head have been described : 1, cylindroids, which are really ex- tremely long and slender hyaline casts; 2, secretion casts, which are formed (probably from an exudate of the epithelial cells) in the tubules of normal kidneys, especially under the influence of irritation by urinary salts ; 3, most of the so-called mucous casts are derived not from the kidney at all, but from the spermatic tubule. AU these varieties, generally termed mucous casts, are remarkable for their extreme length, transparency, and shght refractive power. The clinical significance of tube-casts varies according to the variety and number present, as has been already indicated. Transparent hyaline casts do not necessarily prove the existence of Bright's disease, since they may be found in any case of albuminuria from whatever cause, indepen- dent of renal disease. They are found in the urine in febrile conditions, in obstruction to the systemic circulation such as occurs in diseases of the heart and lungs, in cases of long-continued or intense excitement, etc. They are also found in cases of actual disease of the kidney, especially in cirrhosis of that organ and in the acute nephritis which follows scarlatina and other infectious diseases. The presence of epithelial casts, on the other hand—the term including the granular, fatty, and broad opaque hyaline varieties—indicates a disin- tegration of the renal epithehum, and therefore nephritis. An opinion as to the degree and duration of renal inflammation can be based upon the number and kinds of casts present, especiaUy when taken in connection with the history and symptoms. The number of casts de- pends largely upon the amount of urine excreted, for oliguria is frequently accompanied, either as cause or result, by a retention of the casts in the tubules. It is quite probable that the rapid formation of numerous casts in the kidney may materially diminish the excretion of urine. Free diuresis, on the other hand, is usually accompanied by the expulsion of numerous casts. In acute nephritis blood-casts, epithelial casts with weU-defined cells and nuclei, and broad opaque hyaline casts are especiaUy numerous; in the chronic forms, the granular, hyaline, and fatty casts predominate. The other morphological elements found with or upon the casts are also significant; thus numerous leucocytes are found during acute inflamma- tion, large drops and masses of fat during chronic nephritis, etc. In most cases in which epithelial, granular, or hyaline casts are found in the urine, albumen is also present. Yet it is a fact of the utmost clinical impor- tance that disintegration of the renal epithelium resulting in the forma- tion of casts may occur without albuminuria ; the absence of albumen does 152 DISEASES OF THE URINARY ORGANS. not, therefore, prove the absence of renal disease. Thus in cases of ne- phritis following scarlet fever, it is not rare to find hyaline and epithelial casts without a trace of albumen in the urine ; and in cirrhosis of the kid- ney granular and hyaline casts are sometimes seen even when the urine is entirely free from albumen. In other cases hyaline casts are observed in non-albuminous urine, apparently without renal disease, or at most with hyperemia of the kidney. This is frequent in cases of icterus (VaUin); indeed, Nothnagel discovered that casts appear in every case of intense icterus in which the urine contains the biliary acids, though in many of these instances no albumen is present. Experimentally it has been demon- strated that the injection of the biliary acids into the circulation causes the formation of tube-casts, with or without albuminuria. Fischl has often seen casts in the urine, usually of the hyaline though sometimes of the epi- thelial variety, during ordinary intestinal catarrh ; in many cases no albu- men was discovered. This disintegration of the renal epithelium without albuminuria has been observed experimentaUy as weU as clinically ; it has been produced by the injection of biliary acids and by the introduction into the circulation of renal irritants such as cantharides and turpentine (Schachowa). These substances are known to cause necrosis of the epithelium in the convoluted tubules without at first affecting the glomeruli; herein lies doubtless the explanation of the appearance of epithelial casts without albuminuria. Besides the tube-casts proper, there are found in urine masses of ma- terial resembling them in shape and size, because moulded in the urinary tubules ; some of these may be produced independently of renal disease, though often combined with genuine casts of renal origin. Uric acid and urates are often observed in the urine in the form of tube-casts. In most of these cases this form is of artificial origin, caused by the roUing of the cover glass over the shde during the preparation of the sediment. In nursing children, however, who are known to suffer from uric acid infarct of the kidney, these cylinders are evidently produced in the tubules. They are composed of reddish-brown granules and baUs, sometimes as large as blood-corpuscles, imbedded in a mass resembling mucus. Casts of biliary pigment are sometimes seen in cases of icterus caused by occlusion of the bUiary ducts. Mobius found by the examination of kidneys in such cases that the glomeruli were always free from bil- iary pigment, but that the epithehum of the convoluted tubules and of Henle's loops was filled with granules of bde pigment; he observed, fur- thermore, in the lumen of the tubules numerous cylinders of a roughly granular appearance, composed of biliary pigment. This fact explains the clinical observation that in such cases oliguria and even anuria may occur —the result evidently of the plugging of the urinary tubules by the biliary pigment. These casts of bile pigment often appear in the urine without albumen; sooner or later, however, albuminuria usuaUy occurs in these cases, accompanied by hyaline and even epithelial casts in the sediment. Casts composed of bacteria, or thickly studded with these organisms, are often found in cases of suppurative nephritis (surgical kidney) and of pyemia ; in a few cases of erysipelas and diphtheria also they have been seen. In these cases the appearance of bacteria in the form of tube- casts is quite comprehensible, since the organisms are found in the blood and in the kidneys during these diseases. Recently Litten has described two cases in which the occurrence of casts composed of bacteria is not so easily explained. URINARY SEDIMENTS. 153 The first case was that of a girl nineteen years of age who had previously enjoyed good health. After slight indisposition for several days she sud- denly exhibited severe abdominal symptoms—pain, vomiting, and profuse diarrhoea accompanied by chills and fever (the temperature re aching 41° C.) ; the urine became very scanty, 100 to 200 c.c. daily, and contained much albumen and remarkably broad casts studded with micrococci. Death occurred in three days from uremia. The section revealed enlarge- ment, congestion, and cloudy swelling of the kidneys ; microscopically there were observed irregular local dilatations of the tubules in both cortical and medullary substance. These dilated tubules contained masses of micrococci; the epithelium was in many places fiUed with the same organisms. Similar masses of bacteria were found in the capsules and capillaries of the glomeruli and in the vasa afferentia ; there was, in ad- dition only a slight interstitial nephritis. Litten observed a second case with essentially similar history. Casts from Organs other than the Kidney.—There are frequently found in the urine microscopic cylinders resembling in their general outline those formed in the renal tubules ; these are derived either from the pros- tate or from the testis. Prostatic casts are found occasionaUy in cases of chronic catarrh of the prostate subsequent to gonorrhoea. They are moulds of the prostatic follicles, usually much broader than the renal casts, and commonly studded with pus-corpuscles ; they occur in groups and are accompanied with epi- thelial ceUs from the prostatic urethra. Their composition appears to be simply mucus. Casts of the seminal tubules are occasionaUy encountered in the urinary sediment. They can often be recognized at once by the fact that sper- matozoa, or fragments of them, are found imbedded in the casts ; otherwise they may be caUed mucous casts from the kidney. They are very long, transparent, and dehcate. Spermatozoa.—These ceUs are found in the urine not only after coition, pollutions, and in spermatorrhoea, but also after epileptic seizures. In spermatorrhoea there are occasionaUy found partly developed spermatozoa. Urine which contains semen sometimes exhibits also minute bodies which resemble grains of sago ; these are masses of albumen derived from the seminal vesicles. Fragments of Morbid Growths.—New formations in the bladder and urethra can occasionaUy be recognized by the discovery of fragments in the urine ; neoplasms of the kidney and pelvis, on the other hand, are rarely revealed in this way. Extreme care must be exercised in deciding upon the origin of indi- vidual ceUs found in the urine ; in fact, it is practically impossible to recognize any single ceU as a so-called " cancer cell." For the normal epithelium of the urinary tract furnishes cells of great diversity in shape and size ; caudate and spindle ceUs are present normaUy in the ureter, urethra, and bladder. If many of these be present, remarkable for their large size and atypical shape as weU as for the size and number of their nuclei, a suspicion of a morbid growth may be entertained if the symptoms corroborate such assumption. Yet such great diversity of size and shape of the epithelial cells is witnessed during a simple inflammation of the bladder, that great reserve must be exercised in basing an opinion upon such data. It is quite otherwise, however, when fragments of neoplasms are found in the urine. These may be derived from a cancer or from a papilloma (villous cancer) of the bladder. In the case of carcinoma, fragments of the 154 DISEASES OF THE URINARY ORGANS. tissue appear in the urine only after ulceration has begun, by which time the symptoms and the persistent hematuria have usually rendered the diagnosis almost certain ; it occasionally happens, however, that the symp- toms are so obscure as to puzzle even the experienced surgeon until a piece of the growth is observed. Fragments of papilloma, on the other hand, are often obtained early in the course of the disease; indeed, it has repeatedly happened that by the introduction of a catheter a piece of an unsuspected papiUoma has been withdrawn. This growth presents under the microscope a character- istic appearance, resembling a tree in its outline ; each branch consists of a broad blood-vessel upon which rests a single layer of columnar epithelium. Entozoa.—Four animal parasites of the body occasionally give evidence of their presence by the appearance of the sediment. These are : 1. Echinococcus ; the hooks and even fragments of the enclosing sac may appear in the urine when a cyst located in or near the kidney has burst into the pelvis. 2. Strongylus gigas, a nematode worm, occasionaUy makes its home in the human kidney, though it is far more frequently found in the kidney of the dog. In a few rare instances the eggs and even the adult worms are said to have been found in human urine. It is probable, however, that the diagnosis was erroneous, the worm having been actually an ascaris from the rectum, which much resembles in appearance the strongylus. The latter is distinguished from the ascaris by the possession of six papille around the mouth, while the ascaris has but three. 3. Distoma haematobium, or bilharzia hcematobia, is a trematode which makes its home in the veins of the pelvic organs, especiaUy the bladder and the rectum. The parasite lays numerous eggs in these vessels whereby the vascular channels are occluded, causing hemorrhage and ulceration. It is found almost exclusively in Africa, especially in Egypt; cases in which it has been observed in America appear to be exclusively individuals who have resided in Africa. Such a case came under the writer's observation in February, 1883, in which the urine contained nu- merous eggs and much blood. 4. Filaria sanguinis hominis appears in the urine soon after entering the body. At first the only symptom to direct attention to the urine may be hematuria ; after a time chyluria occurs, the urine now containing masses of fibrin which may seriously impede the evacuation of the bladder. If these masses of fibrin passed during the night be separated into frag- ments and examined microscopically, one or more of the embryo worms can usually be found ; sometimes specimens are observed disentangled from the fibrin and blood. This parasite also appears to be indigenous to tropical countries; it has been found in India, China, Egypt, Brazil, and Australia. But few cases have been observed in Europe and America, and these exclu- sively in persons who have resided in one of the countries named. In addition to these four worms which are parasitic in the urinary organs or in the blood, other animals occasionally find their way into the urinary organs and are discharged with the urine. The most frequent of these is perhaps the thread worm so common in the rectum during childhood ; these not only drop into the vessel, but may even crawl into the urethra in the female. In other cases abnormal communication is formed between the intes- tine and the bladder, through which worms inhabiting the former organ find their way into the urine. One such case is reported in which an in- dividual had several times observed worms issuing from his urethra. At URINARY SEDIMENTS. 155 the age of twenty-eight he was operated upon for stone, and died five days later. The section showed that the vermiform appendix had become ad- herent to the bladder and that a fistula existed between the two organs, closed by a valvular fold of mucous membrane. Fungi.—After exposure to the air there are often found in urine several varieties of fungus, chiefly the yeast or sugar plant and the penicillium glaucum. They are especially prone to develop in slightly acid, concen- trated urine. The sugar fungus occurs with especial frequency in saccha- rine urine, merely because the presence of the sugar renders the urine a favorable soil for the growth of the plant. So far as is at present known, these fungi are never present until after the urine has left the body ; they occur more frequently in albuminous than in non-albuminous urine. Quite otherwise, however, is the significance of the sarcina urine. This fungus, like the sarcina ventriculi, occurs in groups of two, four, eight, etc., but is smaller than its namesake from the stomach. It is seen but rarely in the urine, but when present evidently proceeds from the bladder, where it often occasions a troublesome and obstinate affection. The plants grow in the bladder for weeks or even months, in spite of aU treatment, but finaUy disappear from causes as yet unknown. The patient meanwhile suffers from a low grade of cystitis ; the urine presents a thick flocculent sediment, containing the organisms. Attempts to plant sarcine in the bladders of healthy dogs and rabbits by injection into the bladder and into the jugular vein have always failed (Welcker, Leube). There must evidently be some influence which predisposes the urine and the bladder for the reception of these organisms. In some cases reported the catheter had been previously employed, so that there was a possibility that the plants had been introduced into the bladder in this way ; in other cases no instrument had ever been introduced into the bladder, so that the mode of access of the sarcina remained unexplained. Bacteria.—These organisms, hke the other fungi already mentioned, are found in urine after it has been exposed to the air for a short time. Since they are present in the body during many pathological conditions, and since they are usuaUy so smaU as to pass readily through capillary waUs, they often enter the urine before it leaves the body. They have been found in freshly voided urine in the foUowing conditions: In various infectious diseases accompanied by the presence of bacteria in the blood and tissues ; thus the characteristic bacilli have been found in the urine in cases of anthrax, the spirilla of Obermeier in relapsing fever, micrococci in the various forms of septic infection—pyemia, diphtheria, ulcerous endocarditis, etc. In most cases these organisms seem to have passed from the blood through the glomeruli into the tubules, and appear scattered in the urine. In many cases of septic infection, however, the micrococci are found in masses, usually in the shape of tube-casts, showing that they were growing rapidly in the tubules. Microscopic examination of the kidneys from such cases proves that micrococci frequently invade the tubules as weU as the vessels of the kidney. In the majority of diseases already referred to, the diagnosis is easily made without an examination of the urinary sediment; but a few cases are on record in which an invasion of the kidneys by micrococci has occurred without inducing characteristic symptoms, and in which the diagnosis has rested upon the appearance of bacteria in the shape of tube-casts in the urine. Reference has been already made to two recent cases reported by Litten. In the pathological conditions already discussed, the bacteria are car- 156 DISEASES OF THE URINARY ORGANS. ried to the kidney in the blood ; there is, however, a class of cases in which they gain access to the kidney by continuous growth from the blad- der along the ureter. Such are cases of surgical kidney or suppurative nephritis, foUowing operations upon the bladder and urethra, or conse- quent even upon the simple introduction of a catheter into a chronically distended bladder. In these cases, too, the invasion of the kidney by bac- teria is indicated by the appearance of casts composed of these organisms in the urine. There is, moreover, a class of cases in which bacteria are constantly present in the bladder, where they have been introduced by means of cathe- ters. So long as the vesical mucous membrane retains its normal con- dition and the bladder evacuates itself completely, ordinary bacteria at least do not find a favorable sod for propagation in this organ. Many observers have repeatedly injected fluids containing ordinary bacteria, even putrid hquids, into the bladders of healthy animals; but in every case these liquids and the contained bacteria have been promptly expelled without causing inflammation. It is quite otherwise, however, if the blad- der fail to evacuate itself completely, so that a certain amount of urine is always present in the organ ; for the bacteria of putrefaction, introduced under such conditions, find a favorable sod in the stagnant urine and propagate within the bladder. Thus it happens that in cases of elderly men who in consequence of prostatic hypertrophy, vesical paresis, or other cause, fail to evacuate the bladder completely, the urine soon becomes turbid after the introduction of the catheter. This turbidity is due to the presence of bacteria which are introduced with the unclean instrument and establish themselves in the stagnant urine of the bladder. In this way a previously existing cystitis is aggravated, or an inflammation is induced where none existed prior to the introduction of the instrument. In a few cases Roberts and Furbringer have seen an inexplicable "bac- teruria." The urine contained great numbers of these organisms, whose source could not be ascertained; it emitted an offensive odor, but retained its acid reaction an unusually long time. The complaint, often accom- panied with temporary irritability of the bladder, lasted intermittently for years. Bacillus of Tuberculosis.—This organism has been repeatedly found in the sediment from cases of tuberculous disease of the kidney and pelvis. If present the bacilli are found in the pus derived from these tuberculous lesions ; a drop of the sediment is prepared upon cover-glasses in the same manner as sputum.1 The unanimous experience of all investigators, clinical and pathological, has shown that these baciUi are never found in lesions other than tuber- culous ; hence the presence of these organisms in the urine may be re- garded as absolute proof of tuberculous disease in the urinary or genital tract. The exact location of the lesion must, of course, be determined by the other characters of the urine as well as by the symptoms of the patient. While the presence of the bacilli proves tuberculosis, it is not true that their absence excludes tuberculosis. It has been already discovered that in many miliary tubercles no baciUi can be detected : indeed, cases of tuberculosis are on record in which competent observers have failed to find the bacilli anywhere in the tissues. Hence it may be inferred that tuberculosis of the genito-urinary tract may exist without the occurrence 1 For particulars, see author's Cartwright Lectures for 1883, p. 126. W. T. Keener, Chicago. URINARY SEDIMENTS. 157 of baciUi, at least in discoverable numbers, in the urine. My own experi- ence supports this inference ; for in two cases in which the symptoms and the urine indicated tuberculosis of the bladder-neck, I was unable to de- tect the organisms in the sediment, although I had considerable experience in the requisite manipulation, and had often discovered them in sputum, tissues, and pus from other sources. Leptothrix, a fungus which seems to belong to the family of bacteria, has been in two cases found in freshly voided urine. In one instance, ob- served by Kussner, the patient was a diabetic whose urine contained brownish masses composed of leptothrix threads enclosing epithehal ceUs from the bladder. This phenomenon persisted some weeks, until death ; the section showed a normal bladder containing similar masses of lepto- thrix threads. No information as to their mode of ingress was obtained. In the second case the fungus was derived from the preputial sac, where a mass of the threads was discovered. Accidental ingredients of various kinds are often observed in the urine. Some of these are intentionally introduced by hysterical patients ; indeed, such individuals sometimes deceive the physician by introducing blood as weU as foreign bodies into the urine. In examining the urine from a female the possibility should always be borne in mind that blood, pus, and epithelium observed may be derived from the vagina. Abnormal communication between the urinary tract and various organs sometimes permits the entrance of foreign bodies into the urine. GaU- stones have been found in the bladder and voided with the urine, having entered the urinary tract through a fistula from the intestine or from the biliary duct. Giiterbock recently performed lithotripsy and found that the nuclei of the stones were bihary calcuh. Hairs have been occasionaUy voided with the urine. These are derived from various sources, being sometimes intentionaUy introduced into the bladder (by women) ; in other cases the hairs have been derived from dermoid or ovarian cysts which had opened into the bladder; in these in- stances other animal tissues, such as teeth and bones, have also been evac- uated with the urine. Martini recently observed a new-born child with atresia of the urethra and anus; the posterior wall of the bladder pre- sented the structure of normal skin and was provided with fine hairs ; Martini regarded the case as one of superfoetation. There is as yet no case recorded in which an otherwise normal bladder produced hairs. CHAPTER XVII. CLINICAL EXAMINATION OF THE URINE. As ordinarily practised, even in the examination of applicants for life insurance, the analysis of the urine includes little more than the determina- tion of reaction, specific gravity, and the presence or absence of albumen and sugar. Such an examination is always incomplete and often misleading ; for it frequently fads to reveal abnormality of the kidneys or other organs which are actually present, and, on the other hand, often leads to a diag- nosis of renal disease or diabetes where none actuaUy exists. Now a thorough examination of the urine, quantitative as well as quali- tative, is, of course, too complicated and delicate a process for ordinary chnical use ; yet by a judicious use of a few ordinary reagents a far more accurate and intimate knowledge of a patient's condition can be derived from the urine than is usually obtained. Even without the microscope many pathological conditions, both of the kidneys and of other organs, can be recognized or at least strongly suspected. The following method of examination is used by the writer in ordinary chnical work. While it makes no pretensions to mathematical accuracy nor to quantitative completeness, it nevertheless furnishes aU the information re- quired for diagnostic and prognostic purposes, and can at the same time be executed so easily and speedily that it is perfectly practicable for clinical use. When possible, the specimen for examination should be mixed urine— that is, should be taken from the entire quantity passed during twenty-four hours. Since this is often impracticable, at least two specimens should be obtained on each day, one passed upon rising in the morning and the other voided during digestion at noon or night. The latter specimen, it should be remembered, may contain albumen, though none is found in the urine at other times. The urine secreted during digestion should be neutral or alkaline; decided acidity of such urine indicates an abnormally acid excre- tion. Before conclusions are drawn, however, the physician should assure himself that the bladder has been emptied shortly before digestion began. He should also inquire whether the patient is taking medicine or drinking mineral waters which may materially influence the character of the urine. In many cases it is desirable to have the urine passed at one urination into two different vessels ; an ounce or two, first passed, should be received into one vessel while the remainder is voided into a second. In this way we are often enabled to locate an existing suppuration, hemorrhage, or catarrh in the urethra or at the neck of the bladder. If it be desired to obtain the urine unmixed with the secretions of the bladder and urethra, a soft catheter may be introduced and the bladder thoroughly and re- peatedly washed out, after which the urine that escapes through the catheter is comparatively free from the undesired admixture. If the urine be turbid, the turbidity should be removed (after its cause CLINICAL EXAMINATION OF THE URINE. 159 is ascertained) before applying chemical tests. A turbidity due to urinary salts, pus, and epithelium can be removed by simple filtration. A cloudi- ness due to bacteria which cannot be removed in this way can often be cleared up by shaking the urine with magnesia usta, or with a solution of lead acetate—one part to eight of water—and filtering or permitting the precipitate to fall. The lead also precipitates the sodium chloride and causes the urine to simulate the sugar reaction with caustic potash (Heller's test). For microscopic examination the urine should be permitted to stand twelve to twenty-four hours in an ordinary bottle ; the conical glasses so much employed are undesirable, since much of the sediment adheres to the sloping sides. If immediate examination be necessary, the sediment may be coUected by filtering through fine paper. The examination of the urine includes : A. The determination of the quantity excreted in twenty four hours. This amount should be ascertained not for one day only but for each of several days at intervals. B. The reaction and color. C. The cause of the turbidity, if any exist. D. The specific gravity. This has often but little value unless the quantity of urine excreted in twenty-four hours is known. E. The appearances produced by contact of nitric acid. This acid re- veals : 1, albumen; 2, excess of urates; 3, excess of urea ; 4, excess of indican ; 5, biliary pigment; 6, blood-pigment; 7, vegetable coloring mat- ters ; 8, iodine ; 9, excess of carbonates ; 10, propeptone. F. Effects of heat. This alone reveals: 1, albumen; 2, earthy phos- phates. G. Effects of caustic potash and heat. This combination reveals: 1, sugar; 2, bdiary pigment; 3, blood-pigment; 4, vegetable coloring mat- ters ; 5, uroerythrine. By these simple means—litmus paper, a urinometer, nitric acid, heat, and caustic potash—we can speedily and conveniently detect any ab- normality of the urine of chnical importance, so far as this can be done without the microscope. It is of course necessary, in case certain abnormal features are discovered—such as the presence of sugar or blood—to employ confirmatory tests. A proper interpretation of the results obtained by the reagents above mentioned depends upon the following facts : A. The quantity of urine excreted in twenty-four hours taken in con- nection with the specific gravity furnishes valuable information. Polyuria, with a low specific gravity (1010, for example), may result from transient causes such as the ingestion of large quantities of water; it is also ob- served in cases of hysteria, of diabetes insipidus, of pyehtis and cirrhotic kidney. Persistent polyuria with high specific gravity is rarely found ex- cept in diabetes. Oliguria with high specific gravity is the rule in febrile conditions in cases of diarrhoea or profuse perspiration. Oliguria with low specific gravity is usually, when persistent, indicative of chronic nephritis. By means of the specific gravity and the quantity of urine we can esti- mate with considerable accuracy the total solids and the urea excreted. The last two figures of the specific gravity are multiplied by two (if below 1.018) ; if 1.018 or above, by 2£. The product represents the total solids in grammes contained in 1,000 c.c. (32 ounces) of urine. Thus if a patient pass 40 ounces (1,200 c.c.) of urine in a day, specific gravity 1,020, the estimation of the solids is made as foUows : 20 x 2^=17, 160 DISEASES OF THE URINARY ORGANS. the number of grammes in 1,000 c.c. of urine; in the total quantity, 1,200 c.c, there are of course contained -| of 47, or 56 grammes. Since the urea usually constitutes by weight about one-half of the entire solids of the urine, this calculation furnishes an approximate es- timate of the amount of urea excreted, which would be in the above case 28 grammes. B. The color and reaction of the urine are noted together, since the significance of the color is often explained by the reaction. Pale, almost colorless urine of neutral reaction is often excreted during various neuroses, especially hysteria. Dark yellow or reddish-yellow urine, of acid reaction, is usually ob- served during febrile conditions. Dark brown or reddish-brown urine, of acid reaction and transparent, contains hemoglobin ; if of neutral or alkaline reaction and turbid, it con- tains blood or biliary pigment. A similar appearance may be caused by the excretion of carbolic acid by the kidneys. Bright red urine of alkaline reaction usuaUy contains not blood but vegetable coloring matter, especially chrysophanic acid derived from rhubarb or senna ; the addition of an acid changes the color to yeUow ; an excess of an alkali restores the red color. A simdar reaction is produced by santonin, gamboge, madder, and logwood. A dark brown or almost black color is sometimes observed in cases of melanotic cancer. Dirty green urine is excreted during jaundice from obstruction ; the reaction varies. Dirty blue urine, of acid reaction, usually contains an excess of indican. Many urines, especially those of chddren, exhibit a gradual darkening in color upon standing for a few hours ; the cause of this phenomenon is unknown. C. Turbidity of the urine is caused by urates, phosphates, blood, pus, mucus, or bacteria. Heat dissolves the urates. The addition of a few drops of acetic acid dissolves the phosphates. Turbidity caused by blood or pus is unchanged or increased (through coagulation of albumen) by heat or an acid. A cloudiness due to bacteria is persistent. E. The application of nitric acid is a most important item in the ex- amination, and no less important is the manner in which the acid is intro- duced. A test-tube containing urine to the depth of two inches is held obliquely, and pure nitric acid is permitted to flow down the side until it forms a layer half an inch in depth at the bottom of the tube. The zone of contact of urine and acid presents different appearances according to the composition of the urine : A light brown color is seen in normal urine. A more intense brown color is observed in concentrated and in febrde urine. A white cloud indicates either albumen, propeptone, urates in excess or resins (copaiba, etc.). The distinction between these is simple ; the cloud of albumen appears just at the line of contact between acid and urine, and is of uniform depth throughout. The cloud of urates is formed a little above the surface of the acid; it appears only after the lapse of some seconds, and forms not a ring of uniform thickness but a cloud which curls upward at the centre somewhat like ascending smoke; it disappears upon warming. The resins disappear at once upon the addition of a little CLINICAL EXAMINATION OF THE URINE. 161 alcohol. Propeptone forms a cloud resembling albumen, which disappears, upon heating to 170° F., with the production of an intense yellow color ; upon cooling the precipitate reappears. It is dissolved in an excess of acid. A reddish-brown ring at the line of contact indicates blood-coloring matter ; in most cases albumen is of course also present, so that there is formed a reddish-brown cloud. A bright green ring is produced by bdiary pigment before it becomes oxidized. A brilliant blue or violet results from an excess of indican. A brown zone is produced if the urine contain iodine. An excess of urea (four or five per cent, or more) is indicated by the gradual formation, in the course of three to five minutes, of crystals which project into the layer of acid, and are thus distinguished from the cloud of urates, formed under similar circumstances, which are visible above the acid. An excess of carbonates, such as may occur from the use of mineral waters, is indicated by sparkling or even effervescence. If upon the addition of the acid a bright-red alkaline urine becomes colorless or yellow, the presence of vegetable coloring matters is indicated. After neutralizing with an alkali the red color returns. By means of nitric acid we can not only detect the presence of al- bumen, but also estimate with considerable accuracy the quantity present. This quantitative estimation is based upon the appearance of the cloud at the line of contact: A faint white ring, distinctly visible only against a black background (such as the coat-sleeve), indicates from'one-tenth to one-fourth per ceni of albumen. A distinct white ring, easily seen without a black background, exhibit- ing numerous granules and small lumps, indicates from one-fourth to one- half per cent, of albumen. The presence of large lumps and flakes, some of which fall to the bottom of the tube through the acid, indicates from one-half to two per cent, of albumen. The quantity rarely exceeds two per cent, except in cases of amyloid kidney or acute nephritis. This method of estimating the quantity of albumen present in the urine is extremely simple and convenient for clinical purposes, and fairly accurate. F. Effects of heat. Urine is poured into a test-tube to the depth of two inches; if neutral or alkaline, two or three drops of acetic acid are added. The reaction .should be faintly acid. A white cloud observed upon boiling may be albumen or earthy phos- phates and. carbonates ; the latter are redissolved upon the addition of a few drops of acetic acid. A previous turbidity may disappear upon warming, in which case it was due to the urates ; if it increase, it is due to the phosphates or to blood, pus, or mucus ; if it remain unchanged it is due probably to bacteria. G. A solution of caustic potash (one part to three of water) is added, in quantity sufficient to equal one-half the bulk of the urine in the test-tube. Upon boiling, a heavy sediment falls, consisting of the earthy phosphates ; in normal urine this sediment is about one centimetre thick, if the urine have been poured in to the depth of two inches. A white appearance of the phosphates occurs in normal urine. A red or violet color of the sediment indicates vegetable coloring mat- 162 DISEASES OF THE URINARY ORGANS. ters, usually chrysophanic acid. If brown, the urine may contain bile-pig- ment. A gray color indicates uroerythrine. A rust color is produced by blood. The color of the supernatant urine after boiling with the caustic pot- ash solution may be as significant as the color of the sediment. A yellow, yellowish-brown, or blackish-brown shade indicates sugar. It is found that sugar to the amount of one per cent, causes the urine to assume under these circumstances a canary color ; two per cent., a dark amber color ; five per cent., a Jamaica-rum color; and five to ten per cent., a dark, almost black color, so intense that the urine no longer appears transparent. The addition of a few drops of nitric acid bleaches this dark urine and causes it to emit an odor of molasses. This color-test for the presence of sugar is usually applicable, since the original color of the fresh urine in cases of diabetes is generally very light. By means of heat, nitric acid, and caustic potash, therefore, any ordinary abnormal ingredient dissolved in the urine and possessing chnical signifi- cance can be detected. A positive result by these reagents should be confirmed by special tests ; if no indication of abnormality is furnished, the physician may confidently dispense with further tests and pass on to the microscopical investigation of the sediment. Tests for Sugar.—The ordinary tests for sugar are so cumbersome that they are rarely employed in practice unless a suspicion of diabetes is entertained; and they are so liable to mislead, in consequence of the dis- turbing influence of various urinary constituents and the instabdity of the tests, that the results obtained are often incorrect. The popular copper test is among the least reliable, since the solution decomposes and gives a reaction with an excess of uric acid ; moreover, it fails to detect glucose when the amount is less than one grain to the ounce. There is therefore a large field for a sugar test which is at once delicate, reliable, and stable. Such a reagent seems from present indications to have been found in the Picric Acid Test.—When picric acid is heated in an alkaline solution of glucose, picramic acid is formed, giving to the liquid a deep reddish-brown or garnet color. This reagent possesses the great advantage that it is a test for albumen as well as sugar ; hence both of these substances can be detected simultaneously by a single manipulation. Now glucose is fre- quently found, not only in urines of high specific gravity (with which we are accustomed to associate it in our minds), but also in comparatively light and even very dilute urines ; glycosuria is indeed by no means rare. Hence it is recommended that the picric acid test be employed in examin- ing every urine as a test for both sugar and albumen. This double test is made as follows : to about two inches,of urine in a test-tube there is added an equal volume of a saturated solution of picric acid. If serum albumen be present a turbidity appears which is increased by boiling. About one inch of liquor potasse is then added to the boiling mixture, whereby the albumen if present is redissolved. The boiling is continued for a minute ; a pronounced dark-red or brown color indicates the presence of sugar. If the urine contain two grains or more to the ounce, the mixture becomes quite black (Johnson). It is to be noted that a slight darkening of color is produoed during this test in perfectly normal urine, but the presence of the minutest trace of sugar (as revealed by other reagents) produces a decided change of color such as is never observed with normal urine. The physician should there- fore familiarize himself with the effect of this test upon normal urines be- fore employing it for the detection of sugar. CLINICAL EXAMINATION OF THE URINE. 163 A deepening of color, simulating the sugar reaction, is produced by tannin, ferrous salts, and creatinine in excess. Hence it is desirable to confirm the result by the use of a second reagent. Fehling's test, modified by Professor W. S. Haines, of Rush Medical College, Chicago, is the best of all the copper tests for sugar, having the unusual advantage of stabUity. The foUowing formula and directions for use are kindly furnished by Professor Haines: Pure sulphate of copper.................... 30 grains. Pure glycerine............................ 2 drachms. Pure caustic potash—in sticks............... 1|- " Pure water.............................. 6 ounces. Dissolve the sulphate of copper and glycerine in a portion of the water, and the caustic potash in the remainder ; mix the two solutions, when a perfectly clear, transparent, dark-blue liquid should result, which may be bottled and set aside for use. As usuaUy made it generally throws down a slight reddish deposit upon standing a week or two. This, however, does not affect its value as a test; in using, simply decant the clear liquid from the sediment. Directions for Use.—Take a drachm or two of the test solution and gently boil it, when no change should take place ; now add six or eight drops of the suspected urine and again boil. If sugar be present an abun- dant yellow or yellowish-red precipitate is thrown down ; if sugar is not present, no such precipitate appears, but the color of the test solution will be rendered somewhat lighter and often of a greenish or even of a greenish- yellow shade, by the dilution of the blue test-liquid with the yellow urine. A white flocculent deposit of phosphates, coming from the urine employed, is often seen floating about in the fluid, and should not be mistaken as a reaction for sugar. Care should be taken not to use more than six or eight drops of the suspected urine ; this quantity will be amply sufficient to show the pres- ence of sugar, if it exist in such an amount as to be of any chnical signifi- cance ; while the addition of a larger quantity of urine, whether it be nor- mal or saccharine, wiU sometimes lead to results extremely perplexing to those inexperienced in the use of the test. A few drops of honey, dissolved in an ounce of urine, produces an ar- tificially saccharine urine, which may advantageously be employed by the beginner to learn the exact reaction produced by diabetic urine in the above test. Tests for Peptone.—The most satisfactory method for the clinical de- tection of peptone in the urine is made with Fehling's solution or Haines' modification. This is poured into a test-tube to the depth of an inch, and an equal bulk of urine is floated upon the top. In normal urine a zone of phosphates is formed at the junction of the two liquids; if peptone be present this zone acquires a reddish or pink tint. If there be also a con- siderable quantity of albumen in the urine, the red acquires a violet hue. Additional proof of the presence of peptone can be obtained by now drop- ping into the liquid a drop or two of concentrated picric acid solution; the original red tint becomes deeper, then reddish-yeUow, and finally yellow. Tests for Biliary Pigment.—So long as the biliary coloring matter in the urine remains unoxidized, it can be detected with great certainty; after oxidation, however, its detection is less positive. Gmelin's Test.—Strong nitric acid, which should contain also some 164 DISEASES OF THE URINARY ORGANS. nitrous acid (indicated by red fumes) is poured down the side of an inclined test-tube containing the suspected urine. At the zone of contact there occurs from below upward a series of colors—green, blue, violet, red, and yellow—if bilirubin is present. In many cases the blue and violet are not observed ; in fact, the green is the most prominent and indispensable in the recognition of biliary pigment. Nitric acid without the admixture of nitrous acid sometimes fails to reveal biliary pigment; if pure nitric acid be permitted to stand in the sunlight for some days, the red color indicative of nitrous acid becomes apparent in the bottle. Heller's Test.—Pour into a test-tube about two drachms of pure hydro- chloric acid and drop into it just sufficient urine to impart a distinct color to the acid. After stirring, the mixture is underlaid with pure nitric acid ; at the zone of contact there occurs a play of colors. If the contents of the test-tube be now thoroughly mixed with a glass rod, the same play of colors is observed throughout the entire mixture. This is the most gen- erally applicable test for clinical use. The presence of albumen does not impair the value of the test; indeed, almost the only possibihty of mis- take results from the presence of indican in excess, whereby a blue, violet, and red color may be produced ; the green, however, is lacking, though the admixture of the yellow urine with the blue color of the indican may suggest a green tint. Ultzmann's Test.—To three drachms of urine add one drachm of pure caustic potash solution (one part of potash to three of water) ; shake well, and add an excess of pure hydrochloric acid. The mixture assumes a briU- iant emerald-green color. After the decomposition of the bdiary pigment, there is no certain means for its detection. Probably the best method consists in the addition of one volume of caustic potash solution to two volumes of urine ; a dark color indicates the presence of biliary coloring matter. If upon the addi- tion of a few drops of sulphuric acid this dark color is much deepened, the presumption is strengthened. Tests for Indican.—The simplest is Heller's, which answers for most clinical purposes. A drachm of pure hydrochloric acid is poured into a test-tube, and a few (five to twenty) drops of urine are added with constant stirring. In normal urine the mixture assumes a yellowish-red color ; if an excess of indican be present, a blue tint becomes apparent, its intensity increasing with the quantity of indican. This reaction sometimes requires from five to fifteen minutes. By adding a drop or two of nitric acid, the test is made more delicate. The presence of albumen may mislead, since this substance produces with hydrochloric acid a faint-blue color. It is, therefore, necessary to re- move albumen by boiling and filtering the urine. If biliary coloring matters are present, they should be removed by precipitation with acetate of lead solution (one part to ten of water). Jaffe's test, modified by Salkowski, is somewhat more complicated, but less liable to mislead. Equal parts of urine and strong hydrochloric acid are thoroughly mixed in a test-tube ; a saturated solution of chloride of lime is then added drop by drop until an intense blue color is developed. A few drops of chloroform are added and the test-tube is shaken ; the blue pigment (indigo) is dissolved by the chloroform, which settles to the bot- tom, leaving the urine colorless. In performing this ffest, albumen should be first removed, and highly colored urine decolorized. Test for Chlorides.—It is sometimes clinically important to know CLINICAL EXAMINATION OF THE URINE. 165 whether or not the chlorides are excreted in increased quantity ; not that such excess has in itself especial diagnostic value, but because such knowl- edge enables us to infer whether or not urea is present in normal amount. For since the urine is practically a solution of urea and the chlorides, a normal quantity of the latter with a low specific gravity indicates a de- ficiency of urea. To two inches of urine in a test-tube add three or four drops of nitric acid (to prevent precipitation of the phosphates) and then one or two drops of a nitrate of sdver solution, one part to eight of water. In normal urine a white curdy precipitate is formed and falls readily to the bottom ; if the chlorides are decreased in quantity, no curdy masses are produced, but only a general turbidity. Quantitative Estimation of Urea.—A knowledge of the quantity of urea excreted in the urine has seldom any especial clinical value. For, as has been already stated, the excretion of urea is so largely dependent upon the quantity of nitrogenous food ingested, that the amount of the latter must be carefully determined before inferences as to the extent of tissue meta- morphosis are warranted. It is chiefly in cases of chronic nephritis that the clinical estimation of urea has diagnostic or prognostic value ; if the excretion of urea is persistently much less than the average amount (thirty to forty grammes) an impairment of the renal activity may be inferred with much confidence. The simplest way for estimating the quantity of urea excreted consists in estimating the total sohds in the urine from the specific gravity, by the method already mentioned, and in determining the quantity of chlo- rides with nitrate of silver solution. A persistently low excretion of sohds without any deficiency in the chlorides indicates a diminished excretion of urea. Yet this is a decidedly crude and unreliable method of arriving at the amount of urea excreted, and until recently there was no accurate method of sufficient simplicity for clinical use. In 1877 Dr. George B. Fowler, of New York, submitted a method to which was awarded the prize of the Alumni Association of the College of Physicians and Surgeons, New York. This method has been extensively tested since that time, and has been found to be accurate and trustworthy. The process is based upon two facts : first, that the decomposition of urea lowers the specific gravity of the urine ; and second, that there is a definite relation between the decrease of urea and the decrease in specific gravity. It was found that a decrease of one degree in the specific gravity as indi- cated by the urinometer was produced by a loss of 3^ grains of urea per ounce, that is .77 per cent, of the urine. The method, therefore, consists simply in noting the specific gravity before and after the addition of an agent which decomposes the urea ; the difference between the two multi- plied by 3£ gives the number of grains of urea in each ounce of the urine, or multiplied by .77 indicates the percentage of urea contained in the specimen. To decompose the urea, Dr. Fowler employs either Labarraque's solu- tion or Squibb's chlorinated soda ; seven parts of either of these liquids is sufficient to decompose the urea in one part of urine, unless an excessive quantity be present, in which case the urine should be diluted with an equal bulk of water. Process.—To one volume of the urine add seven volumes of Labar- raque's solution ; decomposition of urea takes place at once, indicated by effervescence from the liberation of nitrogen. The vessel containing the mixture is shaken a few times at intervals, and allowed to stand for two 166 DISEASES OF THE URINARY ORGANS. hours, at the end of which time the decomposition of urea is accomplished. The specific gravity of the mixture is now noted. It is also necessary to determine the specific gravity of the mixture be- fore decomposition ; this is accomplished by multiplying the specific grav- ity of the pure Labarraque's solution by 7, adding the specific gravity of the urine, and dividing by 8. Subtract the specific gravity of the mixture after decomposition from that before decomposition ; multiply the difference by 3^ to find the num- ber of grains of urea per ounce of urine, or by . 77 to find the percentage of urea. Illustration.—If the specific gravity of the urine is 1015 for example, and that of the Labarraque solution 1040, that of the mixed fluid before decomposition wUl be 10 4 0X7 + 101S —1037 If the specific gravity of the mixture after decomposition is found to be 1034, then the difference, 3, multiplied by .77, or 2.21, shows the percent- age of urea. Or we may multiply 3 by 3£, making 10£, the number of grains of urea in each ounce of urine ; this multiplied by the number of ounces excreted in twenty-four hours shows the total excretion of urea for the day. In performing this test, only two precautions need be taken: first, the specific gravities of the different liquids should be taken at the same tem- perature and at the same time ; hence it is advisable to set aside a bottle of the Labarraque solution and of the urine in the same place as the mix- ture, and to make the specific gravity of each after decomposition has taken place in the mixture. Second, if the specific gravity of the urine be very high, showing an unusual amount of urea, it is advisable to dilute the urine with its own bulk of water before adding the Labarraque solution ; for'otherwise some of the urea may escape decomposition from lack of the reagent. In case the urine has been diluted in this way, it is of course necessary to multiply the result indicating the percentage by 2. This test is not impaired by the presence of albumen or sugar. Bedside Tests for Urine. During the last few years certain reagents which had been employed almost exclusively by chemists have been extensively used as clinical tests ; and through the happy device of Dr. Oliver, of Harrowgate, they have been rendered available to the general practitioner in the form of bibulous papers impregnated with the various substances required. The reagents thus utilized are five : for detecting albumen, picric acid, potassio-mercuric iodide, sodium tungstate, potassium ferrocyanide ; for detecting sugar, picric acid and indigo-carmine. The advantages claimed are: (1), greater delicacy, and (2) greater con- venience (when used as test-papers). That several of these reagents are more delicate than the heat and nitric acid tests, revealing a smaller per- centage of albumen, is undoubtedly true ; but that this increased delicacy confers any diagnostic advantage, is doubtful. For traces of albumen in the urine, such as can be detected by the potassio-mercuric iodide only, have no pathological significance unless accompanied by other indications of renal or general disease. Indeed, it is the experience of those who have carefully employed these delicate reagents, that traces of albumen are re- vealed by them in most mines even from apparently healthy persons. Yet CLINICAL EXAMINATION OF THE URINE. 167 the increased delicacy of these tests wiU doubtless confer one clinical ad- vantage ; the more frequent detection of traces of albumen in the urine wiU probably lead to the more frequent microscopic examination of the sediment, without which no positive diagnosis of chronic renal disease should ever be made. The convenience of these tests, in that they can be applied at the bed- side, is also an apparent rather than a real advantage. For the detection of albuminuria at the bedside has no other value than as an indication for the necessity of thorough examination of the specimen at the office ; and this should be made in every case, whether albumen be detected or not; for a negative result with these test-papers at the bedside does not insure the integrity of the kidneys, nor relieve the physician from the obligation to make a further examination of the urine. The additional delicacy of these tests confers a value, therefore, in physiological rather than in clinical applications. Yet the use of these test-papers cannot be too emphatically urged upon all physicians who, from lack of time or other cause, are in the habit of neglecting the exam- ination of the urine except in pronounced cases of renal disease or diabetes. As already stated, such examination should be just as essential in every case of disease as the inspection of the tongue or feehng of the pulse ; and the general use of these convenient test-papers will certainly further diag- nosis and treatment without consuming much time. AU of these reagents used in testing for albumen precipitate also other substances occasionaUy present in the urine—peptones, urates, mucus, al- kaloids, and oleoresins ; these are, however, readdy distinguished from al- bumen by the employment of heat, which clears up all precipitates other than serum albumen.1 The various reagents exhibit different relations toward various sub- stances other than albumen which may be found in the urine. Thus the picric and potassio-mercuric solutions precipitate alkaloids, while the tung- state and ferrocyanic tests do not. These tests may, perhaps, enlarge the field of chnical urinalysis by their power of precipitating propeptone, which forms a cloud resembling serum albumen, but unlike the latter sub- stance graduaUy dissolves as the liquid is warmed, and finaUy disappears at a temperature of about 70° C. Since propeptone is not coagulated by heat, a comparison of tests may establish its presence. Yet the clinical significance of this substance in the urine remains to be determined. Picric acid is, for certain reasons, an especiaUy valuable test; it pre- cipitates albumen in acid and alkaline as weU as in neutral urine. In using the heat test, on the other hand, care must be taken to secure a faintly acid reaction of the urine, since an excess of acid or alkali so transforms serum albumen that it is not coagulated by heat and is doubtless sometimes over looked. Picrid acid can, moreover, be used as a test for sugar; for this purpose it is most convenient and delicate ; both albumen and sugar can be thus detected by a single manipulation, previously described (p. 162). A comparison of these various tests has given in different hands vary- ing degrees of delicacy. Dr. Oliver reports as the result of his own ob- servations that these different reagents detect albumen as foUows : Heat and nitric acid—one part in 6,000 or 7,000 (.02 per cent.) ; potassium 1 Such is the general belief and teaching ; yet Dr. Robert Kirk states that a precipi- tate of strychnine by the potassio-mercuric iodide persisted in spite of heat (Lancet, November 17, 1883). At any rate, caution and confirmatory tests should be employed before drawing final conclusions until all peculiarities of these reagents have been as- certained. 168 DISEASES OF THE URINARY ORGANS. ferrocyanide—one in 10,000 or 12,000 (.01 per cent.); potassio-mercuric iodide, picric acid, and sodium tungstate—one in 20,000 (.005 per cent.). In a recent paper before the New York Academy of Medicine, Dr. G. B. Fowler stated as the result of his observations that the smallest amount of albumen detected by the various tests (the urine having a specific gravity of 1022) was as foUows : Per cent. Heat.............................................2 Nitric acid........................................1 Picric acid........................................1 Ferrocyanide of potassium...........................1 Sodium tungstate..................................1 Potassio-mercuric iodide............................01 Dr. C. W. Purdy made a series of observations as to the comparative delicacy of these tests in detecting serum albumen and egg albumen. For the former he finds that the potassio-mercuric iodide and sodium tungstate are " the most delicate and reliable, and possessing the fewest objections ;" for recognizing egg albumen, on the other hand, he considers heat and nitric acid preferable to all others. Dr. Vincent Harris came to the conclusion, after comparative tests, that " the three tests—picric acid, sodium tungstate, and potassium ferrocya- nide—are about the most delicate albumen precipitants, and should be reckoned as being about on a par, with preference in favor of picric acid." His experience with potassio-mercuric iodide has been unsatisfactory. Although the results quoted show much diversity as to the absolute and relative delicacy of the different reagents in detecting albumen (the diversity due doubtless largely to the varying composition of the urine and of the tests employed) yet nearly aU agree in demonstrating the relative delicacy of the potassio-mercuric iodide. The writer also can, as the result of personal experience, recommend this test as delicate and reliable. Use of these Reagents.—These various tests may be employed as solu- tions, or more conveniently by means of Oliver's test-papers. In using the solutions, care must be taken to add a little acetic or citric acid before in- troducing the reagent. When this latter is added, a cloud is formed at the zone of contact between the two fluids if albumen or certain other sub- stances are contained in the urine. The test-tube is then heated almost to the boiling point; a cloud which persists upon heating is serum albumen.' In using the test-papers, the acidulation of the urine is first effected by introducing a paper saturated with citric acid. About thirty minims of the urine are introduced into the test-tube ; then one or more (if the 1 On account of their convenience the test-papers are preferred for these reactions; and I would cordially recommend the pocket-case containing tfcese papers and other conveniences, which is prepared and sold at a low price by Messrs. Parke, Davis & Co., of Detroit. Provided with this case even the busiest practitioner can make a fair physical and chemical examination of the urine in every case which he attends. The solutions are made as follows : Potassio-mercuric iodide. 3.22 grammes of potassium iodide and 1.34 grammes of mercuric bichloride are dissolved in 100 c.c. of distilled water and filtered. Sodium tungstate. A saturated solution of this salt (about one part to four of water) and another of citric acid (five parts in three of water) are mixed in equal volumes. Since this test solution contains free acid, it is not necessary to acidulate the urine be- fore testing. The potassium ferrocyanide reagent consists of a saturated solution of this salt. Picric acid is employed for testing as a saturated solution made with boiling water, and containing about seven grains to the ounce. CLINICAL EXAMINATION OF THE URINE. 169 urine be alkaline) citric-acid papers are pushed into the tube, so as to produce an acid reaction. Sometimes a turbidity is observed around the paper ; this is produced by the urates and uric acid, mucin, or oleoresins. Upon heating the turbidity disappears unless it is caused by mucin, which is therefore detected by citric acid and heat. After the effect of the citric-acid paper has been noted, one of the papers containing the precipitant of albumen (any one of the four named) is introduced. A cloudiness produced may be due to peptones, alkaloids, etc.; such turbidity disappears upon heating ; if it persist, the cloud is composed of albumen. The papers may also be used as follows (Oliver): " Those who prefer to develop a zone of precipitation along the plane of contact of a test so- lution and the urine can do so with these papers as follows : put the re- agent paper with fifteen minims of water in one test-tube and a similar quantity of the urine with a citric-acid paper into another. When the reagent is dissolved, a portion of the solution is taken up with a pipette and allowed to trickle down the side of the tube, in which it will either glide over the urine, or collect below it." Since the potassio-mercuric iodide is the most sensitive reagent, it ma}' be used first ; for a negative result by this test indicates certainly the ab- sence of albumen. The reaction is often transient, since the iodide soon decomposes in the acid urine, liberating free iodine, which colors the so- lution and obscures traces of albumen. The sodium tungstate test is nearly as delicate as the former, and does not cause the precipitation of alkaloids, though it produced a cloudiness with peptones. Hence a urine which becomes turbid with the iodide paper, but remains clear with sodium tungstate, probably contains alka- loids. The potassium ferrocyanide is considered less delicate than either of the former ; but as it does not precipitate either alkaloids or peptones, it is less liable to mislead during a hasty or careless examination. Dr. Oliver recommends it to those who have had but little experience in the use of urinary tests. By using these three tests in succession, peptones and alkaloids can be recognized with considerable probability ; for the iodide precipitates, both the tungstate peptones only, and the ferrocyanide neither. Hence a urine which becomes cloudy upon the addition of each of the two former tests, but remains clear when the ferrocyanide paper is introduced, probably con- tains peptones. Picric acid has, as already stated, the advantage that it produces a re- action with both sugar and albumen. In using these reagents it must never be forgotten that the test is not complete until the liquid has been heated almost to the boiling point; since the persistence of the cloud when heated is the decisive proof that it is composed of albumen. Tests for Sugar.—The two reagents—picric acid and indigo-carmine— used for this purpose must be employed in connection with an alkali, preferably sodium carbonate. They are not interfered with by the pres- ence of albumen and of urates in excess. To make the picric acid test, twenty-five minims of water and three grains of sodium carbonate are put into a test-tube with one of the picric- acid papers ; then ten minims of the urine are added, and the liquid boiled for fifty or sixty seconds. If sugar be present the mixture darkens rapidly, often exhibiting a dark-red color. In this case the test should be 170 DISEASES OF THE URINARY ORGANS. repeated with smaUer quantities of urine—five, three, and even one minim. If a single minim produces a decided darkening and reddish tinge, the quantity of sugar is probably five or more grains to the ounce. It is to be remembered that normal urine treated in this way produces a perceptible darkening of the liquid ; hence the physician should familiarize himself with the reaction of normal urine before drawing conclusions from this test. Since, moreover, an excess of creatinine may simulate exactly the sugar reaction, a confirmatory test should be employed. A more trustworthy reagent is that with indigo-carmine. One of these papers and a sodium carbonate paper are placed in a test-tube with forty minims of water ; the liquid is then heated untd it acquires a pale-blue color. A drop of the suspected urine is then introduced and the heating continued, care being taken not to agitate the liquid nor to permit active ebuUition. If sugar be present the liquid wdl in the course of a minute present a succession of colors—violet, purple, red, orange, and finally straw color. After cooling and shaking these various colors are exhibited in reversed order, finally terminating in the original blue. The delicacy of the test is increased by using an additional paper saturated with carbonate of sodium. If no change is produced by a single drop of the urine, a second should be added and the process repeated. If only a trace of sugar be present, the change of color wiU not proceed to yeUow, but wiU stoo at one of the intermediate shades. It is to be noted that normal urine produces a simUarreaction when present in larger quantity (five to ten drops). When, however, only one or two drops of the urine have been added, the succession of colors above mentioned may be regarded as positive proof of glycosuria. Care should also be taken not to agitate the fluid during the process, since the contact of oxygen retards or even prevents the change of color. CHAPTER XVIII. DISEASES OF THE KIDNEY. Venous Congestion. Etiology.—Venous congestion of the kidney is a symptom, resulting either from local obstruction to the escape of blood, or from failure of the general arterial circulation. Most cases are included in the latter category, and are incidental to diseased conditions of the circulatory or of the respi- ratory organs. Valvular heart disease, especially stenosis of the mitral or aortic orifice, .are, except during the stage of compensatory hypertrophy, accompaniec y arterial anemia and venous hyperemia; degeneration of the heart muscle, pericarditis, aneurism of the aortic arch and extensive atheromatous degeneration of the arteries, are among the conditions which may seriously impede the arterial circulation and therefore favor general venous congestion. The various affections of the respiratory organs which interfere directly or indirectly with the action of the heart may, by their effects upon the circulation, cause venous congestion ; among these are emphysema, chronic bronchitis and interstitial pneumonia, chronic pleurisy, as well as nearly all the acute affections of the respiratory tract. It is an unusual feature in phthisis, probably because of the coincident anemia. Local impediments to the return of blood from the kidney are rare. In a few cases venous renal congestion has been observed as a result of thrombosis of the inferior vena cava above the entrance of the renal vein ; also from compression of this vein by tumors, ovarian cysts, ascites, etc. The renal congestion which accompanies pregnancy is doubtless in some, though not in all, cases the result of the pressure upon the vena cava by the gravid uterus. Thrombosis of the renal vein itself occurs not infre- quently in nurslings and sometimes in adults as a result of general maras- mus. Morbid Anatomy.—The anatomical appearances vary according to the duration of the renal congestion. In the early period the kidneys are en- larged, so that upon cutting open the capsule the organ protrudes. The stellate veins of the surface are much distended, and on the cut surface there are numerous dark spots produced by dilated blood-vessels ; the Malpighian tufts, are distinctly visible as dark red spots. If the renal congestion have lasted for some weeks, the kidney is found to be hard as well as enlarged; this condition has been termed the " cya- notic induration." At a still later stage, the organ shows signs of atrophy ; the cortical portion has become very narrow, and the epithelium as well as the glomeruli are degenerated. The kidney is anemic, pale, and ex- tremely hard. This hardness is explained upon microscopic examination 172 DISEASES OF THE URINARY ORGANS. by a decided increase in the interstitial connective tissue ; here and there the renal structure has been replaced by connective tissue. The contrac- tion of this tissue results in cicatricial depression of the surface, forming- scars to which the capsule is quite firmly adherent, so that its removal often tears the kidney tissue. Symptoms.—The diagnosis rests partly upon the recognition of disturb- ances in the circulatory or respiratory organs, and partly upon abnormal conditions of the urine. A feeling of weight and tension over the kidneys, increased upon pressure, is an occasion- al symptom. At a later stage some sweUing of the feet, even pronounced dropsy, oc- curs and persists until com- pensatory hypertrophy of the heart is established (in car- diac disease). The condition of the urine varies according to the cause of the conges- tion : if this be the result of some local impediment to the return of blood which does not interfere with the arterial supply to the kidney, the urine is usually increased in quan- tity, contains a large percent- age of albumen, usually also some blood and a few hyaline tube-casts (Fig. 9). If the con- gestion be, as it commonly is, the result of failure of the arterial circulation, so that the blood-supply to the kidney is diminished, the urine is much decreased in quantity, of dark color, acid reaction, high specific gravity, and precipitates a heavy reddish sediment (urates). Albumen is present in smaU quantity or may be absent entirely. Venous congestion of the kidney, when it results from valvular heart disease, is sometimes complicated by embolus and infarct; such complica- tion may be indicated by severe pain in the loin, often accompanied by chiU, fever, and vomiting ; the urine may be suddenly decreased in amount and always contains a considerable admixture of blood. Diagnosis.—A frequent error in diagnosis is to assume the existence of nephritis. Many of the symptoms of renal inflammation are often present; for the cardiac or pulmonary difficulty upon which the renal congestion depends, often produces oedema of the feet and legs, catarrh of the stom- ach and intestine, palpitation of the heart, and shortness of breath—fre- quent symptoms of nephritis ; and the mistaken diagnosis is fortified in many medical minds by the appearance of albumen and casts in the urine. Now nephritis may occur in the course of venous congestion ; indeed, this condition seems to predispose to actual inflammation. But it will be ob- served that the advent of nephritis is accompanied by the appearance of epithelial and granular casts in the urine, while the percentage of albu- men is increased and the specific gravity diminished. So long as the albu- men is found in small quantity (one-fourth per cent, or less), and the spe- cific gravity remains above the normal, while only hyaline casts are present Fig. 9.—Sediment from a Case of Venous Congestion of the Kidney, caused by Mitral Stenosis and Insufficiency: containing a Hyaline Cast, Kenal Cell, and Blood-corpuscles (Eichhorst). DISEASES OF THE KIDNEY. 173 in the sediment, it is practically certain that no nephritis exists, and that none of the serious comphcations of renal inflammation, such as uremia, need be feared. For it is not until atrophy of the kidney has begun—in- dicated by the appearance of granular and even epithelial casts in the urine—that an impairment of the renal function occurs as the result of venous congestion ; and even then the solid constituents of the urine are usually excreted in normal quantity, notwithstanding the oliguria. The dropsy of chronic nephritis is diffuse, while that of simple congestion is localized in the feet and legs. The diagnosis of Bright's disease is often erroneously made where there exists no inflammation, but simply venous congestion of the kidneys; it has been my fortune to see several cases of such Bright's disease cured by the timely administration of digitalis. It should be remembered that not only in cases of pronounced cardiac disease, but even in less serious affections of the heart and lungs, albumen, hyaline casts, and blood will probably be found in the urine as a direct result of circulatory dis- turbance. If in the course of venous congestion of the kidney, embolism occur, the difficulty of diagnosis from actual nephritis is increased. For such embolism usually causes the escape of considerable blood with the urine, giving it the dark smoky appearance often observed in acute nephritis. Moreover, the patient may experience sudden pain over the kidney and suffer from chill, fever, and vomiting. The distinction may be possible upon the following considerations : embohsm occurs in the course of valvular dis- ease of the heart; the pain is sudden and sharp ; the amount of blood in the sediment is much increased, whde the albumen and casts remain essen- tially as before. Treatment.—Since venous congestion of the kidney is merely a symp- tom, the treatment must be directed primarily to the relief of the original affection. In all or nearly all cases two remedies are required, digitalis and an alkaline diuretic; the acetate or citrate of potassium, or an alka- line mineral water combined with digitalis, materially improves the con- dition of the urine and the state of the patient. To reduce a decided dropsy, diaphoresis may be employed as directed in the treatment of acute nephritis ; it may even be necessary to employ mechanical means, such as Southey's tubes, for removing the fluid from the subcutaneous tissue. These patients are usually anemic and may be benefited by iron and quinine. Medicines should be administered in small doses, since there frequently exists catarrh of the stomach and intestine, as a result of which digitalis in ordinary doses produces vomiting and purging, and other remedies are not well borne. Yet it is necessary to secure the introduc- tion of a considerable quantity of digitalis into the circulation ; if the fre- quent repetition of a small quantity (five drops of the tincture) occasion distress, the remedy should be administered as a poultice or fomentation over the loins. In recent years, several drugs have been recommended as means for reducing the excretion of albumen in various renal difficulties ; prominent among these are convaUaria majalis, adonis vernalis, and caffein. None of these has, however, realized the hopes entertained for them; indeed, their value seems extremely doubtful. 174 DISEASES OF THE URINARY ORGANS. Ischemia of the Kidney. Venous congestion of the kidney may persist for a long time without degeneration of the renal structures, if the arterial supply of blood is not materially impaired in quantity or quality. An interference with this arte- rial supply, however, whether with or without venous congestion, causes rapid degeneration of the epithelial ceUs, of the tubules, and of the glom- eruli. Such deterioration of the blood exists in various anemic and cachectic conditions, such as malaria, syphilis, and phthisis, but to a much greater extent in those states which include a disintegration of blood-cor- puscles—chlorosis, leucemia, pernicious anemia, and above all Asiatic cholera. The same condition results from sudden profuse hemorrhage and from chronic intestinal catarrh ; it may often be observed in the ex- hausting summer diarrhoea of chddren. WThile ischemia of the kidney usually results from some disturbance of the general circulation, it is known to occur also in consequence of local interference in the renal circulation. This is frequently observed in cases of lead colic, during which contraction of the renal arteries occurs. It also takes place, according to Cohnheim, in puerperal eclampsia ; and Leyden has demonstrated that renal ischemia is an occasional consequence of pregnancy. Morbid Anatomy.—Benal ischemia is manifested bypaUorof the cortex ; after longer duration, when fatty degeneration has occurred, by a yeUow color. At times this color is diffuse, involving the entire cortex, while at other times the yeUow color is visible only in spots or streaks, indicating local degeneration. The medullary portion usually presents a marked contrast in color, since it is dark red or purple in consequence of venous congestion. Microscopically, there is observed fatty degeneration of the epithelium, especiaUy in the convoluted tubules and the glomeruli. In ischemia of high grade, the interstitial tissue of the kidney usually contains a number of white and red blood-corpuscles, though no vascular rupture can be de- tected. Symptoms and Course.—Ischemia of the kidney is in most cases an ac- companiment of general ischemia, which is indicated by constitutional symptoms. The only features directly connected with the kidney are oliguria, albuminuria, and the j^resence of hyaline casts in the sediment. It is usual to find in cases of cachexia from malaria or syphilis, from chlo- rosis, after profuse hemorrhage, etc., traces of albumen and a few hyaline casts. These latter are sometimes provided with fatty granules, oil-drops, or even disintegrated epithelial cells. If the condition be persistent, there may also be found in the sediment numerous red and white blood-corpus- cles and epithelial cells from the renal tubules and pelvis of the kidney. The quantity of blood is sometimes so great as to give a dark red or brown color to the urine. It has been repeatedly observed that in ischemia of the kidney, tube- casts are* the only sign of the condition found in the urine, and that they are present when no albumen can be detected. Another observation is the frequent occurrence of indican in excess. Prognosis.—The course of the renal affection depends largely upon the cause and the duration of the constitutional condition. If the cause be only transient, such as profuse hemorrhage, the symptoms of renal diffi1 culty may subside, though uremia is possible ; if the renal disturbance re- sults from a persistent cause, actual nephritis often occurs, even though DISEASES OF THE KIDNEY. 175 the original difficulty be ultimately removed. Thus lead poisoning and pregnancy are sometimes the starting-point for chronic and fatal nephritis. The treatment is of course to be directed entirely to the cause of the circulatory disturbance. Ateophy of the Kidney. Atrophy of the kidney—that is, degeneration of the epithelium and ob- literation of the glomeruli—can occur, as already stated, as the result of persistent venous congestion, which causes increase of connective tissue and the so-called cyanotic induration. In this condition the kidney often presents its normal size or even a considerable enlargement. Atrophy of the secreting elements, accompanied by decrease in the size of the organ, is most frequently met as the result of an inflammatory con- dition usually termed chronic interstitial nephritis. But an almost pre- cisely similar appearance, microscopic as well as macroscopic, is encoun- tered without the clinical history and the morbid changes in other organs usual in cases of cirrhotic kidney ; this simple, non-inflammatory atrophy occurs in old age, apparently as a part of the general atrophy to which senile tissues are prone. The autopsy of aged persons, even those who have never exhibited symptoms of renal affection, usually reveals smaU, hard kidneys, whose capsules adhere with more than the usual tenacity, and whose surfaces are marked with depressed scars, to which the capsule is firmly adherent. Microscopic examination shows a slightly increased amount of connective tissue, a granular degeneration of epithelial ceUs, an increased thickness of the Malpighian capsules, and a transformation of numerous glomeruli into homogeneous balls, impermeable to blood. This senile atrophy of the kidney usually attracts no attention during life, since it does not occasion any of the symptoms which direct suspicion to the renal function. An examination of the urine sometimes reveals traces of albumen with occasional hyaline or granular casts. The quantity of urine is apt to be diminished, by which feature the suspicion of renal cirrhosis, aroused by the presence of albumen, can be allayed. If there happen to be cardiac hypertrophy from some other cause, polyuria may also exist, in which case the distinction of simple senile atrophy from renal cirrhosis becomes difficult. Since this condition of the kidney appears to be a natural, or at least inevitable, result of old age, no treatment directed to the kidney is required or profitable. Amyloid Degeneration of the Kidney. Although the amyloid degeneration of the kidney is frequently found as a complication of renal inflammation, and is usually described as one of the forms of Bright's disease, yet it is etiologically quite distinct from ne- phritis, and is merely a local manifestation of a general disease. Since it is desirable to eliminate so far as possible aU the non-inflammatory affec- tions of the kidney from the conception of Bright's disease, I consider it advisable to discuss this degeneration with the other non-inflammatory changes ; even though uncomplicated amyloid change in the kidney is comparatively rare, the degeneration being generally accompanied by chronic nephritis. 176 DISEASES OF THE URINARY ORGANS. Etiology.—Amyloid degeneration is almost invariably a sequel to either chronic suppuration, chronic tuberculosis, syphilis, or scrofula. As to the connection between these pathological conditions and the formation of amyloid matter, we have no definite information, but only theories more or less unsatisfactory. In perhaps the majority of cases chronic suppura- tion, especially as it accompanies pulmonary consumption or caries of bone, pre-exists. Yet suppuration in any tissue, even as in ulcers of the leg or of the intestine, in cancer of the womb, etc., seems sufficient to induce the formation and deposit of amyloid material in the kidney. While the evi- dence of such amyloid change is usually apparent only after suppuration has long existed, yet a few instances are recorded in which it seems to have occurred within three months (Cohnheim) and even in eighteen days (Bull) after pus formation had begun. It is sometimes observed in adult life in individuals who had suffered from scrofulous suppuration of glands and bones in childhood ; and it is found post-mortem where no suppura- tion is or has been apparent. The first symptoms have been observed in occasional cases after the primary affection has been healed and suppura- tion has ceased. Bartels emphasizes the statement that the existence of chronic sup- puration is not of itself sufficient to induce amyloid change unless the suppurating surface be in contact with the air; and assumes that the pe- culiar proneness of scrofulous and syphUitic suppuration to cause amyloid degeneration is explained by the fact that suppuration due to these taints so frequently occurs as ulceration upon the skin and mucous membranes. He says : " Caries of the vertebre may lead to extensive destruction of tis- sue, resulting in the formation of enormous burrowing abscesses, and yet amyloid degeneration of the viscera does not ensue so long as the pus re- mains pent up in a large abscess cavity, and has no access to the air." That such cases of chronic suppuration, excluded from, as well as exposed to the air, do occur without amyloid degeneration, is unquestioned ; but that access of the air is not essential to the occurrence of such degeneration is equally true. For example, I recently made at the Cook County Hospital the autopsy in the case of a woman, twenty-eight years old, who had pre- sented the symptoms—general dropsy, albuminuria, hyaline casts, etc.— which led to a diagnosis of chronic parenchymatous nephritis of " idio- pathic " origin. There was found no nephritis, but exquisite amyloid degen- eration of the kidneys and spleen, the result of caries of the dorsal verte- bre, from the second to the ninth inclusive. The posterior mediastinum was filled with cheesy pus ; no communication existed between the abscess and the surface ; indeed no suspicion of the spinal caries had been enter- tained during life. Syphilis and tuberculosis appear to be direct and immediate causes of this degeneration, since this is often observed in such cases without the intervention of chronic suppuration. It appears probable that even con- genital syphilis may produce the same result. The cause of the amyloid degeneration is evidently not a local condi- tion of the kidney, but a general morbid state manifested in the blood ; for it affects different organs—the liver, spleen, lymphatic glands, intesti- nal canal, suprarenal capsules, and thyroid gland—as well as the kidneys. The spleen seems especiaUy susceptible, sometimes showing the degenera- tion where none exists in other organs. It is doubtful whether the kid- neys alone are ever the subject of this degeneration, notwithstanding Kosenstein's assertion that such was the case in about seven per cent, of his cases. DISEASES OF THE KIDNEY. 177 Numerous instances of amyloid degeneration are recorded in which none of the usual causes were found to exist, and whose origin is still un- explained. If all kidneys removed post-mortem be subjected to the iodine test, a surprisingly large percentage is found to exhibit the amyloid reac- tion. This degeneration is observed more frequently in males than in females, and may occur at any period of life. Morbid Anatomy.—Since the amyloid change is usually a complication of chronic nephritis, the appearances observed in most cases in which such change is apparent are those of renal inflammation. When uncom- plicated amyloid degeneration is met with the kidneys are found to be nor- mal or enlarged, the size depending less upon the degeneration than upon the other changes present. The capsule is easily separated, leaving the surface remarkably smooth, pale, and waxy looking. Upon cutting open the organ, the same waxy appearance is manifest, especiaUy in the cortical substance; the pyramids are frequently deeply injected, presenting a striking contrast in color to the pallor of the cortex. The Malpighian tufts are often prominent as gray translucent points, which have been likened to drops of dew. Although the gross appearance of the organ is characteristic in an ad- vanced stage of the degeneration, yet the critical test consists in the appli- cation of iodine or of aniline (methyl or gentiana) violet, to microscopical sections. The iodine solution should contain three grains of iodine and six of the iodide of potassium in an ounce of distilled water. The aniline test consists of a one per cent, solution of methyl violet. The latter agent is especially satisfactory in staining microscopic sections ; the amyloid ma- terial exhibits a bright red, which contrasts strongly with the violet of the remaining tissue. When the iodine solution is poured over the cut surface in pronounced cases, the Malpighian tufts, which are first and chiefly affected by the de- generation, stand out prominently as dark-brown points ; the arterioles leading to the glomeruli may also become visible as brown lines. Exam- ination of microscopic sections stained with aniline violet often shows the amyloid change where none is visible to the naked eye. Upon microscopical examination it is seen that the capillaries compos- ing the glomeruli present the earliest and most advanced change. These loops lose their characteristic structure and exhibit a peculiar glassy homo- geneous appearance ; their diameter is increased. At an early stage it is often observed that but a small portion of a single loop presents the brown color after treatment with iodine, the remainder of the tuft appearing about normal. At a later stage the brown color is presented not only by the capillaries of the glomerulus but also by the vasa afferentia, the degen- eration evidently proceeding from the glomerulus along the arteriole. It may ultimately involve the vasa recta as well; occasionally in advanced cases the intertubular capUlaries exhibit the brown color ; these vessels thus degenerated are always larger than normal, the increase in diameter resulting from a thickening of the walls and not an expansion of the lumen, which may be indeed decidedly decreased. In the majority of cases the amyloid degeneration is confined to the vessels; in some instances, however, it is found to affect the epithelium and even the interstitial connective tissue. As might be expected, the first epithelial cells to exhibit the amyloid change are those covering the glomer- uli ; next are those lining the straight tubules ; the epithehum of the con- voluted tubules rarely exhibits the amvloid reaction, but usuaUy shows 12 178 DISEASES OF THE URINARY ORGANS. a fatty degeneration. The deposit of amyloid matter in the epithelial cells of the tubules causes a decided increase in size which may much diminish the calibre of these tubules ; they also present a glassy appear- ance similar to that observed in the walls of the blood-vessels. Such epithelial cells are occasionally found in the sediment, where they may be made to exhibit the color reaction with iodine. In a few cases there have been observed deposits of amyloid substance in the kidney tissue of such size as to be apparent as gray specks to the naked eye. Similar masses have been found in the walls of the renal ar- tery ; thrombosis of the renal vein, originating in the infiltration of its walls with amyloid matter, has also been seen. The deposit in the walls of the smaller vessels may result in such contraction of their calibre that inject- ing fluids cannot be forced into the glomeruli; on the other hand, such injection often succeeds in reaching nearly all of the tufts, even those which exhibit the amyloid change (Miinzel). In microscopic sections of the kidney, casts are frequently observed in the tubules ; many of these exhibit the change of color with iodine, indicat- ing their origin in the epithelial cells ; indeed, the coalescence of the tubu- lar epithelium into an amyloid cast is occasionally seen. It has been already stated that fatty degeneration of the renal epi- thelium, especially in the convoluted tubules, is usually seen in amyloid kidneys ; this epithelial degeneration may be so pronounced as to suggest the results of an inflammatory process—nephritis. Since amyloid degen- eration is moreover a frequent complication of chronic nephritis, it is often difficult to decide even with the microscope, whether or not there is an in- flammatory element in the changes presented by the kidneys. Yet non- inflammatory degeneration alone can result in the appearance of fat in the epithelium and even disorganization of these cells. Symptoms and Course.—The symptoms of uncomplicated amyloid de- generation of the kidney are found less in the urine than in the patient's general condition. Since the amyloid change is usually consequent upon a prior abnormal condition, such as suppuration or syphilis, the attention is rarely directed to the kidneys until an advanced stage has been attained. It should, however, be a rule to examine at short intervals the urine of every patient affected with any of those abnormalities already enumerated as originating amyloid change. Unless such special examination is made the condition of the kidney is rarely discovered until dropsy occurs, for there are no subjective symptoms characteristic of the complaint, and the urine presents no objective appearances which attract the patient's atten- tion. The dropsy always appears sooner or later, and is at first confined to the feet and legs ; indeed, as Koberts pointed out, the dropsy of amyloid kidney spreads by extension from the feet, and does not affect the face and thoracic cavities so often as in chronic nephritis. Before the fatal termination the limbs may be swoUen as high as the trunk, in which case dropsy of the peritoneal cavity frequently ensues ; indeed, since the amy- loid change may affect the liver as well as the kidneys, ascites may be an early symptom. The swelling of the feet and legs in cases of consumption often indicates the development of the amyloid change in the kidneys. The occurrence of dropsy is usually preceded or accompanied by a de- cided pallor and waxy appearance of the skin. There are, however, no characteristic changes in other organs significant of amyloid degeneration, unless we except the obstinate vomiting and intestinal catarrh which so fre- quently occur; these seem to be generally due to the amyloid degenera- tion of vessels in the intestinal waU. Otherwise the various organs need DISEASES OF THE KIDNEY. 179 present no evidence of abnormality—a fact which is of the utmost im- portance in differentiating the amyloid degeneration from the inflamma- tory affections of the kidney. There is as a rule no hypertrophy of the left heart, no increased tension of the pulse nor rise of temperature, no cerebral hemorrhage nor changes in the retina, no uremia nor serous in- flammations, and seldom transudation into the pleural or pericardial sac. Upon examining the urine the attention is arrested by the presence of albumen in decided quantity—one-half to one, two, or even more per cent. ; yet in several carefully observed cases the urine has been occasionally or permanently free from albumen, and has been normal in all other respects. The daily quantity usually exceeds somewhat the average amount of health, though great variations in this respect occur, dependent upon the condition of the heart, coincident nephritis, diet, etc. ; the reaction is acid, the specific gravity somewhat diminished (1.005 to 1.015). The urine is remarkably pale and clear, rarely depositing a decided sediment. The normal ingredients are excreted in somewhat diminished quantity ; in a few cases an excess of indican has been detected. Upon microscopic examination of the sediment there are seen lymph- corpuscles, sometimes blood-corpuscles, epithelial ceUs from the kidney, and narrow hyaline casts ; sometimes also very broad, opaque, waxy-look- ing casts, which (rarely) exhibit the brown color upon the addition of iodine. A peculiarity of these amyloid casts, less commonly observed in other varieties, is the frequency and depth of the indentations on the sides. The epithelial cells occasionally turn brown when treated with a dilute solution of iodine ; before pronouncing these amyloid cells, however, care must be taken to distinguish them from the epithelial cells found in normal urine, which exhibit a brown color upon contact with iodine (Furbringer). Diagnosis.—The existence of amyloid degeneration of the kidney can usually be affirmed with confidence if there be dropsy and a highly albu- minous, clear urine without the symptoms in other organs characteristic of renal inflammation ; the probability is much increased if there have been a pre-existing condition prone to cause the amyloid change. The degen- eration is, however, often overlooked, since it may exist without giving rise to the symptoms mentioned ; thus there may be no evidence of suppura- tion, syphilis, tuberculosis, or malaria, the dropsy may appear only late in the disease, and in a few cases no albumen is at any time discoverable, although the post-mortem examination reveals an abundant amyloid deposit Pure amyloid degeneration is readily distinguished from renal cirrhosis by the absence of cardiac hypertrophy, increased arterial tension, uremic attacks, etc., and by the character of the urine. It is, however, often in- distinguishable from chronic parenchymatous nephritis. In many cases the two morbid processes coexist in the same kidney ; for both are pro- duced by the same causes. A decided enlargement of the liver and spleen constitutes strong presumptive evidence of amyloid degeneration ; while if there be no such enlargement and the urine is less profuse, of darker color, of higher specific gravity, cloudy, and deposits a macroscopic sedi- ment containing granular and epithelial casts, the probability is that the kidney is the seat of parenchymatous nephritis ; yet even then the exist- ence of amyloid degeneration cannot be disproven. The difficulties of this differential diagnosis are well illustrated in the observations of Furbinger upon four cases of consumption.1 In these four cases there was chronic pulmonary tuberculosis and tubercular ulceration 1 Virchow's Archiv, Bd. 71. 180 DISEASES OF THE URINARY ORGANS. of the intestine—conditions which especially favor the formation and de- posit of amyloid material. In each of the four Fiirbringer observed the symptoms which usually characterize such deposit—enlargement of the spleen and liver, the appearance of albumen and casts in the urine, dropsy, etc. Yet at the autopsy amyloid degeneration was found in the kidney in only one of the four cases ; in this one the spleen also exhibited the re- action. In the remaining three cases no amyloid reaction could be ob- tained in any of the organs ; in two of these three there was decided parenchymatous nephritis ; in the remaining case no evidence of renal disease was recorded. In every case it is to be remembered that renal in- flammation and the amyloid change may coexist. Prognosis.—After attaining a high degree, and involving the spleen and intestines as well as the kidney, amyloid degeneration appears to be inev- itably fatal, even though the primary lesion from which it results be cured. At an earlier stage, however, recovery may be expected if the original mal- ady subside. Thus cases of relief from amyloid degeneration of the kid- neys following syphilis and malarial influence have been repeatedly re- ported, after cure of the primary difficulty. Gerhardt considers that recovery is by no means infrequent in chddren. It must be admitted that the data upon which this possibility of a favorable prognosis is based are not altogether satisfactory; for, as already stated, the ante-mortem diagnosis of amyloid degeneration is frequently erroneous. In many cases the primary disorder is incurable ; under these circum- stances the amyloid degeneration is necessarily persistent. In other cases a kidney which was originally merely the seat of the amyloid change may subsequently become involved in parenchymatous inflammation, since the causes which produce the one are often sufficient to induce the other. This complication practically abolishes aU hope of recovery, even if the primary difficulty be relieved. The duration, dependent largely upon the nature of the primary affection, varies from a few months to many years. Treatment.—No means are known whereby amyloid material once de- posited can be removed or its further formation directly arrested. The treatment in these cases consists in the attempt to remove the primary morbid condition and to sustain the patient's strength. Protection, therefore, consists chiefly in prevention; to this end the most careful search should be instituted for the detection and removal of syphilitic, tuberculous, or malarial taints, sources of suppuration, etc.; in- deed, the history of previous syphilis in the subject of present amyloid de- generation should induce the administration of the iodide of potassium and mercurials. The predisposing influence of prolonged suppuration should also be taken into consideration as an argument in.favor of early surgical interference in cases of caries, hip-joint disease, large ulcers of the leg, etc. The treatment of such cases should therefore include frequent examination of the urine. Aside from prophylaxis, but little can be done. A nutritious diet, in- cluding the free use of eggs and milk, iron, quinine, and cod-liver oil may prolong the patient's ability to resist the disease. A most annoying and exhausting feature is frequently an obstinate diarrhoea; this can be miti- gated by laudanum and (according to Bartholow) by Fowler's solution, three drops of which may be administered three or four times a day. DISEASES OF THE KIDNEY. 181 Embolism and Infarct of the Kidney. The emboli found in the kidney are usuaUy derived from the cardiac valves, and are therefore especiaUy frequent in cases of endocarditis. In septic infection, however, thrombosis of veins is a frequent occurrence, whose sequel may be embolism of the kidney. The effect of these emboli depends upon their composition and their size ; septic emboli cause suppuration and abscesses in the kidney, while simple fibrinous emboli produce only necrosis. Suppurative nephritis is the usual result in cases of septic infection, and hemorrhagic infarct in cases of fibrinous embolism. The latter occurrence is by no means rare : in three hundred cases of endocarditis Sperling found emboli of the kidney fifty-seven times. The left kidney is found to contain emboli more fre- quently than the right, presumably because the abrupt angle formed by the right renal artery with the aorta protects the right kidney in great measure from these floating masses. Morbid Anatomy.—The changes occasioned in the kidney by emboli of aseptic origin vary with the size of the obstructed vessel. At least two cases are recorded, one by Cohnheim and the other by Friedlander, in which embolism of the renal artery itself resulted in necrosis of the en- tire kidney. Emboli of the intrarenal branches cause infarction, the size of which varies with the calibre and position of the artery plugged by the embolus. As is weU known embolism in the kidney causes a wedge-shaped in- farct, the apex of which lies in the substance of the organ, while the base is found at the surface-. The infarct is sometimes red, its base projecting somewhat beyond the rest of the surface ; its substance consists of the renal tissue in a state of fatty degeneration and flooded with blood-corpus- cles. At a later stage the entire mass is replaced by connective tissue, finaUy resulting in a cicatrix causing a depression in the surface of the kidney. This is the hemorrhagic infarct. The white infarct, originating in the same way, is not hemorrhagic but anemic; the tissue deprived of its blood supjny by the embolus becomes necrotic and undergoes fatty degeneration. The occurrence of numerous emboli results in the formation of irregular cicatrices, which may cause the kidney to present a lobed appearance. Symptoms.—In many cases embolism and infarction of the kidney pre- sent no characteristic symptoms. Cases are on record in which sudden pain and tenderness in the loin, vomiting, chill and fever have indicated the lodgment of an embolus in the kidney in cases of cardiac valvular disease. These symptoms alone are, however, insufficient to establish a diagnosis, unless the urine furnish confirmatory evidence. Hematuria, coincident with the symptoms already mentioned, affords very strong presumption of renal infarction. Exacerbations of the pain and hematuria in cases of renal congestion during valvular heart disease are also frequently due to renal embolism, which may be mistaken for acute nephritis. Treatment.—In the majority of cases treatment is useless ; it is only when the pain is severe or the hematuria profuse that narcotics and hemo- statics are required. 182 DISEASES OF THE URINARY ORGANS. Diffuse Nephritis (Bright's Disease). The literature of Bright's disease during the last twenty-five years has been a mass of divergent theories and views as to the etiology and morbid anatomy of the numerous conditions clinically described as Bright's dis- ease. Several distinct types of renal disease have been clinically recognized under this term, but there has been the greatest diversity of opinion as to the interdependence of these various types, as well as concerning the relations between the clinical symptoms and the morbid anatomy. Much research has been instituted and effort expended to establish a distinct con- nection between the anatomical appearances and the clinical symptoms ; as a result numerous types of Bright's disease have been created, chiefly based upon the microscopical researches of enthusiastic investigators. It is now, however, generally admitted that it is clinically impossible to make such fine distinctions between different forms of Bright's disease as would correspond to the different anatomical pictures, both gross and microscopi- cal, presented by diseased kidneys ; and pathologists as well as clinicians are now content with the recognition of a few types of nephritis with the understanding that a large number of cases properly so-called present, both clinically and anatomically, features common to two or more of these types. As now generally understood, the term Bright's disease is limited to the diffuse inflammations of the kidneys, and excludes other conditions ac- companied by albuminuria and dropsy ; renal congestion and amyloid de- generation, essentially and often entirely non-inflammatory processes, are therefore no longer included under the name Bright's disease, which is synonymous with diffuse nephritis. Three distinct clinical pictures are recognized, associated anatomically with diffuse nephritis ; each of these is regularly accompanied with charac- teristic morbid appearances. There are, therefore, three types of diffuse renal inflammation : (1) Acute nephritis, (2) chronic nephritis, and (3) cirrhosis of the kidney. (1.) Acute nephritis includes the various more or less hypothetical sub-forms which have been designated the first stage of Bright's dis- ease (Frerichs), desquamative nephritis (Johnson), hemorrhagic nephritis (Traube), catarrhal nephritis (Virchow), acute desquamative nephritis (Bartels), croupous and epithelial nephritis, etc. In thus ignoring the finer distinctions of acute inflammation of the kidney which have been made by different pathologists and clinicians, it is not asserted that such distinctions do not exist, but simply that they are clinicaUy impracticable. Anatomi- cally the disease is not always a unit; it is doubtless true that the epithe- lium usually shows under the microscope a more decided departure from the norm than the interstitial tissue ; it is also true that in many cases a decided desquamation or catarrh of the renal epithelium is apparent, and that a croupous exudation occurs in the capsules of the glomeruh and in the lumina of the tubules. But none of these changes comprises the en- tire morbid condition, and therefore none justifies an exclusive appellation ; moreover, no one of these anatomical characteristics is so intimately asso- ciated with a particalar group of clinical features or with an especial etio- logical influence as to justify a subdivision of the general term acute ne- phritis. (2.) By chronic parenchymatous nephritis is designated that form of chronic renal inflammation which is ordinarily accompanied with dropsy, DISEASES OF THE KIDNEY. 183 and which furnishes upon post-mortem examination the large white kid- ney. There has been some dispute as to whether or not it is usually con- secutive to acute nephritis. That it is sometimes so is undoubted ; but that it is frequently a primary affection, beginning insidiously without the pre-existence of acute nephritis, is now undeniable. (3.) 'By cirrhosis of the kidney or chronic interstitial nephritis is des- ignated that form of chronic renal inflammation which is generally accom- panied during life by disease of the heart and arteries, complications in the serous membranes, the retina, etc., but without dropsy. Upon post-mor- tem examination the kidney is found to be small, hard, and often granular. The greatest diversity of opinion has existed as to the origin of cirrho- sis of the kidney. The Germans have, almost without exception, since the appearance of Frerichs' work in 1851, insisted that renal cirrhosis was al- ways and necessarily a sequel of chronic parenchymatous nephritis; that the small granular kidney was produced by contraction from the large white kidney. English authors have been just as positive in maintaining the origin of this condition independently of acute and chronic parenchy- matous nephritis, asserting that the disease is often from the first a prim- ary affection. It is now established beyond aU question that there arises as a primary affection a clinical picture presenting precisely the same feat- ures as may be exhihited by a case of prolonged chronic nephritis; and that in both conditions the kidneys are found post-mortem to be much reduced in size and to contain an excessive development of connective tissue. In short, the two affections are both clinically and anatomically one ; that is, the symptoms and post-mortem appearances may occur either with or without a pre-existing acute and chronic nephritis. It is therefore established that the three distinct clinical pictures, each associated with a definite and peculiar abnormality of the kidney—acute nephritis, chronic nephritis, and renal cirrhosis—are frequently successive stages of the same affection. The two later stages are distinguished as chronic parenchymatous and chronic interstitial nephritis ; these terms imply, not that the affection is confined to the connective tissue in the one case nor to the epithelium in the other, but simply that the preponderance of abnormality is found post-mortem in the epithelium and in the connec- tive tissue respectively. Since both chronic parenchymatous and interstitial nephritis may occur as later stages of an acute nephritis in one individual, it is evident that there can be no sharp line of demarcation between them ; for a gradual transition from one to the other occurs in both clinical symptoms and ana- tomical appearances. In many cases, therefore, there are found the symp- toms belonging to both types, and a large number of diseased kidneys ex- hibit anatomical changes, gross and microscopical, characteristic of both ; these are the transitional forms between the recognized types. The clinical symptoms characteristic of the respective forms of chronic nephritis are not directly dependent upon the condition of the kidney; hence the post-mortem appearances of the kidney cannot be predicted with certainty from the symptoms ; a lack of correspondence between the two is especially frequent in those cases in which the renal cirrhosis is a sequence of chronic parenchymatous nephritis. General dropsy and pronounced albuminuria are usuaUy, though not always, associated with the large white kidney; polyuria with a small percentage of albumen and freedom from dropsy, though usuaUy significant of the small granular kidney, are also found in cases where the autopsy discloses the large white kidney. 184 DISEASES OF THE URINARY ORGANS. Acute Nephritis. Etiology.—This may arise as the extension of an inflammation from lower portions of the urinary tract or from the tissue surrounding the kid- ney ; yet such propagation usually produces a suppurative or chronic and not an acute nephritis. Nearly aU cases of acute renal inflammation are of hematogenous origin. The kidneys are pre-eminently excretory organs, eliminating the natural products of tissue metamorphosis as well as extraneous constituents of the blood. This elimination is accomplished largely through the vital activity of the cells lining the convoluted tubules, and partly, perhaps, through the instrumentahty of the cells covering the glomeruli. Now it is well es- tablished experimentally that acute nephritis arises from the elimination of certain foreign substances, such as cantharides ; and that the inflamma- tion in this case begins and may even be confined to the cells concerned in this work of elimination. Moreover, it is a familiar clinical observation that acute nephritis is a regular feature in those infectious diseases in which a foreign element of infection has been demonstrated ; I refer particularly to the septic diseases—septicemia, pyemia, erysipelas and diphtheria—and to anthrax (malignant pustule). In these diseases it is demonstrated that the morbid element of infection is a microscopic organism ; and it is equally well established that these organisms are found in the inflamed kidney, where they constitute foci of inflammation. In other infectious diseases in which acute nephritis is a frequent occurrence, the infectious material has not yet been localized ; hence the assumption that the renal inflamma- tion is originated by the effort of the excretory cells to eliminate the morbid material, is an inference supported by analogy. As already stated, it has been amply demonstrated upon animals that acute nephritis is originated by the excretion of certain substances used as remedies, especially cantharides. Many clinical observations prove that the same result is produced by the elimination of the same drugs in the human subject; among the most conclusive of these are the observations of Lassar.1 After demonstrating the renal irritation induced by the inunc- tion of petroleum, croton oil, cantharides, etc., in rabbits, Lassar experi- mented with a human subject. A healthy man, twenty-four years of age, was rubbed with Peruvian balsam for the rehef of scabies. In a few days he exhibited general dropsy, which involved the face as well as the extrem- ities. The urine was red, scanty, specific gravity 1.025 ; it contained albu- men, blood, and lymph-corpuscles, fatty epithelial cells from the kidney, hyaline, granular, epithelial, and blood casts ; in short, there was an acute nephritis. The inunctions of balsam were discontinued, after which the symptoms gradually subsided and the urine became perfectly normal. To determine whether or not the nephritis was a consequence of the inunctions or merely a coincidence, Lassar renewed the former condition by rubbing 20 grammes of Peruvian balsam into the skin on each of three consecutive days. After the second inunction a slight albuminuria appeared while the dady urine fell from 3,600 to 1,700 c.c. After the third inunction there was decided albuminuria, the quantity of urine sinking to 1,050 c.c. ; the sedi- ment contained blood-corpuscles, epithelial and blood casts. On the fol- lowing day there was some oedema. The urine amounted to 700 c.c, spe- cific gravity 1.025, very albuminous ; blood and epithelial casts in great 1 Virchow's Archiv, Bd. 77, and Charite-annalen, 1881. DISEASES OF THE KIDNEY. 185 profusion. On the next day there was a general exaggeration of the symp- toms. Under treatment (uva ursi and warm baths) the urine became normal in three days. Several days after the restoration of health the skin was again rubbed with Peruvian balsam ; on the following day there was de- cided albuminuria, but the experiment was abandoned as satisfactorily demonstrating the dependence of acute nephritis in the human subject upon inunctions with balsam. The causes of acute nephritis are chiefly as follows : 1. The infectious diseases, foremost among which, as to frequency, is scarlet fever. The septic diseases, including ulcerous endocarditis, erysip- elas and diphtheria ; typhus, typhoid, yellow, and malarial fevers, pneu- monia, small-pox, and acute rheumatism are some of the morbid conditions with which acute nephritis may be expected. Scarlatinal nephritis begins usually about the end of the third week, but may be delayed until the fifth or even the sixth week. In very many instances the little patient is apparently convalescent before the first symp- toms of the renal affection are manifested ; and the serious, often fatal ill- ness which then ensues is falsely attributed by the laity and by some physicians to neglect in protecting a child from "taking cold." The fact seems to be that exposure to cold has but little if any influence in origi- nating nephritis after scarlet fever ; the inflammation is evidently produced by the specific infectious material. Yet whUe no especial care is necessary in preventing the child from enjoying fresh air in a proper way, it is abso- lutely imperative that the physician shall keep a strict supervision over the general condition and especiaUy the urine of the patient until the sixth week has expired. This is necessary not only in the severe and dangerous cases of scarlet fever, but also in the mild ones ; indeed, nephritis is not uncommon in those instances in Avhich scarlet fever is manifested quite in- distinctly by soreness of the throat and perhaps an indefinite rash with slight fever—the so-called abortive form—or even when these symptoms have been scarcely noticed ; for in certain epidemics the nephritis may be the only observed manifestation of scarlatina. There is, unfortunately, nothing in the history of scarlet fever upon which we may predict the probabdity of renal complication ; it occurs in many mild cases and fails to appear in certain severe instances ; the general character of an epidemic may furnish a clue, for in some renal in- flammation is an almost constant feature, while in others it is a rarity. The condition of the cervical glands should be carefully noted ; for the observations of Wagner and Leichtenstern have shown that nephritis is an especiaUy frequent complication when these glands are much swoUen, and that the beginning of nephritis during convalescence is often accom- panied with a second enlargement of these glands. In most cases of scarlet fever albumen can be discovered during the first or early in the second week ; this febrile albuminuria must be dis- tinguished from the albuminuria of nephritis, which rarely occurs before the third week. It may be, indeed, impossible to draw a sharp line of de- marcation between the two conditions, unless a daily microscopical exam- ination of the sediment be made ; for the onset of renal inflammation may be very insidious and unaccompanied with chdls, dropsy, increased excre- tion of albumen, or other prominent symptom. 2. Inflammation, especially when of septic origin or accompanied with suppuration, is frequently followed by acute nephritis. Various surgical affections and operations, chronic and suppurating diseases of the skin, puerperal fever, and extensive burns, are examples. During the existence 186 DISEASES OF THE URINARY ORGANS. of such conditions, frequent examinations of the urine should be made. Inflammation of the heart and its valves, of the lungs and pleura, are occa- sionaUy, though less frequently, compUcated with acute nephritis. 3. The introduction into the system of certain substances excreted by the kidneys. Foremost among these as to the degree of irritation is canthar- ides, the external application of which is sufficient to induce this result ; but copaiba, though less irritating, is probably more frequently responsi- ble for acute nephritis, because it is given so extensively in the treatment of gonorrhoea. Turpentine, cubebs, squdls, salicylic acid, mercury, phos- phorus, arsenic, the chlorate and even the nitrate of potassium are cred- ited with the same ability, when taken to excess or by peculiarly suscep- tible individuals ; at any rate, the administration of these drugs should be carefully avoided during any irritation or inflammation of the kidney. The list of medicines might be indefinitely extended, since individual cases of acute nephritis from numerous drugs have been reported. Possibly alcohol has induced it, as asserted by Goodfellow ; Penzoldt produced fatal nephritis in dogs by administering ethyl and amyl alcohol. Various poisonous substances produced within the body are also capa- ble of exciting acute renal inflammation ; this has been demonstrated of the biliary acids (Nothnagel, Leyden). Various substances commonly employed as topical applications may cause renal irritation and inflammation ; among these are carbolic acid, iodoform, petroleum, mustard, pyrogallic and chrysophanic acids, naph- thol ; Lassar observed a fatal case of acute nephritis following inunctions with petroleum in the treatment of scabies. It is certain that the effect of these drugs upon the kidney depends largely upon individual disposition ; when employing them, the physician should not fail to detect, by examination of the urine, the possible effects upon the kidney. 4. The disturbance of the circulation resulting from " taking cold " is undoubtedly productive of acute nephritis, though often utdized as an etiological scapegoat where other causes are responsible. The relation between cause and effect has not yet been satisfactorily explained ; yet the fact has been demonstrated. Midler showed that cooling of the skin causes arterial hyperemia in the dog ; Lassar induced genuine acute nephritis in rabbits by suddenly immersing the animals, after cutting off the hair, in ice-water ; hematuria can be induced in some individuals by simple immersion of the feet in cold water. The renal irritation is pro- duced by a sudden change of temperature of the skin rather than by pro- longed exposure to uniform cold. Simple mechanical irritation of the skin, such as the scratching in cases of scabies and prurigo, seem sufficient to induce at least renal irrita- tion ; Wolkenstein produced albuminuria in animals by pencilling with the Faradic brush. Pregnancy constitutes either a cause or at least a predisposing influence to acute nephritis ; the arrest or termination of gestation is usually fol- lowed by restoration of the normal renal function. The existence of a chronic nephritis renders the individual especially susceptible to an attack of acute renal inflammation. In some few cases acute nephritis must be referred to injury, such as a blow, in the region of the kidney ; in other instances it is due to the formation of concretions of uric acid and urates in the renal tubules. Several constitutional dis- eases, especially syphilis, consumption, and malaria, seem to predispose to renal inflammation ; it is observed also quite frequently in various DISEASES OF THE KIDNEY. 187 chronic diseases of the skin, eczema, psoriasis, and pemphigus ; it is a fre- quent complication of extensive burns, and is a regular feature of the acute septic diseases. In some cases no probable cause nor predisposing influence for an ex- isting acute nephritis has been discovered. In some of these an invasion of the kidney by bacteria appears to be responsible, as in the two cases of acute nephritis and uremia observed and related by Litten, to which ref- erence has already been made. Acute nephritis occurs with far greater frequency in certain climates than in others ; it seems to be especially common on the sea-coast and in regions where the climate is variable, exhibiting sudden changes of tem- perature and moisture. In very hot as well as in very cold regions the disease is practicaUy unknown except in connection with infectious and toxic agents. The frequent sequence of acute nephritis upon scarlet fever accounts for the fact that it is so often observed in childhood. Morbid Anatomy.—The gross and microscopical appearances of the kidney vary according to the duration of the disease as well as with the cause. At an early stage the kidney is enormously enlarged, even to twice its normal size ; the capsule is smooth and transparent and easily separated from the organ. Upon section a serous fluid mixed with blood escapes, showing oedema as well as congestion of the kidney ; the Malpighian tufts appear as prominent dark red points, whUe the cortex of the kidney ex- hibits the purple color of intense congestion. At different points, smaU hemorrhages are observed, usually not larger than a pin's head and located chiefly in the cortex. At a later stage the color of the cut surface is much lighter, approaching a yeUow or gray ; the size of the organ, while greater than normal, is less than in the former case. Here and there are seen dark red spots, indicating the still congested vessels. Upon microscopic examination there is at first evident only intense con- gestion and cloudy swelling of the renal epithelium. Capillary hemor- rhages are numerous, especially in the capsules of the glomeruli and in the straight tubules. At a later period the epithelial ceUs, especially of the convoluted tubules, are found in a state of rapid proliferation, the products of' the catarrh sometimes filling the lumen and distending the tubule beyond its normal cahbre. Many of the epithelial cells exhibit pronounced fatty degeneration. In acute nephritis following an infectious disease a similar catarrh is ob- served in the epithelium of the capsules ; indeed, the affection is so much more pronounced here than in the rest of the kidney, that it has been termed glomerulo-nephritis or capsulitis ; the frequency of this occurrence after scarlet fever has also given rise to the designation scarlatinal nephri- tis. The capsules contain masses of cells which are themselves sufficient to compress the glomeruli and thus interfere seriously with the circulation through them ; there is found in addition, as Friedlander has recently shown, swelhng and fatty degeneration of the capillary walls, which further interfere with the passage of the blood. These anatomical facts explain the familiar clinical observation that the diminished excretion of urine which constitutes a serious feature in every acute nephritis is especially formi- dable in the disease after scarlet fever, and that there is under these circum- stances an especial necessity for securing the excretion of water from the glomeruli; indeed, this fiUing up of the capsules with cells and nuclei constitutes almost the only abnormality observed in some fatal cases of scarlatinal nephritis. 188 DISEASES OF THE URINARY ORGANS. In many cases of acute nephritis the kidneys alone present abnormal appearances, though the body generaUy is as a rule dropsical. The drop- sical fluid is found in the subcutaneous connective tissue generally as well as in the various serous sacs and frequently in the alveoli of the lungs. In occasional cases the mucous membrane of the larynx exhibits a similar dropsical swelling. It has lately been demonstrated, anatomically as well as clinically, that acute dUatation and even hypertrophy of the heart is not infrequent in the course of acute nephritis, especially during the infectious diseases. The urinary channel, the kidney, pelvis, ureter, and even the bladder are occasionaUy found in a state of inflammation. Acute inflammation may, as already stated, arise as a complication in the course of chronic nephritis ; in this case the anatomical appearances in the kidney as well as elsewhere present the changes characteristic of both affections. The acute nephritis which arises in the course of septic diseases is often marked by the appearance of miliary abscesses, originating in emboli of bacteria. Symptoms and Course.—The disease may begin quite abruptly or very insidiously ; in children especially suspicion is often first aroused by the occurrence of oedema, manifested either as dropsy of the feet or as puffiness of the eyelids and broadening of the bridge of the nose. When it occurs as a sequel to scarlet fever, acute nephritis is sometimes unsuspected until the initial symptoms of uremia are manifested. I was recently summoned in haste to see a chUd in convulsions. The little patient had been appar- ently well in the morning, somewhat drowsy in the afternoon, had been put to bed at eight o'clock, and at midnight was found in convulsions. I ascertained that the child had about four weeks previously suffered from a mild attack of scarlet fever, which had confined him to the bed only a few days; the physician in attendance had discontinued his visits some time previously. A little urine which I was enabled to obtain was very albu- minous and contained numerous blood-corpuscles and epithelial casts. Death occurred before daylight from uremia. The child had been re- garded for a week as convalescent, and no suspicion of the existing renal inflammation had been entertained. In the greater number of cases, especially those occurring in adults as the result of exposure to cold, acute nephritis is ushered in with one or more severe chills, followed by decided fever; the latter may be transient, the disease running its course without any constant elevation of tempera- ture. Nausea and vomiting, loss of appetite, headache, and constipation indicate some constitutional disturbance; the locality of this disturbance is often indicated by pain and tenderness in the loins, though this symptom is by no means constant or essential. An early symptom in some cases is irritability of the bladder ; urination is frequent and often painful, a smaU quantity of bloody urine being voided at each act. This symptom, taken in connection with the appearance of the urine, may, if the oedema be slight and undiscovered, raise a mistaken suspicion of cystitis. Meanwhile a prominent symptom famihar to the laity usuaUy becomes apparent—dropsy. The swelling is often first observed around the eyes, usually spreading over the entire surface, but sometimes affecting only the face and the genitals. The distribution of the oedema depends somewhat upon the patient's position, being usuaUy most pronounced in the depend- ent portions of the body. The dropsy may change entirely the facial ex- pression as well as interfere with the movements of the hmbs ; a pecuharity DISEASES OF THE KIDNEY. 189 often observed is a broadening and flattening of the bridge of the nose, caused by the swelling on either side. The oedema is at first usually sub- cutaneous, but sooner or later the large serous sacs are also involved, and oedema of the glottis, the lungs, or the brain may close the scene. Dropsy, though usual, is not a constant symptom ; moreover, it may exist during scarlatina without nephritis (Quincke). The most characteristic symptoms are found in the condition of the urine. This is always scanty, turbid, and red, brown, or smoky in appear- ance from the admixture of blood; the smoky tint is seen in very acid urine. The quantity is always diminished, sometimes to 200 or 300 c.c. per day; even complete anuria may occur. In nearly every case albu- men is present in appreciable amount, often from one-half to two per cent. ; when coagulated by heat and allowed to settle, the albumen may occupy from one-fourth to one-half of the test-tube. While this method by de- posit of the coagulated albumen may be a convenient way for daily com- parison, it should be remembered that it doe3 not afford a means for esti- mating even approximately the actual percentage of albumen in the urine ; this quantity is rarely more than two per cent. It is clinically important to note that in some cases of acute nephritis, especially those following scarlet fever, the temporary absence of albumen is not rare ; hence a failure to detect albuminuria does not necessarily prove the absence of nephritis. In acute renal inflammation from other causes it has also been occasionally observed that the urine, although gen- erally albuminous, may for days at a time be free from albumen. The sediment furnishes important information, and the microscopic ex- amination of it should never be omitted ; for epithehal casts and renal epithelium are present even when no albumen can be detected. The sedi- ment is usually copious, and consists largely of the acid urates ; the im- portant elements present are, however, blood-corpuscles, leucocytes, renal epithelium, and casts (Fig. 10). Blood-corpuscles are rarely absent, even though the gross appearance of the urine may not indicate their presence ; they may constitute the bulk of the sediment. In some cases they are doubtless overlooked even upon mi- croscopic examination, since they are often devoid of the usual coloring matter and show many variations in size and shape; thus they frequently exhibit the crenated form and are found in various sizes from the usual diameter to mere points ; these are the so-called " microcytes." In some few cases the red corpuscles have been seen to execute amoeboid move- ments ; they are often seen adhering to hyaline or epithelial casts. The tube-casts observed vary much in quantity and variety. If the urine contain considerable blood, aggregations of blood-corpuscles in the shape of casts are usuaUy seen. In some cases there is an abundance of epithelial casts, while in others, especially those which follow scarlet fever, but few such cylinders are seen, the greater number being hyaline and granular. The hyaline casts are often provided with oil-drops and granules, urates, crystals of calcium oxalate, and in a few cases crystals of hematoidin. Sometimes they exhibit a tint derived evidently from the coloring matter of the blood, while at other times their appearance suggests that of the casts found in amyloid degeneration of the kidney. The preponderance of one or another element of renal origin in the sediment is sometimes significant as to the course of the disease. Thus epithelial cells and casts in abundance indicate an especial implication of the renal epithelium, a condition which may be overlooked, since the quantity of urine excreted may be but little diminished; on the other 190 DISEASES OF THE URINARY ORGANS. hand, but few renal cells or epithelial casts may be observed in those cases in which the glomeruli suffer especially, although the amount of urine ex- creted is much diminished. In these cases of glomerulo-nephritis there is often present an especiaUy large amount of blood. As already stated, epi- thelial casts are sometimes found without albuminuria ; they are frequently observed at an earlier period than the albuminuria, and sometimes persist for a considerable time after the albumen has disappeared from the urine. The number of leucocytes observed varies much in different cases; in some instances their abundance indicates a catarrhal condition of the renal epithelium. They are doubtless often mistaken even by experienced ob- servers for renal epithelial cells. Fig. 10.—Sediment from Acute Scarlatinal Nephritis, containing Hyaline, Granular, and Amyloid Casts, Renal Epithelium, Blood-corpuscles and Leucocytes. The sediment always contains a considerable amount of granular matter, which consists largely of urates. There is also an abundance of fatty granules furnished by the debris of epithelial cells. In some cases casts composed entirely of granules of uniform size and glistening appearance are observed ; these granules exhibit with the ani- line coloring matters the reaction characteristic of micrococci. Such casts are seen quite often in cases of acute nephritis from septic infection—pye- mia, puerperal fever, etc. ; they are also seen in cases of nephritis arising by extension of the inflammation from the pelvis to the tubules ; and in a few cases such casts have been found in cases of nephritis of unknown origin. In some cases of acute nephritis the patient experiences a constant de- sire to micturate, though but a few drops of urine are expelled at each act. This symptom is not to be taken as evidence of cystitis, unless supported by other indications. If the renal inflammation have been caused by can- tharides, copaiba, or turpentine, or if these remedies have been employed DISEASES OF THE KIDNEY. 191 internally or externally in the course of the affection, strangury may occur ; in cases of poisoning by cantharides extensive fibrinous clots have formed in the urine, rendering the use of the catheter necessary for the evacuation of the bladder. In the last few years it has been demonstrated that an appreciable dila- tation of the heart is a frequent phenomenon ; it is an almost constant and often an early symptom of scarlatinal nephritis in children. If pronounced it can be detected by physical examination ; but even when unrecognizable, it may cause severe asthma and cyanosis. This dilatation is observed especially in the left heart, and so suddenly that it may be mistaken for effusion into the pericardium ; it may be so severe as to constitute the im- mediate cause of death. Dilatation of the heart may be suspected if blood murmurs are distinctly audible ; these disappear when compensatory hyper- trophy is established, a process which may be accomplished in a surpris- ingly short time. Dilatation and hypertrophy are the result of an in- creased blood-pressure, which is indicated by the unusual tension of the pulse. This increased tension is constant in severe uncomplicated cases, and is accompanied by a retardation of the heart-beats (Riegel). In favorable cases no implication of other organs is observed. The symptoms already described continue with more or less constancy for one or two weeks. It is noticeable that the condition of the urine may vary extremely during this time ; not infrequently the blood and even the albu- men disappear, so that the urine shows no abnormality except upon micro- scopic examination. This return of the normal appearance sometimes deceives the physician into the hope that the renal inflammation has sub- sided. Such hopes are, however, usually blighted in a day or two by a return of the blood and albumen in perhaps even larger quantity than be- fore. In many cases there is no permanent improvement in the condition of the urine for two, three, or even four months ; periods of improvement alternate with exacerbations. A diminution in the quantity of -urine is usually accompanied with an increase in the oedema. Sooner or later there occurs a permanent improvement (in non-fatal cases) which is marked by a decided increase in the excretion of the urine ; the amount excreted may indeed much exceed the normal quantity, even three- or fourfold. The excretion is especially copious when the oedema has been extensive. The emaciation which has occurred (though perhaps concealed by the anasarca) now disappears, sometimes to be succeeded by an unusual development of adipose tissue. The blood usually disappears from the urine, though the albumen may be detected for months after the patient is apparently convalescent; casts too, even of the epithelial variety, may persist even longer than the albuminuria. In a certain number of cases, constituting only a small percentage, the kidneys never resume their normal condition. The patient makes an ap- parent recovery and enjoys good health for months ; perhaps the albumen disappears from the urine. But after the lapse of some months the dimin- ished excretion of urine, its turbidity and high specific gravity, the marked albuminuria, oedema, etc., show that the inflammation of the kidney has become chronic. Complications.—The oedema sometimes occasions serious and even fatal complications by accumulation in the pulmonary vesicles, the pericardial, pleural, meningeal, or peritoneal sacs. In occasional cases the mucous membranes become cedematous, and a fatal termination may result from sudden oedema of the glottis. These serous transudations may occur in the course of a few hours, and can scarcely be distinguished from the prod- 192 DISEASES OF THE URINARY ORGANS. ucts of inflammation ; it must be remembered that sudden dilatation of the heart is often developed, simulating effusion into the pericardial cav- ity. In some few cases these serous effusions become purulent, usuaUy in cases of nephritis following infection ; the use of the trocar or aspirator for removing the liquid is unsafe. GMema of the subcutaneous tissue may cause localized sloughing of the skin ; the swelling of the scrotum is sometimes so great as to impede the exit of urine, and require the use of the catheter. Gastric and intestinal irritation and catarrh are frequent symptoms in the course of nephritis, especially when it follows scarlet fever; these may doubtless be produced by simple oedema of the mucous membrane, though it is possible that an inflammatory action also occurs ; loss of ap- petite, obstinate vomiting, and diarrhoea result from this irritation of the alimentary canal. Inflammation of the serous membranes and of the lungs is an occasional complication. Loss of vision may result from simple ane- mia of the retina, or may be due to an actual inflammation of this structure. The most serious as well as the most insidious danger to be appre- hended in the course of an acute nephritis is, however, uraemia. The probability of such serious retention of the urinary constituents increases of course with the diminution in the quantity and specific gravity of the urine ; yet uremia may occur in cases where the comparatively free excre- tion of urine has allayed any fears of this complication, and where no dropsy exists. A suspicion of uremic poisoning should be entertained if there be con- tinuous or violent headache (a frequent sign in the nephritis of pregnancy), sudden impairment of sight or hearing, repeated vomiting, somnolence or drowsiness, asthmatic attacks, watery diarrhoea, intense itching of the skin, spasms of the muscles ; profuse epistaxis and irritability of temper are also frequent premonitory signs of the retention in the blood of a dan- gerous amount of urinary constituents. Yet the attack may occur without the exhibition of these preliminary symptoms ; children especially are known suddenly to fall into coma and convulsions even when apparently convalescent from scarlet fever ; since, moreover, the symptoms of nephritis after scarlatina are often obscure, it is incumbent upon the physician to examine the urine at intervals for two or three weeks after such an attack, even though the child be apparently free from disease. The duration of scarlatinal nephritis is variable ; death may occur in a few days or after the lapse of many weeks. Recovery—the termina- tion in about two-thirds of the cases—is seldom attained in less than a month, and may be postponed for several months, perhaps by relapses into the acute stage. In some instances the kidney never recovers its functions completely ; after an interval of apparent health, lasting several months or a year or two, the symptoms of chronic nephritis become apparent. The persistence of albuminuria or casts or both for some weeks after the dis- appearance of other symptoms is not unusual in cases which ultimately recover entirely. The nephritis of diphtheria is developed during the intensity of the disease and is more frequent in severe cases. Much albumen and blood are contained in the urine; yet recovery from the renal complication is the rule if the patient survive the primary disease ; Leyden has seen cases ultimately recover after lasting more than a year. During the course of typhoid fever nephritis is most frequent in the second week; its symp- toms may be so prominent as to distract attention from the original affec- tion, especially if the history be incomplete ; for this reason French DISEASES OF THE KIDNEY. 193 authors describe it as a "renal form " of typhoid. Uremia is not uncom- mon, and the prognosis is in general grave. The renal inflammation is often accompanied with catarrh of the urinary channels ; the number of leucocytes may thereby become so great as to simulate pus. Acute nephritis developed during the course of croupous pneumonia appears on the fourth or fifth day and subsides in eight or ten days; it is not a serious complication. The acute renal inflammation which compli- cates inflammatory rheumatism seems to appear only in those cases in which the endocardium is involved in the inflammation ; this nephritis frequently becomes chronic (Leyden). Syphilis is considered responsible for many cases of chronic but for few of acute renal inflammation ; Fiirbringer has repeatedly observed mild desquamative nephritis during secondary syphilis. That malaria produces acute as well as chronic nephritis must be admitted ; according to the re- cent observations of Kelsch and Kiener, it causes in Algiers almost as many cases as does scarlet fever. This form of acute nephritis frequently becomes chronic. Diagnosis.—A typical case of acute nephritis can hardly escape recog- nition or be confounded with other affections ; even when the initial chill, vomiting, etc., are absent, the dropsy and the scanty, bloody, and albumi- nous urine render the diagnosis easy. Yet not all cases are typical, and as a result acute inflammation of the kidney is often overlooked or discovered only when uremic symptoms become prominent. In acute nephritis fol- lowing scarlet fever especially the dropsy may be inconsiderable until the affection is well established. In not a few cases albumen is absent from the urine temporarily ; and in the absence of these two prominent symp- toms—oedema and albuminuria—the physician who does not use the mi- croscope is not in a position to recognize the renal inflammation. It has been asserted by Mahomed that there is a pre-albuminuric stage of acute nephritis, indicated by the high arterial tension and the escape of hemoglobin from the kidneys ; and that if this stage be recog- nized, the development of renal inflammation may be averted by exciting the skin and bowels to brisk action. The hemoglobin can be detected, if no albumen be present, by the following test: To two or three drops of urine in a small test-tube, one drop of the tincture of guaiac and four or five drops of ozonized ether are added ; the tube is shaken ; the ether col- lects then at the top of the liquid. If hemoglobin be present this upper layer of ether exhibits a blue color, while the urine below is colorless. This test may be of value if the urine be frequently examined during and after an attack of scarlet fever. The possibdity of previous scarlatina, even without angina or exanthem, should be made the subject of inquiry, particularly during an epidemic of the disease. A not infrequent error in diagnosis is the assumption of nephritis in cases where simple congestion of the kidney alone exists. If this be the result of valvular heart disease, the two prominent symptoms—oedema and albuminuria—are usually present, and a considerable number of casts is observed in the sediment. The distinction can, however, be made without difficulty in most cases ; the existence of the cardiac lesion and the evi- dences of venous congestion elsewhere together with the gradual develop- ment of the symptoms indicate the dependence of the renal disturbance upon the heart ; moreover, the dropsy of acute nephritis affects the face as soon as the feet, while that of cardiac disease extends from the feet up- ward by continuity. The percentage of albumen is usually greater in nephritis than in renal congestion, and blood-corpuscles are more numer- 13 194 DISEASES OF THE URINARY ORGANS. ous in the sediment. The microscopic examination of the sediment usually affords conclusive evidence as to the nature of the renal complaint ; while congestion of the kidney produces numerous hyaline casts, inflammation furnishes epithelial and granular casts in abundance. Hemorrhage from the kidney foUowing embolism and infarction may also suggest the existence of acute nephritis. The distinction is sometimes rendered less easy by the simdarity in history between the two ; thus em- bolism may begin with decided pain in the loins, chill, fever, and vomiting. If this occur during the course of venous congestion of the kidney, the similarity to acute nephritis is even greater. It wiU be found, however, that the sediment does not contain the casts characteristic of renal inflam- mation, and that the percentage of albumen is not greater than can be furnished by the blood present. Another difficulty in diagnosis arises from the possibility that a present acute nephritis may be an exacerbation of a previously existing chronic nephritis; for this affection may have lasted for some time unsuspected, and it predisposes to attacks of acute renal inflammation. If there be no previous history pointing to the existence of acute nephritis its recognition may be impossible until the most pronounced symptoms of the acute affection have subsided. FinaUy, care must be taken to discriminate, dur- ing the course of a febrile affection, between actual nephritis and febrile albuminuria ; in making this distinction the microscope is indispensable. Prognosis.—In many cases the patient recovers perfect health ; yet this fact does not justify a habit of favorable prognosis, since even mild cases may develop unexpected and serious complications. Moreover, a chronic nephritis may be a sequel of the acute inflammation. A favorable prognosis must therefore always be made with caution and reservation, and can be sustained only by careful dady examination of the urine as weU as of the patient's general condition. During convalescence relapses are frequent and may be occasioned by slight provocation, such as exposure to cold; after scarlet fever children require especial care to prevent this accident. Treatment.—The treatment of a patient suffering from acute nephritis is determined largely by the etiology of the affection, as well as by the condition of the kidneys as indicated in the urine. In some cases it is the result of malarial or syphilitic infection, or it may have been produced by the use of medicines. Thus Bartels narrates a case in which the appear- ance of the urine led him to suspect and finally discover that the patient was using cantharides ; the discontinuance of this aj:>plication was followed by immediate return of the urine to its normal condition. In every case, therefore, inquiry should be made as to the possibility of these specific in- fections, as well as concerning the diet and the drugs which the patient may have used internally or externally ; such inquiry may elicit informa- tion that shall lead to special therapeutical measures—the iodide in a syphilitic individual, quinine in malarial conditions, etc. If the patient be a child or youth, careful inquiry will often elicit a history of recent scarla- tina, perhaps unrecognized and manifested only by soreness of the throat or a doubtful rash. Certain general measures—rest, quiet, and warmth—are applicable in all cases ; the inflamed renal tissue as well as the secondarily disturbed digestive tract profit by an unirritating diet; this should consist chiefly or exclusively of milk ; if the patient tire of this alone, eggs, broths, and a little meat are permissible, notwithstanding the excess of nitrogenous material contained therein. Best in bed is an absolute necessity, not only for the comfort of the patient, but also for the avoidance of certain attend- DISEASES OF THE KIDNEY. 195 ant dangers ; thus the acute dUatation of the heart, the transudations in various serous cavities, and the arrest of the cutaneous excretion, are less apt to occur and to entail serious consequences if the patient remain warmly covered in bed. There are so far as known no means for arresting the local inflamma- tion in the kidney ; like most acute inflammations, nephritis appears to be a self-limited disease. The efforts of the physician are therefore directed first to securing the vicarious excretion of the constituents of the urine, and second to the removal of the products of inflammation from the kid- neys. The excretion of the urinary constituents can be accomplished in large part by the skin and the bowels, which are supplementary to the kidneys even in health. By arousing them to increased activity, the urea and salts which the inflamed kidneys fail in large part to excrete can be eliminated, and their deleterious influence upon the system generally prevented. The cutaneous excretion is readily increased by the use of warm baths; the patient is placed every day and allowed to remain for twenty to forty minutes in a bath maintained at a temperature of 38° to 40° C, is then rolled in blankets and allowed to perspire for one or two hours. Although one or more pounds of water escape from the skin during this time, the urine is usually increased in amount, presumably from the absorption into the circulation of the liquid and urea contained in the serous and subcu- taneous spaces. These warm baths may not be employed in every case ; they frequently cause faintness, mental anxiety, and difficulty of breathing, or even sudden collapse ; uremic attacks have been brought on by them, apparently from the sudden return into the circulation of the urea and salts contained in the oedematous fluid. If the patient exhibit in advance any dyspnoea or failure of the heart, these baths should not be employed ; in their stead the cold pack—which is free from the depressing influences of the bath—should be used. The patient is wrapped in a wet sheet, then covered with several blankets until free perspiration has been induced. If this fail, advantage may be derived from Ziemssen's method of wrapping the patient in hot cloths. In urgent cases in which the skin cannot be aroused to action by such measures, pilocarpine must be administered ; one-twelfth to one-eighth of a grain of the nitrate or one-fifth of a grain of the hydrochlorate may be injected subcutaneously. This remedy may induce not only salivation and vomiting, but even dangerous depression of the heart and oedema of the lungs ; these iU effects can be to some extent averted by administering one or two teaspoonfuls of brandy half an hour before the injection. Yet the remedy must be used with extreme caution whenever the condition of the heart or lungs is unsatisfactory ; it is noteworthy that the diaphoretic effect of pilocarpine is less certain when the kidneys are inflamed than in health. The bowels should be stimulated to free excretion. This can be ac- complished by the administration of small doses of podophyUin (one- twelfth grain) ; more decided effect is produced by the compound jalap powder, ten or twenty grains of which may be administered at intervals of four hours until free purgation is induced. If the case be urgent, and symptoms of uremia threaten, the most active cathartics—elaterium and croton oil—are required. Mercury should be avoided. A most important part of the treatment is addressed to the kidney itself. It has often been argued that the inflamed kidney, like any other inflamed tissue, should be afforded perfect repose ; to this end it has been 196 DISEASES OF THE URINARY ORGANS. advised that excess of liquids and all diuretics should be avoided. This plan is excellent in principle, except in so far as it ignores the fact that one of the chief dangers to the integrity of the kidney, as weU as to the life of the patient, lies in the obstruction of the urinary tubules and cap- sules of the glomeruli by the accumulation of epithelial cells and casts. Oliguria is a pronounced symptom, especially in the acute nephritis follow- ing scarlet fever and other infectious diseases ; and the danger of uremia increases, generally speaking, as the amount of urine diminishes. The reason for this oliguria is found in the accumulation of cells and nuclei in the tubules, but especially in the capsules of the tufts ; in the latter locality the catarrh and accumulation of cells is often so great as to compress and practically obliterate the glomeruli, rendering them impermeable to blood. It is evident, therefore, that an effort must be made to keep the blood cir- culating through the glomeruli and to secure a free transudation of water into the capsules so as to remove the products of the catarrh ; the neces- sity for this free excretion of water is especially great in the acute nephri- tis of the infectious diseases. A consideration of these facts leads to the adoption of just that line of treatment of the kidney which is empirically found in practice to be most beneficial: the object should be to increase the arterial pressure in the kidney and to supply the blood with an abundance of water. At the same time it is desirable and quite practicable to refrain from stimulating the secreting cells of the convoluted tubules. To administer turpentine, ju- niper, or squills would be disastrous, since these stimulate the already in- flamed secreting structures. The only diuretics whose employment is both unobjectionable and imperative are digitalis and water. The former, by its stimulation of the heart and of the renal arterioles, increases the arte- rial pressure in the renal vessels, whereby an increased transudation of water occurs and the glomeruli are kept pervious ; both of these results are furthered by the presence of water in large quantity in the blood. Digitalis should be administered in more than the usual quantity. If the tincture must be used (it is not always reliable) from thirty to forty minims should be given in the course of every four hours, until the quantity of urine is decidedly increased ; this amount is too large to be borne by the already irritable stomach, unless divided into doses of five or ten minims each. The pulse should be carefuUy observed and a decided decrease of its frequency should be the signal for diminishing the quan- tity of the drug. If practicable, the infusion of digitalis should be used rather than the tincture ; two to four drachms may be given to an adult and a correspondingly smaller dose to a child. The patient should drink an abundance of water ; and in order to secure his compliance with this direction, it should be prescribed not as vulgar drinking-water, but as an alkaline mineral water, or the " cream of tartar lemonade," made by dissolving a sufficient quantity of bitartrate of potassium in hot water, pouring off the clear solution when cold, and add- ing slices of lemon and sugar to the taste. It is, however, desirable to avoid the administration of potassium salts, since the recent investigations of Fleischer, D'Espine, and others indicate that the accumulation of these salts constitutes an important factor in the production of uremia. It is therefore better to substitute the bicarbonate, acetate, and tartrate of sodium for the more popular potassium salts as diuretics in the treatment of nephritis, acute or chronic. These alkaline solutions are beneficial both in increasing the excretion of water and in dissolving the inflammatory products with which the tubules are encumbered (Gerhardt). DISEASES OF THE KIDNEY. 197 It was formerly customary to apply cups or leeches over the region of the kidneys ; it is probable that these measures, employed at the very out- set of the affection, are useful; but the same effect can be produced by the application of poultices or hot fomentations to the loins. These may also be made the vehicle for the administration of an infusion of digitalis, if the drug be rejected by the stomach and rectum. The premonitory symptoms of uremia require a more vigorous em- ployment of the principles already discussed. The intestinal tract should be stimulated by croton-oil or elaterium—one or two drops of the former or a quarter of a grain of the latter being administered by the mouth. The skin should be excited by the subcutaneous injection of one-third of a grain of pilocarpine ; or four ounces of the infusion of jaborandi, made from one drachm of the leaves, should be given by mouth or rectum. In the absence of this agent a hot-air bath or wet-pack must be used. If con- vulsions have occurred and the patient be plethoric, venesection may be practised. The convulsions can often be controlled by the inhalation of chloroform or by the administration of chloral (twenty to forty grains) by the mouth or rectum. The injection of large doses of morphine—half a grain at once, repeated in two or three hours if necessary, until two grains have been given—has been successfully practised by Loomis and Bartholow. The choice of measures to be employed in treating uremia is to be determined largely by the condition of the pulse ; for if there is decided cardiac weakness, shown by a small, rapid, and feeble pulse, hot baths and pilocarpine are dangerous. In this case the physician must rely upon active diuresis, the wet-pack, croton-oil, and cardiac stimulants, especially digitalis and camphor. If, on the other hand, the pulse is strong and full, venesection in adults and cups or leeches to the neck in chddren, are in- dicated. A fair substitute for venesection is chloroform narcosis, though ether must be strictly avoided. After the patient awakens somewhat from the uremic coma, advantage has been derived from the inhalation of oxy- gen —six to eight litres every three hours (Lagrave). Violent asthmatic attacks may be relieved by large mustard plasters or dry cupping over the chest; also by morphine and chloral, if the condition of the heart permit their use. Pronounced oedema often requires treatment, and can be relieved by free diuresis, diaphoresis, and saline cathartics. It may become necessary to afford a local outlet for the transuded serous fluid ; the practice of making incisions in the skin of the extremities and of the genitals is liable to the objection that it favors the development of gangrene and erysip- elas. Probably the best method consists in the insertion of hypodermic needles (which should be nickel-plated) in the skin ; these are held in posi- tion by adhesive plaster and connected with narrow rubber tubes which are conducted into basins of carbolized water. After the subsidence of the acute symptoms, extreme care is necessary to avoid an exacerbation of the renal inflammation. The albuminuria and the casts persist for weeks or even months after the fever and oedema have disappeared ; during this time excessive bodily exertion, imprudent expos- ure to cold or draughts, or over-indulgence at table may provoke a relapse. The individual is much debilitated by an attack of acute nephritis; the disappearance of the acute symptoms and of the gastric irritability should therefore be foUowed by the administration of tonics. Iron is especially valuable ; quinine and malt liquors should also be prescribed. Wines, brandy, etc., should be allowed but sparingly, because of their irritant effect upon the kidneys. 198 DISEASES OF THE URINARY ORGANS. Various remedies have been recommended for the purpose of reducing the quantity of albumen excreted by the kidneys during convalescence from the acute form as well as in chronic nephritis; among these are fuchsin and the tincture of cantharides. The former has been extensively tried and found to be valueless ; as to the latter Bartholow says : " In acute desquamative nephritis, after the subsidence of the acuter symptoms, good results are obtained from cantharides. The local condition in which this remedy is serviceable consists in hyperemia with loss of vascular tonus." I have seen one case in which the administration of five drops of the tinct- ure three times a day, after the severer symptoms had subsided, was fol- lowed on the third day by a decided aggravation of the symptoms, the urine showing a pronounced increase in the amount of blood, albumen, and casts present. In the absence of other discoverable provocation, sus- picion attached to the cantharides ; the remedy is capable in sufficient quantity of arousing acute nephritis in a previously healthy kidney. Convallaria, Adonis vernalis, and caffein have thus far failed to furnish the anticipated benefits. Nitro-glycerine, so strongly recommended by Robson and indorsed by Bartholow, is worthy of a trial; one minim of an alcoholic solution—one part to one hundred of alcohol—may be adminis- tered three times a day if it produce no unpleasant effects, such as headache, etc. It is understood that this remedy must be handled ano] administered with great caution. Chronic Parenchymatous Nephritis. Etiology.—In the majority of cases chronic nephritis (parenchymatous) arises insidiously as a primary affection ; it has usually existed some months before a positive diagnosis is made or even a well-grounded suspicion enter- tained. The recognition of the etiology is therefore not possible in all cases ; but it has been established that the disease appears as the effect of certain causes, among which the following are most prominent: Syphilis and malaria. The dependence of the disease upon syphilitic infection is shown by the rapidity with which, in many syphilitic individ- uals, it yields to iodide of potassium and mercurials, remedies which in other persons are quite ineffectual. The especial frequency of the disease in certain malarial districts and its increase during malarial epidemics have been often noticed ; it seems probable that a comparatively short sojourn in a malarial region may be sufficient to arouse a chronic nephritis. The ten- dency of malarial influence to induce nephritis varies in different districts ; thus Bosenstein saw the renal complication rarely in northern Holland, while on the eastern shore one-fourth of aU the cases of chronic nephritis were in his opinion produced by malaria. During an epidemic observed by Heidenhain nearly every case was foUowed by nephritis. In Algiers malaria is, according to Kelsch and Kiener, productive of numerous cases of chronic renal inflammation. Exposure to cold and moisture. Such exposure occurs from living in damp dwellings as well as in moist and changeable climates ; the disease is especiaUy frequent upon certain sea-coasts. Chronic suppuration is sufficient to induce chronic nephritis as well as amyloid degeneration of the kidney ; either or both of these affections may therefore be observed in the subject of caries and necrosis of bone, con- sumption, chronic ulceration of mucous or cutaneous surfaces, etc. The abuse of alcoholic drinks is generaUy considered responsible for the DISEASES OF THE KIDNEY. 199 occurrence of chronic nephritis. It seems probable, however, that the effect is not immediate and direct, but is brought about by digestive dis- turbances induced by the alcoholics. That chronic poisoning with mercury, arsenic, and lead can induce chronic inflammation of the kidney is extremely probable. In a comparatively small number of cases chronic renal inflammation can be definitely traced to an an acute nephritis. This prolongation of an acute into a chronic renal inflammation seems to occur with relative fre- quency after scarlet fever, syphilis, malaria, and exposure to cold. Habitual overindulgence in nitrogenous food is doubtless responsible for many cases of chronic nephritis as well as of cirrhosis of the kidney. This is an almost universal hygienic error in England and the United States, though it is impossible to determine with accuracy the extent of its influ- ence in producing the disease. Chronic parenchymatous nephritis is rarely observed in youth, being pre-eminently an affection of adult life ; the symptoms usually appear be- tween the twentieth and fiftieth years. In a few cases it has been ob- served in chddren afflicted with congenital syphilis ; in one reported by Bradley the usual signs of chronic nephritis were developed by a child four months old, the subject of congenital syphilis. Chronic suppuration seems to produce in children the amyloid degeneration rather than chronic in- flammation of the kidney. Males are more frequently attacked than fe-> males—a fact which is doubtless explained by the differences in the occupations of the sexes. Morbid Anatomy.—The anatomical appearances vary extremely with the period of the disease. The typical kidney of chronic nephritis is that usu- ally designated by English authors the large white kidney. This is not, however, the only form observed; for this large kidney finally undergoes contraction (if the patient survive long enough) into the small granular kidney; yet the symptoms—which are determined by many other factors than the condition of the kidney—do not necessarily undergo a change corresponding to the alteration in the renal structure ; hence all gradations between the large white and the red contracted kidney are found post-mor- tem in cases which present a more or less perfect chnical picture of chronic parenchymatous nephritis. Wagner, supported by several German pathol- ogists, believes that the large white kidney results as a rule from a com- bination of chronic nephritis and amyloid degeneration. The large white kidneys (Wilks) may be from two to three times the normal size and correspondingly increased in weight. The capsule is tense and retracts when the organ is laid open ; it is often thickened and white, in certain spots particularly. The kidney itself is of a yellowish color ex- cept where the vessels are deeply injected ; this injection is confined chiefly to the medullary portion of the organ. The yellow color of the cortex is intensified in spots and stripes corresponding to portions of the tubules and glomeruli around which inflammatory products have accumulated. That the yellow color is due to fatty degeneration is evident upon simple inspection and is demonstrated by the appearance of fat drops upon the knife. Upon microscopic examination the attention is especially arrested by the pronounced degeneration of the renal epithelium. The epithelial cells, chiefly or even exclusively of the convoluted tubules, exhibit advanced fatty degeneration, manifested not only by the presence of granules and drops of fat, but also by the coalescence of cells which frequently obstruct the lumen of the tubule entirely. 200 DISEASES OF THE URINARY ORGANS. The interstitial connective tissue exhibits less pronounced changes, but is nevertheless in a state of inflammation. This is indicated by the pres- ence of masses of leucocytes, which are found chiefly around the glomeruli and the convoluted tubules. An actual increase in the amount of mature connective tissue is also visible at different places. The glomeruli, too, present evidences of inflammatory action. Some of the capsules are filled with a granular albuminous or fatty substance by which the tufts themselves are compressed ; the epithelial cells are swollen, often proliferating, and frequently exhibit fatty degeneration. The capil- lary walls of the tufts may also show fatty change and decided swelling ; the glomeruli are usually devoid of blood. At a later stage of the disease the kidney is much decreased in size, being perhaps even smaller than the normal organ. In this condition the degenerated epithelial cells have disappeared, leaving, perhaps, granular masses in the tubules. The tubes themselves are collapsed, even obliter- ated by adhesion of the opposite sides. Many of the glomeruli exhibit similar changes ; the capsules are thickened, the tufts themselves shrunken or even transformed into a homogeneous mass devoid of blood. Sometimes the capsule is filled with a dark granular mass, which presents no similarity to the original structure, but which is decomposed with effervescence upon the addition of nitric acid. This granular mass is the result of calcification consequent upon the previous fatty degeneration. At this stage the interstitial connective tissue is much increased; the masses of young cells present in the large white kidney have become trans- formed into streaks of connective tissue which frequently extend to the Burface of the cortical portion and produce cicatricial depressions. In con- sequence of this new formation of connective tissue, the capsule of the kidney is decidedly adherent, its surface uneven and even granular. The microscopic appearances of these kidneys vary according to the de- gree of shrinking which has occurred ; the appearances characteristic of the large white kidney remain to a greater or less extent. In the organs other than the kidney various changes are observed: the serous cavities contain fluid and sometimes pus ; the lungs frequently exhibit catarrhal pneumonia ; the intestine is inflamed and the lower por- tion perhaps ulcerated ; the heart is dilated or hypertrophied. Symptoms.—In a few cases chronic nephritis is a continuation of an acute inflammation ; in these instances the albuminuria and dropsy may persist in slight degree after apparent convalescence from the acute attack, and may become gradually more pronounced with the lapse of time. In other cases an interval of several months or years may elapse between the subsidence of the acute nephritis and the discovery of the chronic form, during which period the patient apparently enjoys perfect health; finally a gradual emaciation and pallor, with general debility and perhaps slight dropsy of the feet, direct attention to the urine, where the cause of the difficulty is revealed. In the majority of cases chronic nephritis is a primary affection and begins insidiously. At present dropsy and albuminuria are regarded as the first positive symptoms of the affection ; but in many, perhaps aU, cases the disease has existed for some time before these symptoms are discovered or even discoverable. While a diagnosis of chronic nephritis can scarcely be made until the characteristic features of the urine are observed, yet sus- picion of this condition should be aroused by various other symptoms. Thus debility, emaciation, an unusual and persistent pallor, occurring without evident cause, should be regarded as an imperative indication for DISEASES OF THE KIDNEY. 201 the examination of the urine—not once only, but several times at intervals of days—as well as for an inquiry into the history of the patient as to the previous occurrence of acute nephritis, syphilis, malaria, and the other known causes of chronic renal inflammation. The earliest symptoms of chronic nephritis are often such as mislead the physician as well as the patient into a suspicion of disease in other organs ; thus it has repeatedly happened that patients have been long treated for anemia, general debility, etc., without any suspicion of renal disease and without any examination of the urine, until a gradual impairment of vision has led the patient to consult an ophthalmic specialist; the discovery of the so-called albuminuric retinitis has led to an examination of the urine, which was found loaded with albumen. So too a chronic diarrhoea has proved most obstinate and has defied explanation and treatment until the condition of the urine has been discovered ; frequent chills have been considered malarial until albu- minuria or oedema has been detected. Chronic gastritis, intermittent dys- pepsia, " bilious" attacks, asthmatic seizures, palpitation of the heart, short- ness of breath, are among the symptoms which may be caused by chronic inflammation of the kidney even before dropsy has become apparent. These it is true, are more frequently misleading in cases of renal cirrhosis, since this latter condition is, as a rule, not accompanied by the oedema which usually attracts the attention early in the course of chronic nephritis. If we would make it a rule to examine the urine at least chemically in every case, if the fact were generally appreciated that such examination is at least as necessary to a knowledge of the patient's condition as the feeling of the pulse, it is probable that chronic nephritis would be oftener detected at an early stage. In every case of obscure difficulty affecting the general nutrition of the patient or any of the internal organs, repeated examina- tions of the urine, chemical and microscopical, are absolutely essential. At present it happens but too often that no suspicion of renal disease is entertained until the patient is alarmed by the swelling of his feet. Among the earliest symptoms of chronic nephritis is emaciation ; this is usually accompanied by a decided impairment of strength, sometimes amounting to absolute debility. In many instances there occur, even at an early stage, derangements of the alimentary canal; the appetite is im- paired, the digestion poor, and the bowels irregular. It sometimes hap- pens that the emaciation and debility are regarded as the result of this digestive disturbance, or conversely, where, as a matter of fact, both are secondary to the more profound disturbance associated with renal inflam- mation. Dropsy occurs in almost every case sooner or later. It is often noticed at first in the feet, apparent in the evening and disappearing during the night. In other instances it may be general from the beginning, involv- ing the subcutaneous tissue of the face, trunk, and limbs, and fiUing the serous sacs even before the skin is greatly swollen. In still other instances the dropsy is confined to one or more localities, the scrotum being often involved. QMema of the glottis constitutes a dangerous complication, usually occurring in connection with general dropsy, but sometimes (espe- cially in cases of syphilitic origin) appearing suddenly and without ex- tensive oedema. Acute inflammations of serous membranes frequently occur in the course of the disease and sometimes usher in the attack. Bronchitis and pneumonia, oedema of the bronchi and lungs are also observed, the latter sometimes before the general dropsy is excessive. The appetite is usually impaired; indigestion with or without vomiting, and obstinate diarrhoea 202 DISEASES OF THE URINARY ORGANS. indicate derangement of the alimentary function. Impairment of vision is frequent; it usually occurs gradually, and not suddenly, as in acute nephritis ; it is often explained by the appearance of the retina, which in- dicates localized inflammation. Catarrhal or purulent inflammation of the middle ear is an occasional complication. Pronounced pallor, emacia- tion, and debility indicate the imperfect state of nutrition which prevails throughout the body. The pulse and temperature may remain normal, though occasional elevations of the body heat are transiently observed and the pulse is at times small and feeble. Cardiac hypertrophy occurs not only in those cases in which renal cir- rhosis is developed, but also where no such change in the kidney is per- ceptible post-mortem ; according to the observations of Ewald and Ley- den, it exists in about one-half the cases of large white kidney, though never in the same degree as when associated with renal cirrhosis. Acute dilatation of the heart, usually transient, has been noticed (Heitler) accom- panied with dyspnoea and cyanosis. In a certain percentage of cases hyperesthesia and paresthesia in various parts of the body constitute a prominent, sometimes indeed the first symptom. Occasionally the patient complains that joints of fingers and toes seem to be numb and dead ; or they may be the seat of intolerable itching. The urine furnishes most characteristic and important signs in chronic nephritis. The quantity is usually diminished, sometimes even to 300 or 400 c.c. Such oliguria is, however, transient; the quantity varies ex- tremely, and may temporarily exceed that of health. The specific gravity varies inversely as the quantity, sometimes reaching 1.030 or even 1.040 when the oliguria is pronounced, and again sinking to 1.010 or 1.005 when the urinary excretion is more profuse. The urine has usually a dark brown or reddish color and is turbid ; the turbidity depends partly upon the anatomical elements of the kidney and urinary channels present, and partly upon the acid urates which are kept suspended in the albuminous fluid. The urine contains albumen, often in large amount, which may reach from two to four per cent, by weight of the fluid ; the percentage varies on different days and at different hours of the same day ; it occa- sionally happens that the urine is transiently free from albumen The re- action is commonly acid. The urinary solids are usually excreted in less than the normal amount, even at an early stage of the disease ; this is especially true of urea and of the phosphates. That the activity of the kidney is seriously impaired is shown by the slow excretion of various medicaments, whose presence in the urine can be detected ; this tardiness of excretion has been especially demonstrated in the case of the iodide and bromide of potassium. The fact is one of great practical importance ; for there may readily occur a gradual accumulation of remedies in the blood of patients suffering from chronic nephritis ; the administration of narcotics, for example, in the usual doses and at the ordinary intervals may result in narcotic poison- ing in consequence of the diminished excretory activity of the kidney. Jaarsveld and Stokvis have discovered that during chronic nephritis ben- zoic acid administered by the mouth is not converted into hippuric acid, although healthy kidneys always effect this change. Although the quantity of urea excreted is usually less than in health, uremic poisoning is by no means frequent. The explanation lies doubt- less in the fact that the quantity of urea produced is much less than in health. The patient consumes less nitrogenous food, and tissue metamor- DISEASES OF THE KIDNEY. 203 phosis is less active than in the normal condition ; hence, although the ex- cretion of urea and salts is less than that of a healthy person, it is usually sufficient to prevent the accumulation of these urinary ingredients in the blood. Much urea and urinary salts are also stored away in the cedema- tous fluid throughout the body—a fact of practical importance ; for Bar- ters has observed violent uremic convulsions induced by profuse diapho- resis (warm baths) ; the uremic intoxication in this case is brought about by the return into the blood of the dropsical fluid containing urea and salts, the absorption of this fluid being promoted by excessive perspiration. The urine precipitates a thick white sediment; microscopic examina- tion shows an abundance of tube-casts, at first chiefly hyaline but after- ward granular, fatty, and epi- thelial as well. At a more advanced stage, broad, in- dented casts of glistening ap- pearance are observed, sug- gesting the amyloid degen- eration. Yet this degenera- tion cannot be assumed upon the presence of occasional casts of this variety alone, since they are found in cases of simple chronic nephritis. On the other hand, the same causes which produce chron- ic nephritis are also produc- tive of amyloid change, so that the two often occur in the same kidney. The epithelial cells from the kidney which are found in the sediment of chronic nephritis are not usuaUy rec- ognizable as such, since they are far advanced in fatty degeneration. Distinct epithelial casts are com- paratively few, whUe highly granular casts (derived from the epithelium) are very numerous. Leucocytes are usuaUy found in abundance, and reel corpuscles can often be discovered ; in exceptional cases the quantity of blood is large. The abundance of hyaline and granular casts has been already referred to as characteristic of chronic nephritis in distinction from other forms of renal disease. In a few cases this feature is, however, absent; Ackermann observed such an instance, in which, during the last three months of life, tube-casts could rarely be found, although they had been previously abun- dant ; upon section the pelves of the kidneys were found to contain several drachms of yellow slimy liquid, found upon microscopic examination to be filled with tube-casts which had settled in the pelvis and had not escaped with the urine. Course and Duration.—The disease is frequently fatal within a year, but has been known to last for six and even eight years. It is often compli- cated by acute exacerbation, or rather by the occurrence of acute nephritis, to which the chronically inflamed kidney appears especially predisposed. Such attacks are accompanied by the appearance of blood in considerable quantity in the urine. On the other hand, remissions often occur; the Fig. 11.—Sediment from Chronic Parenchymatous Ne- phritis, containing hyaline, granular and fatty casts, fatty epi- thelial cells and granules. 204 DISEASES OF THE URINARY ORGANS. excretion becomes more abundant, the dropsy diminishes, the albumen disappears from the urine, and the patient's general condition improves so much as to encourage the hope of recovery. Yet either from some im- prudence on the part of the patient or from unknown causes, the symp- toms of the disease usually recur with their original force. The fatal termination may result directly from any one of several com- plications. Intercurrent inflammations of the serous membranes or of the lungs frequently cut short the life of the patient; erysipelas and gangrene of the skin may foUow incisions for the rehef of the dropsy, or spontaneous bursting of the skin ; indeed, they may occur without any solution of con- tinuity. Thrombosis of veins foUowed by embolism in the lungs or the brain is sometimes observed ; suffocation may result from extensive and sudden effusion of serum into the pulmonary alveoli, the bronchial tubes, or the glottis ; obstinate diarrhoea and dysentery may hasten the exhaus- tion of the patient; and general marasmus usuaUy occurs if the patient escape a fatal result from these complications. In comparatively rare cases death results from cerebral hemorrhage ; uremia is less frequent than in renal cirrhosis. _ In other instances the two most prominent symptoms—dropsy and albuminuria—disappear almost entirely ; the urine is now excreted in ex- cess and contains only a trace of albumen ; the patient's general condition improves. These signs usuaUy indicate, not the subsidence of the renal affection, but its transition to the condition of so-called interstitial inflam- mation, which may permit the individual to live for several years in com- parative comfort, but is sure to terminate fatally. The development of increased arterial tension and of hypertrophy of the heart confirms the belief that such transition is occurring. Wagner has recently described under the name " chronic hemorrhagic Bright's disease without oedema " a form of renal inflammation character- ized by recurring hematuria (which may last for several days and be ob- served at intervals of weeks or months), and by an entire absence of oedema. During these intervals the urine resembles that of renal cirrho- sis. The general health is not materially disturbed ; the disease may last two or more years. Aufrecht regards this as a chronic interstitial nephritis with periods of hemorrhagic inflammation ; this conception meets a serious objection in the fact that cardiac hypertrophy is usuaUy absent. Bartels describes as " attacks of intercurrent acute nephritis in the course of renal cirrhosis " a condition which Fiirbringer's investigations lead him to regard as "acute hemorrhagic Bright's disease during chronic nephritis previously devoid of symptoms." Neither the history nor the examination of the urine reveals a chronic inflammation of the kidney ; there may be even no albuminuria ; the physician is consulted either be- cause of the hemorrhagic attack or on account of some complicating affec- tion, especially consumption. The acute renal symptoms may subside and the urine become perfectly normal; the diagnosis of chronic nephritis rests, therefore, upon the post-mortem examination. The case commonly results fatally at an early date, though rather from the complicating dis- ease than from the nephritis. Diagnosis.—The recognition of chronic nephritis is usually easy after the dropsy has become a noticeable symptom. From acute nephritis it is distinguishable by the history alone ; also by the absence of blood from the sediment, extensive dropsy, and nature of the casts. It is to be re- membered that an acute nephritis may complicate a chronic renal inflam- DISEASES OF THE KIDNEY. 205 mation, in which case the diagnosis rests upon the symptoms and previous history. From renal cirrhosis chronic nephritis is distinguished by the fact that the former is rarely accompanied by dropsy ; in it the excretion of urine is excessive, the albumen shght, and the sediment smaU ; moreover, hyper- trophy and dilatation of the heart and an abnormaUy tense pulse are almost constant symptoms of renal cirrhosis; albuminuric retinitis and uremic attacks frequently occur. At a later stage, when contraction of the kidney has taken place, the symptoms are practically indistinguishable from those of renal cirrhosis; for the disease is essentially identical in both cases. A previous history of dropsy, pronounced albuminuria, etc., shows that the present affection is a sequel to chronic nephritis rather than a primary lesion. The distinction of chronic parenchymatous nephritis from simple amy- loid degeneration of the kidney is often difficult and even impossible. Etiology, symptoms, and urinary appearances may be identical or at least indistinguishable in the two ; moreover both affections are often present in the same case, induced by a common cause. In renal inflammation the casts observed in the urine usually show decided fatty degeneration of the epithelium, Avhich is less pronounced in the amyloid condition ; in the latter the excretion of urine is often greater than normal, while in the former it is less. In chronic renal inflammation there is usually an abun- dant sediment of casts and epithelium, while in the amyloid degeneration there may be no appreciable sediment. Enlargement of the liver and spleen and a persistent diarrhoea are more frequently symptoms of the amyloid change than of chronic nephritis. Yet none of these differences can be rehed upon for a positive diagnosis between the two affections ; fortunately such differential diagnosis is not absolutely essential in treat- ment. Previous to the appearance of dropsy, the recognition of chronic ne- phritis is difficult and uncertain ; in a few cases persistent albuminuria and the presence of granular casts in the sediment reveal the cause of the obscure derangement of nutrition and functions which is usually present; but it must be remembered that even persistent albuminuria of slight degree does not, in the absence of granular casts, necessarily prove the existence of renal inflammation. If there be decided loss of flesh, debility, persistent diarrhoea, irritability of the stomach, or other impairment of function of obscure origin, careful and repeated examination of the urine should be made ; a history of previous syphilis, malaria, scarlet fever, or repeated pregnancies constitutes an additional reason for thorough exam- ination of the urine. Attention has already been directed to the fact that general arterial anemia, with or without venous congestion, may cause albuminuria and oedema of the feet; this condition is frequent in cases of valvular heart dis- ease, chronic malarial infection, advanced consumption, etc. The absence of pronounced renal disease can be determined in such cases only "by a microscopic examination of the sediment, which reveals the absence of epithelial and granular casts. Prognosis.—This is generally unfavorable ; yet instances of recovery from chronic nephritis (or perhaps amyloid degeneration of the kidney, from which the former affection is often indistinguishable intra vitam) are well authenticated. In these cases the renal affection seems to have been induced by syphilitic or malarial affection and to have yielded to specific treatment. In such instances a return of the symptoms is apt to follow, 206 DISEASES OF THE URINARY ORGANS. though these can be again dispelled by similar treatment. It is therefore extremely important to ascertain if possible the presence of such infection as a guide to prognosis as well as to treament; and to remember that a chronic nephritis due to syphditic infection and yielding to specific treat- ment, may occur in an individual who has been for years entirely free from other evidences of the specific taint. The renal symptoms may exist without any other manifestation of syphilis, and simply in consequence of exposure to cold or errors in diet. Eichhorst relates the following case : A man acquired syphilis at the age of twenty-five ; six months later albu- minuria and the signs of chronic parenchymatous nephritis were observed, but disappeared under the use of mercurial inunctions and sulphur baths. Four years later a relapse of the renal affection appeared without percep- tible cause and w7as again cured by antisyphilitic remedies. Fifteen years after acquiring syphilis, and ten years after the last manifestation of the infection, the patient had a third attack of chronic nephritis, promptly cured by the iodide of potassium and iron. In the absence of this or other specific infection, but little hope of recovery can be entertained ; a comparatively sudden onset of the disease, the early appearance of dropsy, and pronounced albuminuria offer a better prospect of recovery than the more insidious and chronic attack. Treatment.—The therapy is determined by the etiology of the disease in those cases in which it can be traced to a definite and specific infection. The existence of a syphilitic or malarial taint, even though it have been long latent, is an indication for the use of remedies especially adapted to the relief of these affections. In some cases the nephritis can be traced with considerable probability to some other morbid condition, the removal of which may perhaps be followed by recovery from the renal complaint; thus it has repeatedly happened that a nephritis developed in the course of chronic suppuration, has subsided upon the cessation of this discharge; and Bardeleben saw a recovery after amputation of a leg which had been the seat of chronic suppuration. It is just possible that the renal com- plaint in these surgical cases was not inflammation but amyloid degen- eration. If the nephritis cannot be traced to any one of these definite and remediable morbid conditions, there appears to be no way for influencing directly the condition of the kidneys. The indications for treatment are in that case : first, to improve the condition of the blood, by supplying the needed ingredients and by removing the urinary constituents with which the circulating fluid is encumbered ; and second, to prevent and relieve, so far as possible, the complications which frequently accompany the com- plaint. The first indication, the repair and maintenance of nutrition, must be secured by a proper diet rather than by medicines, though these have an important subordinate position. The regulation of the diet is often a perplexing matter ; for the alimentary canal is so irritable that the most nutritious diet provokes gastric uneasiness, vomiting and purging. If the stomach and bowels permit, the patient should partake liberally of fish, eggs, milk, vegetables, fruits, and fat meat, and sparingly of lean meat. If the stomach be too irritable to permit a mixed diet, or if such food seem to aggravate the symptoms, careful experimentation must discover what nutritious articles are best retained and digested. An ex- clusively milk diet has been much recommended, and has proven ex- tremely beneficial to those patients who can comfortably digest three to four quarts of unskimmed milk daily. The quantity of urine is increased, DISEASES OF THE KIDNEY. 207 the amount of albumen diminished, gastric and intestinal complications are subdued, and the general condition much improved. Unfortunately many patients cannot endure such diet, even with the addition of coffee or cognac, as recommended by Wagner; yet by combining other food with milk at first, the patient's stomach can sometimes be educated to the exclusive milk diet. Whatever articles of food be Selected, care should be takent hat al- bumen is supplied in abundance ; for the patient is suffering a constant drain, amounting perhaps to two, three, or even four drachms of albumen daily. This loss of nutritious material must be supplied, even if the albumen excreted in the urine increases somewhat upon such diet. For so long as the blood receives from the stomach more albumen than is lost through the kidneys, the exact degree of albuminuria is a minor item, since we have no proof that the passage of albumen into the urine aggra- vates -in any way the renal affection. Another important item is that food should be supplied at short in- tervals and in comparatively small quantities. The subjects of chronic nephritis are invariably anemic and derive much benefit from the continuous administration of iron. The tincture of the chloride combined with sweet spirits of nitre is generally well borne ; five to fifteen minims may be administered three times daily. If it cause distress at the stomach, Basham's mixture should be tried; this may be prescribed as follows : Tinct. ferri chloridi.... 3 ijss. Acidi acet............ 3 ij. Liq. ammon. acetatis. . § iij. M. S. Tablespoonful three times a day in half a glassful of water. Syrupi simplicis, Aque..............ad. The citrate of iron and quinine is also a good form for the administra- tion of this remedy. Advantage maybe derived by combining strychnine, quinine, or gentian with the iron ; the following prescription is useful in such cases: Ferri redacti......... gr. xv. | Ext. nucis vomice..... gr. iij. Quinie sulphatis...... gr. xx. j M. Fiat pil. no. xx. S., one before meals. The drain upon the system, compensated in some degree by food and drugs, can be much diminished by bodily rest. This is a most important item, the value of which is readily seen by comparing the condition of the patient and of the urine during a period of activity with that observed during an interval of rest in bed. Another advantage derived from repose is the avoidance of sudden changes in temperature. It is not intended that the patient should be confined to a close room ; air and recreation are essential, but they should be secured with the least possible expenditure of force. In order to relieve the kidneys of functional activity and to secure the excretion of the urinary ingredients, the skin and the bowels should be kept active. Except in the later stages of the disease, a sufficient degree of cutaneous activity can be secured by warm clothing and frequent warm bathing. The patient should wear flannel next the skin in all seasons, and should most carefully avoid exposure to cold and draughts ; indeed, if cir- cumstances permit, he should reside in a dry, warm climate which does not 208 DISEASES OF THE URINARY ORGANS. exhibit sudden changes of temperature. It may become necessary to se- cure additional excretion by the skin ; in this case pilocarpine may be administered. Frequent warm baths and an occasional wet-pack will do much toward promoting cutaneous activity without the depressing and in- jurious effects of more vigorous measures. (See Treatment of Acute Nephritis, p. 194.) Laxatives should not be employed until it becomes evident that the skin alone is incapable of supplementing completely the renal function ; for the intestinal tract is usually in a state of irritation, diarrhoea being a frequent feature. When the dropsy has become excessive, however, it is necessary to produce purgation ; this should also be induced at the first intimation of uremic poisoning. Elaterium—one-eighth to one-fourth of a grain—or a drop of croton-oil may be occasionally employed ; for more habitual use, the compound jalap powder or Hunyadi water is less objec- tionable. Free purgation rapidly affects the patient's strength as well as the dropsy, and should be discontinued so soon as the imperative indica- tion for its employment has passed. As to the kidneys themselves, but little can bed one. By regulating the diet and by prohibiting active exercise, the amount of urea produced can be kept at a minimum and the demand for secretory activity in the re- nal cells correspondingly reduced. By the ingestion of an abundance of pure water, the urine is diluted and the products of inflammation re- moved from the capsules and tubules ; the patient should drink habit- ually a mild alkaline water containing but little if any of the potassium salts. The importance of this measure is scarcely appreciated among us; our mineral waters are but too often prescribed promiscuously and em- pirically, without an intelligent appreciation of the objects to be attained or the means for attaining them. The sufferer from chronic nephritis is benefited by the free use of an alkaline water which does not contain an excess of mineral ingredients. Under its use disorders of the stomach and intestine are much improved, the albumen excreted is diminished, the dropsy decreases, and the excretion of solids is often increased. Without ignoring the other factors which exert a beneficial effect at the different springs, it is certain that the free use of the waters alone is a most valuable feature in treatment. This has been often demonstrated of the Vichy, Carlsbad, and Marienbad waters ;. they can be taken in quan- tities sufficient to produce a marked effect upon the urine and upon the general health, without irritating the intestines. The waters more heavily laden with laxative salts—such as Hunyadi Janos—should be avoided. The effects of the various mineral waters of the United States have not been so carefully studied as to permit a positive statement as to their in- dividual applications ; those of the Arcadian Spring, Waukesha, Wis., and the Buffalo Lithia, Va., are among the best. If the patient can be persuaded to drink an abundance of such mild alkaline water—the quantity being regulated by the effects in each in- dividual case—no diuretics are required ; otherwise the excretion of urine should be furthered by using the citrate or acetate of potassium, which may be combined with the infusion of digitalis if the heart's action be feeble. Malt liquors are allowed in moderate quantity, but wines and whiskey should be employed as stimulants only, if at all. In administering medicines as well as food extreme care should be taken to avoid irritation of the stomach. Various remedies have been at different times asserted to possess the power of diminishing the excretion of albumen in chronic nephritis ; tannic DISEASES OF THE KIDNEY. 209 and gallic acids, eucalyptus, ergot, nitric acid, and more recently fuchsin and nitro-glycerine, have been employed for this purpose with, at best, doubtful success. Possibly each of the remedies has conferred benefit in particular cases ; but their promiscuous employment has certainly failed to substantiate the claims made for them. Excessive dropsy requires mechanical relief ; the fluid in the serous cavities can be removed by the aspirator, and in the subcutaneous tissue by Southey's tubes or nickel-plated hypodermic needles. Incisions into the skin should be avoided, since they promote sloughing and erysipelas. Excoriations, which frequently occur on the scrotum and thighs, can be often healed by dusting with the oleate of zinc. The patient should be impressed with the necessity for a careful ob- servance of the hygienic and dietetic requirements of his unfortunate sit- uation ; for in this way he will secure the greatest probability for avoiding the complications which so frequently terminate the case. Disorders of the stomach and bowels often complicate the case and render treatment more difficult. These disorders are often due to oedema of the intestinal and gastric mucous membrane; their successful manage- ment requires the use of measures which diminish the general dropsy. Cirrhosis of the Kidney. Renal cirrhosis, or chronic interstitial nephritis, occurs either as the sequel of chronic parenchymatous nephritis or as a primary affection. It is practically impossible to determine, except by a history of previous oedema, whether or not renal cirrhosis in a given case is primary or sec- ondary. Etiology.—The disease is observed almost exclusively in middle or ad- vanced life, though it is occasionaUy found in young persons, in chddren, and even in infants ; Buhl records a case in a child eighteen months old. The causes of the affection are chiefly certain influences' peculiar to adult life ; several of these are weU ascertained. Gout is a frequent pre- cursor of renal cirrhosis, which is undoubtedly caused by the same factors that induce the gouty condition ; possibly the retention of uric acid in the blood, demonstrated in cases of gout, may be the exciting cause. High living, with or without the development of gout, is certainly a sufficient cause, presumably through the overstimulation of the kidneys in the effort to remove the excessive nitrogenous waste material derived from the food. The abuse of alcoholic liquors is frequently followed by renal cirrhosis, which, with cirrhosis of the liver, is often seen in the habitual drinker ; the Germans are inclined to doubt the frequency of this affec- tion as a result of alcholic excess. Lead poisoning is a frequent cause ; it is possible that chronic poisoning with other metals may also produce it. Chronic inflammation of the urinary passages, pyelitis; cystitis, and stricture are sometimes followed by renal cirrhosis ; the connection be- tween the two is not clear ; possibly there occurs an extension of the in- flammatory process, though the autopsy does not as a rule support this view. Some authors are inclined to ascribe the renal affection to the in- jurious influence on the kidneys of the various balsams and oils which are so commonly used in the treatment of inflammations of the bladder and urethra. Various constitutional conditions also predispose to it; syphilis,, ma- ll 210 DISEASES OF THE URINARY ORGAXS. larial fevers, chronic disease of bone, while more frequently producing amyloid change or chronic parenchymatous nephritis, are also held responsi- ble for renal cirrhosis. From the frequency of this affection in men of the upper classes, it has been assumed that prolonged mental anxiety is suffi- cient to induce the disease ; yet it is especially difficult to eliminate the other possible influences to which such individuals, frequently given to ex- cesses of various kinds, are exposed. Hereditary influence is by most writers considered an important etio- logical factor. It is certain that various members of the same family are frequently the subjects of the affection ; thus Eichhorst mentions a family, several members of which have come under his own observation: the grandmother died of renal disease with uremia, the mother has had for fif- teen years the symptoms of renal cirrhosis, two sons died of uremia, aud a daughter twenty-two years old has the signs of cirrhosis of the kidney. While the facts are undoubted, it may be a question whether the predis- posing influence in the different members of the same family is hereditary or consists in the common exposure to other causes resulting from a com- mon mode of life. In a considerable number of cases no antecedent cause or predisposing influence can be discovered. The renal affection appears to be merely one manifestation of a general disease of the arteries throughout the body. Since these cases are especially frequent in advanced life, it has become the custom to regard senility itself as a predisposing influence or even a cause. Morbid Anatomy.—The anatomical appearances vary extremely accord- ing to the stage of the disease as well as with the etiological influences. While chronic interstitial nephritis is clinically a unit regardless of the etiology, several distinct types of morbid kidneys are recognized anatomi- cally, dependent largely upon the cause of the affection. The two most prominent types are those designated by English authors as "the red contracted kidney" and the "granular kidney." The former of these presents the appearances observed in cases of primary renal cir- rhosis, while the latter is usually found as the contracting stage of the large white kidney. Numerous transitional forms are found. The red contracted kidney is much reduced in size and weight, meas- uring often only one-half of the normal. The surface is reddish brown, uneven, and granular; the prominences of this surface may be of uniform size and generally diffused, or of varying dimensions and limited to cer- tain localities. The protuberances exhibit the reddish-browm color charac- teristic of the organ, while the fissures between them are of a grayish or white tint. This difference in color corresponds to the difference in structure, the prominences being composed of renal tissue, the fissures of connective tissue. The capsule is thickened, opaque, and adherent to the parenchyma, espe- cially over the cicatricial depressions ; the blood-vessels of the capsule are frequently enlarged and communicate freely with the vessels of the fat mass surrounding the organ. The renal vessels at the hilus often exhibit an- atomical changes ; the renal artery especially is apt to be thickened and hard ; occasionally thrombosis of the renal vein is observed. The cortical substance is remarkably narrow and at points almost ob- literated. Both this and the medullary part exhibit numerous cysts, rarely exceeding the size of a pea, and filled with a gelatinous or semi-purulent mass. These may be located also upon the surface of the kidney projecting above the general level. The pelvis of the kidney is usually large and often exhibits catarrhal or even purulent inflammation. DISEASES OF THE KIDNEY. 211 The gouty kidney, as well as that which follows chronic poisoning with lead or alcohol, presents essentially the same features. In cases of gout there are often found infarcts of uric acid and urates, which appear as grayish stripes in the medullary portion and whitish points in the cortex. These infarcts are located chiefly in the lumen of the urinary tubules, but also in the interstitial connective tissue. These changes are observed in both kidneys as a rule, though fre- quently more advanced in one than in the other; indeed, different por- tions of the sameJridney may exhibit great differences in the stage of the affection, some parts even of small kidneys retaining an approximately normal appearance. Upon microscopic examination of the kidney, the most prominent ab- normal feature is the excess of interstitial connective tissue. This is evi- dent not simply by the increase of the intertubular spaces, but also by the disappearance of the proper kidney structure in certain portions of the organ, where it is replaced by broad bands of connective tissue. In other portions there are found masses of brown cells indicating the con- tinuation of the connective tissue formation. Many of the glomeruli are shrunken and surrounded by a stratified capsule many times the normal thickness ; other tufts are completely obliterated, the space being occupied either by a mass of connective tissue or by a homogeneous, hyaline struct- ure. The cells of the tubules are granular, and in many parts absent alto- gether, the tubules being coUapsed and obliterated. The cysts so often found in cirrhotic kidneys arise partly from the tubules and partly from the glomeruli. In the former case the lumen of the tubule is at some portion compressed by connective tissue, after which the cavity above this point becomes dilated and filled with a colloid, gelatinous material which appears to result largely from metamorphosis of epithelial cells, and in which leucin and tyrosin are frequently found. In this form of renal disease the blood-vessels are always thickened, chiefly by a new formation of connective tissue just under the internal coat of the smaU arteries—" endarteriitis obliterans ;" this thickening may be- come so great as to occlude the lumen of the vessel entirely. The vascular wall presents in many cases a hyaline appearance resembling the amyloid degeneration, but not responding to the reaction with iodine. This form of thickening affects espscially the middle and outer coat of the arteries ; it has been described by Gull and Sutton as " arterio-capillary fibrosis." In the renal sclerosis which is secondary to chronic parenchymatous nephritis, the kidney presents a somewhat different appearance. The sur- face is more uneven, the granulations larger, the color yellow (from fatty degeneration of the epithelium), and the cysts less numerous. Microscop- icaUy less connective tissue is observed. The granulations present do not necessarily depend upon diffuse interstitial thickening, since they are often found in cases where but little increase of connective tissue is observed. Conversely, the absence of granulations does not prove the absence of in- terstitial hypertrophy, since, as Leyden has shown, the large white kidney, presenting a smooth surface, often shows extensive increase of the connec- tive tissue and the symptoms of chronic interstitial nephritis. Renal cirrhosis is accompanied with abnormal conditions of other organs. Foremost among these are the changes observed in the circula- tory apparatus: the heart is found in a state of dilatation and hyper- trophy, usually of the left ventricle only, though sometimes of both sides; fatty degeneration is often present in circumscribed areas. Inflammation of the heart-muscle in the areas of obliterated blood-vessels is also noticed. 212 DISEASES OF THE URINARY ORGANS. Endocardium and pericardium are often the seat of inflammation, recent as well as old; thickening and calcification of the valves, fatty degen- erations of the endocardium and aortic waU are not infrequent; transu- dation, exudation, and adhesions are found in the pericardium. The larger vessels, especiaUy those at the base of the brain, are thickened, their calibre diminished, and the lumen sometimes obliterated (endarteriitis obliterans). The other serous membranes, particularly the pleura and peritoneum, are occasionaUy found in a state of inflammation, okl or recent. The lungs exhibit catarrhal inflammation with or without cecTema. The mucous membranes, especially the bronchial and intestinal, are in a state of catarrh, often showing blood extravasations and (intestinal) ulceration. The liver frequently exhibits evidence of cirrhosis. Thickening of the arachnoid and dura, sometimes inflammation of the same, is observed ; oedema of the brain is an occasional appearance. Extravasations within the cranium and in the retina may usuaUy be discovered. Bartels asserts the frequent occurrence of thickening of the cranium bones. Amyloid de- generation of the kidney as weU as of the spleen and hver are occasional accompaniments of renal cirrhosis. Symptoms.—The development of interstitial nephritis as a continuation of the chronic parenchymatous inflammation, is revealed by the gradual disappearance of the dropsy, the diminution in the percentage of albumen, the increased excretion of urine, and the appearance of decided cardiac hypertrophy. The more frequent chronic interstitial nephritis which begins, not as a sequel to an earlier stage of renal inflammation, but as a primary affection, is extremely insidious in its approach. At an advanced stage renal cirrhosis is marked by evident and unmistakable symptoms ; but during the earlier part of its course it is often unrecognized and even unsuspected. For the symptoms caused by early cirrhosis do not attract attention to the kidney; in fact, the disease may appear primarily as an affection of the arterial system, so that the symptoms caused by it may be exhibited by arterial derangements in other organs. Thus a patient may die suddenly from cerebral hemorrhage, and the post-mortem reveals cirrhotic kidneys, though no suspicion of renal or perhaps of other disease had been enter- tained. Another suffers from indigestion, and has frequent headaches, perhaps accompanied by epistaxis ; the latter symptoms are referred to the gastric disturbance, until albumen is discovered in the urine. In fact, the greatest diversity of symptoms may be manifested in various organs as a result of that condition. Derangements of the circulatory organs may be long exhibited without symptoms which call attention to the kidneys. The patient complains for months of nothing else than a constant and annoying palpitation of the heart, especially frequent after physical exertion or mental excitement, but often occurring without appreciable cause. Shortness of breath without discoverable lesion of the thoracic organs is also an early symptom. Per- sistent headache, especially hemicrania, or neuralgia may call for treat- ment ; these are often accompanied by vomiting, which occurs particularly in the morning—a combination of symptoms that may, under certain cir- cumstances, lead to a presumption of pregnancy. Chronic rheumatism affecting the joints as well as the muscles, and often accompanied by paroxysms of sharp pain ; profuse and persistent bleeding at the nose, hemorrhage from the stomach or bowels ; dyspepsia, chronic diarrhoea, and frequent vomiting—any of these may be regarded as DISEASES OF THE KIDNEY. 213 primary affections until the subsequent history of the case or a closer ex- amination reveals a lesion of the kidneys. In other instances the first symptoms may be failure of the sight, amounting perhaps to complete blindness in one or both eyes ; this loss of vision may be sudden, but is more frequently a gradual impairment, the true nature of which is recognized by examination with the ophthalmo- scope. It occurs in about one-fourth of the cases of renal cirrhosis, far more frequently, therefore, than in other forms of renal disease. Roaring in the ears accompanied by a feeling of faintness, and deafness, produced by many different causes, are in some instances attributable to the disease in question. Persistent and recurring hoarseness (from chronic oedema of the laryn- geal mucous membrane) has been noted by Waldenburg as a precursor of the more pronounced symptoms of interstitial nephritis. Affections of the nervous system of the most diverse nature originate in this same condition ; headache, hemicrania, have been already men- tioned ; a prominent symptom may be insomnia, often so pronounced as to require the use of anodynes. Neuralgias of various portions of the body, often in the shape of obstinate sciatica, may long be the only manifestation of the latent disease. Epileptiform convulsions, produced by chronic uremic poisoning or by genuine meningitis, are sometimes noticed. Cases are recorded in which the individual was treated for weeks for supposed malarial poisoning; the frequent chills and fever manifested were ultimately discovered to originate in chronic uremia from renal cir- rhosis. Asthmatic attacks are recognized as one of the early symptoms of this disorder ; shortness of breath is often seen before and after the stage of compensatory cardiac hypertrophy, and may occur suddenly during the existence of such hypertrophy from acute dilatation of the heart. In a certain number of cases there occurs general emaciation and debility without apparent cause; there may be no symptom pointing to a lesion of the kidney or of other organs until an examination of the urine is made. \ Inflammations of internal organs are frequent and often overlooked because they are accompanied with less fever and constitutional disturb- ance than is usuaUy the case. This is especially true of lobar pneumonia, pericarditis, and pleurisy ; any one of these may exist in the subject of renal cirrhosis without occasioning such pain or rise of temperature as would direct attention to the part in question. In one personal case a man of sixty-three, long the subject of renal cirrhosis, but enjoying very fair health, complained of nausea, loss of appetite and general malaise ; the temperature was only 99.5°, there was no complaint of pain, nor did the urine exhibit any decided change from its usual condition. The fee- bleness of the pulse, contrasting strongly with its previous tension, led to an examination of the heart; an extensive exudation in the pericardium was detected. At the autopsy, two days later, the diagnosis of pericarditis was confirmed. Uremia may manifest itself in most diverse ways: sometimes it is as dyspepsia and chronic diarrhoea, with or without vomiting ; sometimes it appears as asthma or obstinate bronchitis ; again it may be manifested by convulsions, which are indeed occasionaUy the first symptoms leading to a thorough investigation of the case. Any of these conditions in an indi- vidual more than thirty years of age, should be a signal for repeated exami- nations of the urine ; .on the other hand, every patient known to suffer from renal cirrhosis should be submitted to a thorough examination of in- 214 DISEASES OF THE URINARY ORGANS. ternal organs—the heart and lungs especially—when a temporary failure of the health is observed. Since none of these symptoms point directly to the kidney as the source of the difficulty, or as the organ in which the general morbid condition can be detected, the examination of the urine is but too often overlooked ; or if made, it consists merely in testing a single specimen for albumen. Such examination often furnishes negative results, which may be regarded by the physician as conclusive proof that the kidneys at least are not at fault; his attention is therefore directed to other organs, and the real difficulty re- mains for a long time undiscovered. There are various objective symp- toms which may lead the physician, or even the patient himself, to suspect renal disease and thus cause an early examination of the urine ; among these are frequency of urination, especially at night; shght swelling of the feet; firmness of the pulse, pulsation of the temporal arteries, pallor and dryness of the skin. Thirst and increased excretion of urine may lead the patient to fear that he is the subject of diabetes. In comparatively few cases the one symptom known to the laity as an indication of renal disease —dropsy—is present; this occurs but rarely in primary renal cirrhosis. A slight swelling of the feet and ankles, causing an unusual tightness of the boot, may escape detection ; more pronounced dropsy is seen only when, from some failure of the circulation, often temporary, the urinary secretion does not attain its usual amount; such causes are fatty degene- ration of the heart, pericarditis, endocarditis, exposure to cold and moist- ure. Even in these cases the oedema and slight albuminuria, if detected, may be mistaken for consequences of the cardiac condition. The earliest, most pronounced, and constant symptoms of renal cir- rhosis are observed in the circulatory system ; indeed, the heart and ar- teries furnish information quite as significant and essential as the urine. The condition of the pulse, which is hard, full, and quick, is often of itself sufficient to direct attention to the urine. Actual measurements of the pulse show that the tension is really increased in this disease as much as fifty per cent, above the normal ; sphygmographic tracings also* show the unnatural tension of the artery by the secondary waves. This condition of the pulse is associated with hypertrophy of the left ventricle or of the entire heart. Such hypertrophy is in itself, in the absence of valvular disease, sufficient to arouse a suspicion of renal cirrhosis. It is important to remember that in certain cases the heart may exhibit no hypertrophy, even when other characteristic symptoms are present, and when the autopsy reveals contracted kidneys. Cohnheim has emphasized the fact that this absence of cardiac hypertrophy is the rule in those cases in which amyloid degeneration complicates the renal cirrhosis ; it is therefore to be expected in the subjects of prolonged suppuration, syphilis, tuberculosis, etc. The result of this hypertrophy of the heart and disease of the arteries is a series of symptoms quite characteristic of the affection—palpitation of the heart, "rush of blood" to the head, congestion of the face, dizziness, epis- taxis, and often hemorrhage within the cranium. The so-called gallop rhythm of the heart—a doubling of the second sound—asserted by Po- tain to be characteristic of renal cirrhosis, has been recently shown by Friintzel to occur in other affections also. The relation between renal cirrhosis and the coincident cardiac hyper- trophy has been the subject of much dispute and investigation for many years past. By some it has been assumed that the cirrhosis was the pri- mary affection, and that in consequence of the occlusion of numerous blood-vessels in the kidneys, the blood-pressure was increased and the hy- DISEASES OF THE KIDNEY. 215 pertrophy of the heart induced. Others have maintained that the general disease of the arteries, in other organs as well as the kidneys, was the pri- mary difficulty and cause of cardiac enlargement. It would exceed our limits to recapitulate the observations, clinical and experimental, which have been adduced to support each of these hypotheses. Notwithstanding the reported demonstration that, by transient ligature of the renal arteries in dogs and rabbits, chronic interstitial nephritis and secondary cardiac hypertrophy have been induced (Grawitz, Israel, Lewinski, denied by Zan- der), the weight of evidence indicates that the original affection is a disease of arteries throughout the body, as a consequence of which blood-pressure is increased and cardiac hypertrophy induced.. Whether or not this gen- eral disease of the arteries is a result of the accumulation in the blood of materials which should be eliminated by the kidney, is undetermined. The diagnosis of the renal participation in the general disease is made by the characteristic appearances of the urine. The quantity excreted is increased sometimes enormously (Bartels records a daily excretion of 12,000 c.c.) ; from 2,000 to 4,000 c.c. is a frequent daily amount. In many cases the quantity excreted during the night is greater than that passed by day, and the pitient's rest is disturbed by frequent caUs to urinate. The urine is in consequence of its dilution of unusually light color, often with a green- ish tinge ; it is of acid reaction, unless rendered otherwise by medication. Tlie specific gravity is less than normal, usually about 1.010, varying with the amount excreted ; it is higher by day than at night, corresponding to the lessened excretion during the day. It is remarkable that during inter- current febrile attacks, the specific gravity remains, contrary to the usual rule, below normal; an observation of this sort should direct attention to the possibility of renal cirrhosis. The diminution in specific gravity seems to be dependent simply upon the polyuria and not upon a decrease in the amount of solids excreted ; for, until the latter period of the disease, the amount of urea and salts remains at or near the normal figure. The phosphates are, however, retained to a considerable extent, and Fleischer observed that phosphoric acid adminis- tered to a subject of renal cirrhosis is not excreted as completely as by healthy kidneys. At a later period of the disease there is a retention of all the solid constituents, including urea ; indeed, a somewhat diminished ex- cretion of urea is often observed during the earlier course of the disease. Fleischer found that a patient suffering from this affection excreted less urea than a healthy person, when both were kept upon the same diet. The urine usually contains albumen, though this may be absent for days or weeks at a time—an absence which sometimes misleads the physi- cian who is accustomed to regard non-albuminous urine as proof of the integrity of the kidney. The proportion of albumen is ahvays small, usu- ally not more than 0.1 or 0.2 per cent. ; yet such a percentage in so large a quantity amounts to several (three to six) grammes per day. It is notice- able that the urine excreted during the night is more frequently free from albumen than that evacuated during the day, a fact to be borne in mind in determining the nature of the complaint ; if the morning urine only be examined, it may be found non-albuminous, yet later in the day it contains albumen. Plrvsical exertion or mental excitement usually causes an in- creased excretion of albumen ; and uremic attacks or outbreaks of gout are preceded and followed for some time by increased albuminuria. The existence of renal cirrhosis is not excluded by the absence of albumen even upon repeated examinations, since a few cases are on record in which no albumen was at any time found in the urine, although the section re- 210 DISEASES OF THE URINARY ORGANS. ??* vealed unmistakable cirrhosis and the symptoms other than albuminuria were characteristic. Indeed, Schuchardt records a carefully observed case in which the urine was always normal in every respect until just before death ; the autopsy revealed pronounced atrophy and inflammation of the kidney. But httle or no sediment is macroscopically visible. Upon microscopi- cal examination, however, there are found tube-casts, chiefly hyaline, but occasionally granular (Fig. 12). Now and then a cast studded with cells from the urinary tubules, or with uric acid, urates and oxalate of calcium, is ob- served. During transient exacerbations of the renal af- fection, and after uremic or gouty attacks, a considerable number of epithelial casts and renal epithelial cells may be found in the urine. Leucocytes, and sometimes red corpuscles, are present in small number. Course and Duration.— The general appearance of the patient often betrays no especial abnormality, while at other times the skin is unusuaUy pale, dry, and harsh. A frequent symp- tom is persistent and annoy- ing itching, which is present day and night, and drives the patient to des- peration. In other cases obstinate eczema is developed, which yields but slowly to treatment and breaks out afresh without provocation. The gen- eral nutrition usually remains unimpaired, though emaciation is sometimes observed, and the individual may complain of corresponding loss of strength. AU these symptoms occur, however, less frequently and with less prominence than during the course of chronic parenchymatous ne- phritis. The disease may last for many years even after its discovery, and has usually existed for a considerable time before the diagnosis is made or its nature even suspected. On the other hand the life of the patient may be cut short by any one of the numerous complications so often observed, among them uremia, cerebral hemorrhage, inflammation of the lungs or serous membranes, catarrh of the intestinal tract, or oedema of the lungs or glottis. Recovery from pronounced and undoubted cirrhosis of the kidney has never as yet been reported. Among the most characteristic, though by no means most constant, symptoms observed are the changes which occur in the retina. These may be suspected from the impairment of vision of which the patient complains ; amblyopia, dimness of vision, musce volitantes, and other distortions of the sight occur. An occasional incident is sudden and complete blindness affecting one eye and disappearing in the course of a few days ; in other instances both eyes are simultaneously affected, apparently from no anatom- ical change, but from incipient uremia. In the retina there are observed yellow spots, which often surround the Fig. 12.—Sediment from Renal Cirrhosis. DISEASES OF THE KIDNEY. 217 optic papilla, but more frequently are located in and around the yellow spot, where they are arranged as rays radiating from this point. In other cases the spots have no definite topographical relations either to the papiUa or to the macula lutea. These spots are occasioned partly by fatty degen- eration in the granular layers of the retina, partly by hypertrophy of the nerve-fibres, both changes apparently resulting from pathological changes of the retinal vessels. Aside from this so-called "retinitis albuminurica" there is observed, in cases of renal cirrhosis, the appearance known as "choked disk," the result of venous congestion. All of these abnormalities of the retina may subside when due to renal cirrhosis ; the last named, however, occasionally results in atrophy of the disk. Apoplexy of the retina, as well as of the brain, is often found in these cases of renal disease. Failure of the hypertrophied heart from fatty degeneration, or acute intercurrent disease, causes a change in the clinical picture : the urine be- comes less profuse, the specific gravity somewhat higher, the percentage of albumen is increased, digestive disturbances are aggravated, perhaps slight dropsy becomes apparent, and uremic symptoms threaten. Second- ary dilatation of the heart, causing dyspnoea, asthma, palpitation, etc., may follow. Diagnosis—The difficulties of diagnosis arise not from the resemblance of the symptoms to those produced by other affections of the kidney, but from the fact that these symptoms may be exhibited during a long period chiefly or entirely by other organs. After the polyuria, albuminuria, and tension of the pulse are recognized, the diagnosis is easy. A systematic examination of the urine in every case of disease would often reveal an un- suspected renal cirrhosis. It is readily distinguished from acute and chronic parenchymatous nephritis by the profuse excretion of urine, its clear color, low specific gravity, slight sediment, and small percentage of albu- men ; the absence of dropsy, the presence of lesions in the heart, arteries, nervous system, and eye are additional factors in making up a diagnosis. During acute exacerbation the urine may present the changes characteristic of acute inflammatory process and dropsy may be present; indeed, there may be an acute nephritis engrafted upon an undiscovered renal cirrhosis. After the subsidence of this, however, the features of the latter affection persist. In the absence of cardiac hypertrophy—either from temporary cause or from a comphcation with amyloid degeneration—the urine may be diminished and the percentage of albumen increased; indeed, dropsy may exist in slight degree. The distinction from simple amyloid degeneration of the kidney is rarely difficult; for in the latter condition the urine is less abundant and contains a greater percentage of albumen ; there is no evidence of cardiac hypertrophy or changes in the retina, while there is usually enlargement of the spleen and hver; the history, too, indicates the origin and nature of the affection. The complication of renal cirrhosis with amyloid degenera- tion produces a puzzling condition which cannot always be recognized ; for there may be no changes in the heart or arteries, while the other symp- toms indicate interstitial nephritis. The polyuria may lead to a diagnosis of diabetes insipidus ; indeed, it is probable that this mistake is not rare. Careful consideration of the other features in the case wiU easily lead to a correct distinction between the two. Senile atrophy of the kidney, though perhaps indistinguishable from renal cirrhosis by post-mortem inspection of the organ, is easily distin- guished clinically; for this purely senile atrophy is accompanied with a diminished rather than an increased excretion of urine ; there is no cardiac 218 DISEASES OF THE URINARY ORGANS. hypertrophy nor increased arterial tension ; albuminuria is rare and uremia absent. In his ardent search after latent renal cirrhosis, the physician must guard against the temptation to make this diagnosis in cases of intermit- tent or persistent albuminuria when the other symptoms are absent; for such albuminuria may exist without any form of renal disease, and its oc- currence is usually preceded by symptoms in the circulatory and digestive organs at least which explain the significance of the albumen. The coin- cidence of increased arterial tension, persistent headache, dyspepsia or diarrhoea with albuminuria, should be regarded as strongly suggestive of renal cirrhosis and as ground for maintaining a constant supervision of the patient. Yet it must be admitted that, even with the most careful atten- tion to all diagnostic points, cases occur in which the presence or absence of renal cirrhosis can be determined only after considerable time has elapsed. It is certain that intermittent or constant albuminuria, even associated with a decided increase of vascular tension, may last for some months and then disappear permanently. Possibly such cases are really instances of incipient or localized renal cirrhosis, or the albuminuria may originate in conditions independent of the kidney. Such cases must be distinguished from those of genuine and undoubted renal cirrhosis in which remissions lasting, perhaps, weeks or months occur, during which periods no albumen is found in the urine. Prognosis.—No instance of recovery from pronounced and undoubted renal cirrhosis is yet recorded ; yet the affection is not incompatible with many years of comparatively good health. Instances are known in which patients have survived fifteen and even twenty years after the detection of the renal affection, and the physical and mental powers are frequently re- tained without serious impairment for six or eight years. Yet the con- dition is liable to so many complications, often fatal, that no security to life is afforded. Cerebral hemorrhage, uremia, oedema of the lungs and glottis, may occur suddenly in the midst of apparent health. Treatment.—The object of treatment is in the majority of cases merely the protection of the patient from the consequences of the disease ; for the nature of the primary affection is often undiscoverable. The attempt to arrest the increase of connective tissue in the kidney by remedies addressed to that organ must be, and as a matter of fact is, futile, since this cirrhosis is merely one result of a constitutional condition. In those cases in which a definite cause can be assumed, such as syphilis or lead poisoning, the administration of remedies known to counteract these specific influences is occasionally followed by success. The iodide of potassium with or without the bichloride of mercury has been known to arrest the morbid changes in the kidneys and arteries, and thus to restore the individual to comparative health. Since, moreover, a syphilitic taint may lurk unsuspected and un- discovered, the iodides may be in almost every case administered with propriety. In most instances, even in some of undoubted syphilitic history, these remedies produce no appreciable effect in arresting or even retarding the morbid process. Certain other drugs have seemed at times beneficial; thus Bartholow recommends the chloride of gold, and says, "Better results even " (than the iodides), "the author believes, are procured from the careful and persistent administration of the chloride of gold or of gold and sodium." "These remedies, intended to arrest the hyperplasia of the con- nective tissue, should be prescribed with a definite relation to the presumed cause—iodide of potassium and bichloride of mercury, in those with a DISEASES OF THE KIDNEY. 219 syphilitic history ; iodide of potassium in those poisoned by lead ; and chloride of gold and arsenic in those cases of unknown origin." Aside from such measures of doubtful utility, nothing can be done by drugs to check the increase of connective tissue in the kidney or the de- generation and thickening of the arteries. The treatment consists simply in efforts to maintain the nutrition of the patient, and to avoid the numer- ous complications which beset him in the course of the disease. A judicious diet constitutes a most important feature of the treatment. The food should be nutritious and plentiful, but contain no more nitro- genous matter than is necessary for health. The diet may consist largely of milk, eggs, and vegetables ; fat meat is permissible, but lean meat should be taken sparingly. Wines and liquors of all kinds should be avoided un- less required for purposes of stimulation. These dietetic principles, though generally applicable, must not be regarded as inflexible rules ; individual wants and peculiarities often require the use of beer or light wines ; the obstinate dyspepsia which so annoys and debilitates the person, may be re- lieved by these when other measures fail. Careful observation of the effects upon the general condition and the state of the urine must constitute a considerable factor in prescribing the diet. The body should be warmly clothed, the skin being protected by wool in all seasons; the greatest care should be taken to avoid exposure to cold and moisture, since simple wetting of the feet may precipitate a uremic attack. Residence in a warm, dry, and uniform climate has sometimes seemed to retard or even to arrest the disease. Rast of body and mind is conducive to the welfare of the patient and the avoidance of comphcations. Prolonged mental exertion and intense excitement may, like excessive bodily exercise, provoke rapid progress of the disease or the outbreak of complications. It is not desirable to confine the patient to bed or to forbid ample exercise, except during those periods when the heart is especially feeble. It is only necessary to avoid excess of bodily and mental activity which a healthy man may undertake with im- punity ; for the subject of renal cirrhosis is an invalid, .however objection- able and unfounded this idea may seem to him. The loss of albumen can be readily compensated through the food, and does not constitute an important factor of the complaint. Among drugs, iron, quinine, and mineral acids may be administered almost continuaUy. After a long course of iron, headache and gastric dis- turbance are indications for its discontinuance ; it should be renewed after an interval of rest. Some experimentation may be necessary to discover the most suitable form for the administration of iron ; the most generally useful is Basham's mixture, though the citrate of iron and quinine may be substituted for a time with advantage. Some of the complications which render this disease so dangerous arise from hypertrophy of the heart and degeneration of the vascular walls. We are acquainted with no means for arresting either of these processes ; in fact, an attempt to prevent the cardiac hypertrophy would be unjustifiable and, if successful, disastrous, since the continued activity of the kidney can be maintained only by increased effort on the part of the heart. The only safety against complications on the part of the circulatory organs lies in the avoidance of physical and mental exertion and excitement. At a later period it may become necessary to stimulate rather than quiet the heart; for after a time the compensatory hypertrophy, which at first enables the kidneys to excrete the usual amount of solids, fails to keep pace with the increasing degeneration of these organs, or gives place to 220 DISEASES OF THE URINARY ORGANS. dUatation or fatty degeneration of the heart-muscle. This failure of the heart is indicated by the diminished excretion of urine and by the increased percentage of albumen ; it caUs for cardiac stimulants, especially digitalis. A uremic attack may be expected, if the amount of urine is de- cidedly decreased. Many premonitory signs may occur ; such are muscu- lar twitchings, sudden failure of sight, double vision, intense occipital pain, cerebral excitement, insomnia, etc. The occurrence of any of these should lead to an immediate examination of the urine ; if the amount is decreased, the albumen increased, or the solids lessened, the skin and bowels should be stimulated without waiting for pronounced uremic symptoms. Purgatives and a hot bath or wet-pack often suffice in the earlier stages of the disease ; at a later period it is necessary to employ pilocarpine subcutaneously, as already directed. The inhalation of chloro- form or amyl nitrite, chloral by the mouth or rectum, or a hypodermic in- jection of morphine in large doses, as practised by Loomis, may be required to control the convulsions. In the treatment of the numerous complications which arise in the course of the disease—dyspepsia, diarrhoea, inflammation of serous mem- branes, asthma, etc.—one fact is to be borne in mind, namely, that since the renal activity is impaired, the elimination of drugs is less rapid and complete than in other conditions ; hence powerful remedies, especially narcotics, must be employed with the greatest caution. Some of these complications, especially those manifested by the digestive tract, may be averted and abated by the daily use of warm baths, whereby the ex- cretory activity of the skin is favored. The various troubles originating in cerebral congestion may be to some extent avoided by securing regular evacuations from the bowels ; in case of emergency such congestion may require venesection, though depressing measures are in general contra- indicated. Fatty Degeneration of the Kidney. This condition is usually associated with fatty degeneration of other organs, and is found in various anemic and cachectic states—con- sumption, scrofula, pernicious anemia after profuse hemorrhage, chronic suppuration, etc. It is observed as an accompaniment of acute febrile affections, especially the infectious diseases; it may result from ex- tensive disease or injury of the skin, such as burns, and may follow the prolonged or excessive use of various toxic agents, such as phosphorus, arsenic, etc. _ Fatty degeneration is frequent in old age without other apparent cause ; it is then usually associated Avith a simdar condition of the liver and of the heart. This state of the kidney is not usually recognizable during life. It is often accompanied by a slight albuminuria, and it is said that in a few cases fat has collected in appreciable quantity so as to make a slight scum upon the surface of the urine. Since the fatty kidney performs fairly well its functions, and since other organs similarly affected (especiaUy the heart) are apt to fail earlier than the kidney, the con- dition of the latter constitutes no imperative requirement for medication ; moreover, treatment offers a hope of success only when it can be employed for the removal of a known cause, such as anemia or phos- phorus poisoning. DISEASES OF THE KIDNEY. 221 Suppurative Nephritis. This form of renal inflammation differs from Bright's disease both anatomically and etiologically ; it is not a diffuse but a circumscribed in- flammation. Etiology.—It may result either from direct extension of a previous in- flammation, or from metastasis, the transfer of inflammatory elements from other organs b}r means of the blood ; also from direct mechanical in- jury to the kidney. Suppurative inflammation by extension of the inflammatory process is most frequent after cystitis and pyelitis ; it so frequently follows the last-named affection that it is often termed pyelo-nephritis. This name is properly applied only to cases of suppuration in the kidney following pyelitis, and ignores instances in which the disease is produced by other influences. It may also be induced by the extension of a perinephritic inflammation, the result of wounds or injury in the renal region. Concretions in the substance of the kidney, infectious emboli from dis- tant foci of inflammation, are occasional causes. It is possible that certain acrid diuretics, such as cantharides, copaiba, and turpentine, may by simple contact arouse suppurative inflammation in the pelvis and the kidney. Suppurative nephritis of metastatic origin may occur during any of the septic diseases ; it is not unusual in pj'emia, septicemia, puerperal fever ; but occurs with especial frequency in cases of ulcerous endocarditis. Yet it may also result from local inflammations of septic origin without general infection ; Buttcher has described a remarkable case of pulmonary ab- scess, with secondary abscess in the kidney ; in the latter were found elastic fibres from the lung, demonstrating the origin of the local renal in- flammation in an embolus from the lung. The extension of inflammation from the tissues surrounding the kidney or from the lower urinary channels is the most frequent cause of suppura- tive nephritis. Thus it occurs as the result of psoas abscess, tuberculosis of the vertebre, abscess of the liver or of the spleen ; more frequently from inflammation in the bladder or the pelvis of the kidney; and these may be in turn induced by most diverse pathological processes and oper- ative procedures in any portion of the urinary channel. Thus the presence of stones in the bladder or in the pelvis of the kidney, occlusion of the ureter by renal calculi, hypertrophy of the prostate are sometimes followed by suppurative nephritis ; the numerous conditions of the bladder and ureter which require operative interference are extremely productive of renal suppuration. Paresis of the bladder as it occurs during disease of the spinal cord and in old age from hypertrophy of the prostate, strict- ure of the urethra, phimosis, frequently call for surgical interference, which is apt to be followed by suppurative nephritis. In previous pages atten- tion has been already directed to the condition known as " negative press- ure "—that condition in which, in consequence of obstruction to the evacuation of the urine, distention and increased pressure in the urinary channels behind the obstruction occur. The sudden relief of this in- creased pressure by the removal of the previously existing obstruction is followed by intense congestion and inflammation of the previously dis- tended channels ; hence it happens that operations for phimosis, division or divulsion of a narrow stricture, the evacuation of the bladder by lithot- omy or hthotrity, even the introduction of a catheter, may be sufficient to 222 DISEASES OF THE URINARY ORGANS. induce this inflammatory process. The frequency of suppurative nephritis after these surgical procedures has caused the adoption of the name "sur- gical kidney " to designate this affection. It is worthy of note that although the inflammatory process usually in- volves the bladder before proceeding to the kidney, yet in some cases severe and even fatal inflammation of the latter organ occurs without pro- nounced inflammation of the lower urinary passages. In some few cases the formation of concretions in the substance of the kidney itself has been followed by suppuration in the organ ; renal abscesses are occasionally found in the subjects of diabetes. Rare cases are recorded in which sup- purative nephritis appears to have been the direct result of injury, such as a blow or wound over the kidney ; in such instances the renal inflammation is usually subsequent and apparently secondary to suppuration in the peri- nephritic tissue. In stiU other cases no cause can be assigned for the origin of the disease. Morbid Anatomy.—This varies with the stage of the affection. The size of the organ may not be abnormal, but its surface and parenchyma are studded with grayish points, often round, at times linear, and varying in size from the limit of the visible upward. At a later stage abscesses are seen ; indeed, the entire organ can be transformed into a mass of pus from the coalescence of the initial abscesses. The capsule of the kidney is thickened and adherent, and at times per- forated by openings which may lead into any of the neighboring organs— colon, liver, lungs, small intestine, stomach, into the peritoneal cavity or even through the abdominal wall; in other cases the pus does not extend beyond the mass of fat which envelops the kidney, but this may be so en- larged and distended as to constitute an extensive tumor readily percepti- ble through the abdominal wall. In many instances the pus undergoes cheesy degeneration, which may be followed by calcification, at least in spots. Sometimes the cheesy mass is more or less completely absorbed and replaced by a growth of connective tissue, Avhieh results in contraction and deformity of the kidney. The extent and subsequent changes depend largely upon the cause of the suppuration ; when clue to inflammation of the lower urinary passages, concretions, or traumatic influence, the inflammation is often limited to one kidney ; if caused by metastatic deposits, on the other hand, both kidneys are usually affected. Upon microscopic examination a considerable portion of the renal sub- stance may be found of normal appearance ; in the immediate vicinity of the abscesses there are evidences of acute inflammatory condition. Upon examining a miliary abscess there will always be found, in cases of metas- tatic origin, and often in those resulting from inflammation of the bladder, masses of micrococci in the walls of the abscess and mingled with the pus. If the observer be fortunate enough to have included in his section an in- cipient abscess, so small that the contents do not fall out in the prepara- tion of the object, he wUl find that the centre is composed of a mass of these spherical bacteria, usually constituting an embolus in a minute blood-vessel—one of the intertubular capillaries or a capiUary loop in a glomerulus. Occasionally such an embolus is found before suppuration has occurred ; the mass of micrococci is surrounded by a zone of inflamed renal tissue, the epithelial cells being swollen and granular ; a few scat- tered leucocytes are observed, indicating the beginning of abscess forma- tion. In metastatic suppurative nephritis the masses of micrococci are often DISEASES OF THE KTDNEY. 223 observed as grayish stripes, which are found to be blood-vessels filled with these organisms. In the cases which arise by extension from the bladder and ureter, the bacteria are observed as plugs filling the urinary tubules. The pelvis of the kidney usually exhibits morbid appearances ; it is dilated, the mucous membrane is swoUen, perhaps eroded and coated with thick mucus and pus. The ureter is the seat of similar changes. Calculi or masses of pus are found in the pelvis and in the dilated ureter. Symptoms.—The symptoms vary according as the pelvis of the kidney is or is not extensively implicated in the inflammatory process, the symp- toms of pyelo-nephritis being somewhat different from those of a suppu- rative inflammation limited to the kidney alone. In the latter case the recognition of the affection is ordinarily difficult or impossible. So long as the pus is produced as miliary abscesses only— a condition usuaUy consequent upon ulcerous endocarditis or other septic process—no symptoms are observed which direct attention especiaUy to the kidney ; there may be a chill and fever, but these occur as a part of the primary affection. The collection of pus in larger quantities is usually followed by the famihar symptoms of such condition—repeated chills, re- mittent fever, profuse perspiration, emaciation, and diarrhoea ; while these symptoms indicate suppuration in some internal organ, they do not locate the process in the kidney. Sooner or later various symptoms may be manifested which indicate that the renal tissue is the seat of a morbid process. Pain and tenderness upon pressure in the region of the kidney are frequent, though by no means constant phenomena. The pain is most severe in the loin, but radiates toward the navel, into the groin and down the thigh ; contraction of the cremaster is often observed. Limitation in the movement of the lower extremity on the corresponding side is an occasional symptom, more fre- quent after the inflammation has extended to the perinephritic tissue or the pelvis. Sometimes the patient can rest easily only on the opposite side ; or he may find least discomfort when he lies upon the abdomen. Tne pain is often intermittent or remittent in character, and is sometimes increased to an agonizing degree. A tumor may be observed when the suppuration has become extensive. This is rarely seen until the pus has broken into the pelvis of the kidney The distinction of this from other tumors which may occupy the same locality is by no means easy. The extent and location of these tumors may vary considerably, and they present no peculiar and characteristic features. Distinct fluctuation is not frequent. Abscess of the kidney can sometimes be distinguished from perinephritic abscess by the fact that the former is less profuse and is susceptible of more definite limitation ; from tumors of the spleen and hver by the absence of movement during respiration, and by palpation, since the fingers can be inserted between the tumor and. the spleen or liver. The urine furnishes some information ; the most constant abnormal ingredient is blood, which may be present in such amount as to give the urine a smoky color, or in such small quantity as to be recognizable only by the microscope. Pus may be absent until an abscess of considerable size has opened into the pelvis ; and even if present, the source of the pus cannot be definitely located, unless accompanied by other elements, such as fragments of renal tissue. Even though there exist a tumor in the renal region, one cannot be sure that pus found in the urine proceeds from the kidney substance or renal pelvis ; thus Ogle observed a case in which a large abscess formed behind the left kidney from caries of the 224 DISEASES OF THE URINARY ORGANS. second lumbar vertebre ; the pus burrowed downward and broke into the bladder. The urine always contains albumen, which may be no greater in amount than is naturally furnished by the pus and blood present; in pyelo-ne- phritis, on the other hand, the amount of albumen often exceeds that which would correspond to the pus, and may be considerable even when there is but little sediment. Tube-casts are often found, usually only the hyaline and granular forms, though occasionally an epithelial cast or one composed whoUy of bacteria is cliscoverd. ' In a few cases small portions of renal tissue have been expelled with the urine ; Wiederhold saw such a piece as large as a pigeon's egg and containing distinct urinary tubules. The discharge of such pieces locates definitely the seat of the suppuration, but is so rarely observed as to be practically unavailable. So soon as the pus has escaped into the perinephritic tissue, various additional symptoms may be manifested. The pus may burrow into the skin, which becomes swollen, oedematous, and doughy ; or it may perforate the intestine, causing purulent stools ; into the peritoneum, etc ; indeed the case then becomes one of perinephritic inflammation. In a few cases pa- ralysis of one or both legs has been seen, apparently the result of an as- cending neuritis, originating in or around the kidney and extending to the spinal cord. In most cases of suppuration in the kidney the pelvis becomes sooner or later involved in the morbid process. In many other cases the inflam- mation has extended from the pelvis to the kidney. A suppurative ne- phritis is, therefore, either from the beginning or at a later stage, a pyelo- nephritis ; the inclusion of the pelvis in the morbid condition renders the diagnosis less difficult. Pyelitis and Pyelo-nephritis. In every case of pronounced pyelitis the inflammatory process extends to the renal papille which project into the pelvis ; anatomically, therefore, there may be no grounds for distinguishing a pyelitis from pyelo-nephri- tis, but clinically such distinction is quite important; an inflammation of the pelvis implicating only the papillary portion of the kidney is distinct in symptomatology, prognosis, and treatment from one in which the in- flammation extends to the deeper portions of the organ. Pyelitis may be a primary or secondary affection, and may pursue an acute or chronic course ; it is usually chronic and secondary, and, therefore, like cystitis, a symptom of other morbid conditions. Its course, duration, and termination are determined largely by the affection which produces it. The inflammation is at first catarrhal, but may rapidly become purulent or hemorrhagic ; croupous and diphtheritic inflammations of this as of other mucous membranes are observed in the course of certain infectious diseases. Yet diphtheritic pyelitis is far less frequent than the report of autopsies indicates; ulceration and necrosis of the mucous membrane is not necessarily an evidence of diphtheritic inflammation, since it is a fre- quent feature of simple purulent pyelitis. Some blood escapes into the pelvis during the ordinary catarrhal and purulent inflammation ; the quan- tity is much greater in those constitutional conditions which include a tendency to extravasations in the mucous membranes generally, presuma- bly from abnormal conditions of the blood or blood-vessels—scurvy, per- DISEASES OF THE KIDNEY. 225 nicious anemia, hemorrhagic small-pox. OUivier has described under the name pyelo-nephrite hemato-fibrineuse a hemorrhagic form of pyelitis which is peculiar to old age, and is apparently a local manifestation of general arte- rial disease ; there exists a sclerosis of the arteries and consequent tendency to the formation of aneurisms. The rupture of miliary aneurisms in the pel- vic mucous membrane is followed by the formation of clots, which are sup- posed to produce an inflammation by mechanical irritation. Etiology.—Simple retention of urine, due to some mechanical impedi- ment in the urinary channel, is sufficient to produce pyelitis ; this inflam- mation is therefore a frequent sequence of urethral stricture, prostatic hyper- trophy, vesical calculi or neoplasms, paresis of the bladder, tumors (especially cancerous) of the womb, pregnancy, etc. The ammoniacal decomposition of the urine is not essential for the production of pyelitis, though the in- flammation is much aggravated when such decomposition occurs. So long as the surgeon refrains from instrumental interference in the bladder and urethra, the urine retained in the pelvis and bladder rarely undergoes the ammoniacal change ; and if such instrumental interference—the introduc- tion of a catheter, dilatation of a stricture, removal of a vesical stone, etc. —be intelligently performed, but little if any aggravation of either pyelitis or CA'stitis need occur. When, however, such operation is performed with- out reference to the condition of the bladder, an aggravation of an existing pyelitis, usually with ammoniacal fermentation of the retained urine, is the regular result (see Urethral Fever). Pyelitis also arises as a simple extension of inflammation, most fre- quently in the bladder, but occasionally in the kidney or perinephritic tis- sue. Cystitis induced by mechanical irritation of a stone, eAren Avithout instrumental interference, usually produces pyelitis also—a complication which materially lessens the patient's chances for recovery after operation ; hence the earliest possible removal of the stone is desirable. It is a familiar observation that pyelitis is a frequent affection during pregnancy as Avell as in the puerperal state ; also after gynecological op- erations. Different etiological factors are responsible for various cases. There can be no doubt that the pyelitis A\Thich originates during pregnancy is frequently produced by simple retention of urine in consequence of compression of the ureters by the enlarged uterus ; while the cases winch arise after delivery are produced partly by the extension of pelvic inflam- mations and partly by the sudden evacuation of the urine previously re- tained in the distended pelvis ; probably many of the so-called " idiopathic " cases of puerperal pyelitis originate in this way. It is Avorthy of note that even when pyelitis seems unmistakably to have been produced by an ex- tension of vesical inflammation, the mucous membrane of the interven- ing ureter may exhibit little or no abnormality. The acute and severe infectious diseases may produce an inflammation of the renal pelvis as of other mucous membranes ; among these are cholera, small-pox, diphtheria, and the septic diseases ; diabetes and the acute gastro-enteritis of nurslings are also frequently complicated with pyelitis. The inflammation which occurs during the acute infectious diseases is often croupous or diphtheritic ; it possesses comparatively little clinical sig- nificance because it is often overlooked, and because its importance is overshadowed by the constitutional affection. Foreign bodies in the pelvis—blood-clots, fragments of tissue, parasites —arouse pyelitis either by direct mechanical irritation or by serving as nuclei for the formation of renal calculi; calculous pyelitis is doubtless the most frequent of all forms. 15 226 DISEASES OF THE URINARY ORGANS. The administration of certain irritant drugs—cantharides, balsams, turpentine, etc.—is credited Avith the responsibility for certain (doubtless rare) cases of pyelitis, usually of the croupous variety. Neoplasms may also originate the disease ;"it is a regular feature of cancer or tuberculosis of the pelvis or kidney. ^ In a certain number of Cases no definite cause can be assigned; hence they are referred to "taking cokl." The implication of the ^fclney may consist merely in a catarrh of the straight "tubules, or may amount to a suppurative nephritis ; the extent of the renal implication is determined chiefly by the cause. Suppurative nephritis is especially frequent in those cases produced by inflammation and operation in the lower portion of the urinary channel. Morbid Anatomy.—The morbid appearances vary according to the stage and degree of the inflammation ; they are in general those of catarrh of a mucous surface. Ulceration may occur even when no foreign bodies are present. In cases of chronic pyelitis capillary new formations project into the cavity, covered with a deposit of urates and phosphates. Dilatation of the pelvis is usual in chronic and frequent in acute pyelitis; it seems to result from temporary occlusion of the ureter, either by simple swelling of the mucous membrane, or by plugs of mucus, pus, and blood. Hydro- nephrosis and pyonephrosis in slight degree may occur; indeed, extreme dilatation of the pelvis and consequent atrophy of the renal tissue is a pos- sible result. Masses of cheesy pus mixed with urinary salts are commonly found. When the kidney also is inflamed, it presents the morbid appearances of suppurative nephritis or of a diffuse inflammation, at first affecting the pyramids and subsequently involving the cortical portion ; chronic inter- stitial nephritis, and even complete atrophy of the kidney may follow the occlusion of the ureter and pelvis by caseation and calcification of pus. Symptoms.—Simple catarrhal pyelitis often exists undetected during life, partly because it may occur without pronounced subjective symptoms, and partly because the objectiAre symptoms are chiefly to be discovered by an examination of the urine—wdiich is not always made ; in many cases. too, the primary lesion is of such a nature as to obliterate the distinctive features of pyelitis ; such is the case when it results from chronic cystitis, puerperal affections, operations upon the pelvic viscera, etc. Acute pyelitis may be ushered in Avith severe chill and fever, perhaps vomiting also; acute pain over the kidney and radiating into the groin may be experienced. Such cases are comparatively rare, and are distinctly observed chiefly during pregnancy and the puerperal state, and as a com- plication of gonorrhoea. In chronic cases there may be no distinctive symptoms aside from the characters of the urine. When associated, as it frequently is, with cystitis, frequent and somewhat painful urination may be the subject of complaint, the patient voiding but little urine at a time. This symptom is also seen without inflammation of the bladder, when the pyelitis is of calculous origin; and because associated with pus and blood in the urine, it may mislead the physician into a diagnosis of cystitis. Pain in the loin is a frequent though not constant symptom ; it may be of a dull aching character and occasionally sharp and severe, suggestive of renal colic. In the latter case it is felt along the course of the ureter, in the genitals, perhaps in the thigh. This pain seems to be caused largely by transient hydronephrosis ; it varies in severity with the freedom with which the urine is discharged, being greater when temporary obstruction DISEASES OF THE KIDNEY. 227 and oliguria exist. It may be felt over both kidneys, even when the in- flammation exists on one side only. There is frequently some tenderness upon pressure over the kidney. Variations in the quantity of pus discharged with the urine are often quite characteristic of this affection. If the ureter of the affected side be obstructed by pus, mucus, concretions, etc., the pus disappears from the urine evacuated, since this is furnished by the healthy kidney ; after a time the obstruction is overcome and a sudden discharge of pus Avith the urine is noticed. These phenomena are accompanied by corresponding symp- toms ; during the excretion of clear urine—while the opposite ureter is obstructed—constantly increasing pain and tenderness on the affected side, perhaps a chill, fever, and vomiting are noticed. The copious evacuation of turbid urine occasions an immediate subsidence of these symptoms. In occasional cases the obstruction to the ureter produces such a de- gree of hydronephrosis as to cause a perceptible swelling in the region of the kidney. The dimensions of this tumor vary with the other symptoms ; it increases in size Avhen the urine becomes clear and the pain severe, and diminishes Avhen the pus is again discharged and the pain subsides. The characters of the urine vary Avith the cause and compli- cations of the pelvic inflamma- tion. If there be no ammonia- cal decomposition in the lower urinary channels, the urine is acid, pale, and in a pronounced case has a low specific gravity, due to the fact that the quan- tity excreted in twenty-four hours is much increased (e\'en to twice the usual amount). This polyuria is especially great in cases Avhere chronic inflam- mation and cirrhosis of the kid- ney have supervened. It may be so pronounced as to mislead into a diagnosis of diabetes in- sipidus, a mistake to which Op- Fio. 13.—Sediment from Acute Pyelitis ; Epithelial Cells DOlzer CaUed attention from the Pelvis, Leucocytes, and Blood-corpuscles. The sediment contains pus and blood, the amount varying at different times even in the same case (Fig. 13). The pus-corpuscles are often massed into plugs or threads, similar to those produced in the urethra during gleet. Numerous epithehal cells are seen, and it has been asserted that the locality of the suppuration can be recognized by the appearance of these accompanying cells. Now, it is true that in pyelitis short columnar cells with large nuclei, adherent in masses, are especiaUy frequent; but neither the arrangement nor the form of the cells is characteristic of pye- litis ; for these, as weU as the caudate and bipolar cells often considered characteristic of this affection, are also produced in the bladder and urethra. It is unsafe, if not impossible, to base a diagnosis of pyehtis upon the epithelial cells found in the sediment. So soon as the inflammation has extended to the tubules of the kidney (and even before, if there be decided fever) hyaline casts appear in the sediment ; the presence of granular casts may be regarded as indicating the implication of the kidney, i.e., pyelo-nephritis. In cases of cysto- 228 DISEASES OF THE URINARY ORGANS. pyelitis, casts composed of or thickly covered with bacteria are seen (Fig. 14). The urine always contains albumen, even though but little pus be pres- ent ; the extension of the inflammation to the kidney is indicated by a still greater percentage of albumen. This excess of albumen over the quantity which can be expected from the amount of pus present is, there- fore, in afebrile cases, an important item in recognizing the implication of the kidney ; yet it is less decisive than the evidence furnished by the mi- croscope. FlO. 14.—Sediment from Pyelo-nephritis; Casts studded with Bacteria, Epithelium from the Pelvis, Leucocytes, Blood-corpuscles and scattered Bacteria (Fiirbringer). The kidney becomes the seat either of a diffuse inflammation sometimes terminating in cirrhosis, or of a suppurative nephritis. The latter is the rule when cystitis also exists—therefore, after injudicious use of the catheter or instruments—and is especially frequent in old men at the commencement of " catheter life."' This complication is marked by remittent fever, fre- quent chills, somnolence, a small and rapid pulse ; in short, the features of subacute uremia or pyemia. In old men the fever and constitutional dis- turbance may be slight, and the source of the difficulty overlooked. The pyelitis of the puerperal state is usually indicated by pronounced symptoms which cannot be overlooked nor misinterpreted. Its onset is marked by chill, fever, and pain over one or both loins ; there is decided tenderness in this locality. The pain is acute and may simulate renal colic. The urine is acid and contains a decided amount of albumen and some pus. An acute pyelitis is occasionally seen during or immediately after gon- orrhoea ; it is secondary to cystitis and is marked by pronounced symptoms —chill, fever, severe pain in the loin, occasionally vomiting and intense headache. In the Venereal Clinic at Vienna, Finger saw this complication twelve times among four hundred and ninety-five cases. It is usuallv of brief duration ; is favored by bodily exertion and indulgence in alcoholics. DISEASES OF THE KIDNEY. 229 In a few cases the subsidence of the pyelitis has been accompanied by the disappearance of both cystitis and gonorrhoea. In a few rare cases (Vidal, Rosenstein) severe pyelo-nephritis has originated during the course of gonorrhoea and has become chronic. Diagnosis.—A pronounced case of acute pyelitis is as a rule easily rec- ognized by the symptoms already mentioned. Chronic pyelitis, on the other hand, is frequently for a long time over- looked ; and Avhen pus is discovered in the urine, great care is necessary in distinguishing betAveen pyelitis and cystitis. The reaction of the urine does not serve to differentiate, since it may be acid or alkaline in either of the two affections ; the form of the epithelial cells and the percentage of albumen afford a probability but not a certainty in diagnosis. The appear- ance of hyaline, granular, and bacterial casts with the pus makes the diag- nosis quite positive. In the absence of these elements the existence and location of pain are important features. Pyelitis is frequently painless ; the pain if felt is often referred to the loins. Cystitis is rarely painless, and the pain is felt behind the symphysis and in the perineum. These are, however, by no means absolute rules, since the pain of pyelitis is some- times referred to the bladder-neck and is accompanied with frequency of micturition. When secondary to cystitis, pyelitis 7 Irritability of the bladder in tumor, 285 Irritable weakness, 337 Ischaemia of the kidney, 174 Kidney, absence of one, 3 amyloid degeneration of the. 175 atrophy of the, 175 bleeding from the pelvis of the, 144 Buret on displacement, 2 cirrhosis or chronic interstitial nephri- tis, 183 diagnosis of amyloid degeneration, 179 ; venous congestion of tbe kid- ney, 172 diffuse nephritis, Bright's disease, 182 displacement of the, 2 etiology of the, 171 fatty degeneration, 220 morbid anatomy in amyloid degener- ation, 177 ; in embolism, 181 ; in is- chaemia, 174; in venous congestion, 171 portion of the urinary channel, 4 prognosis of ischaemia, 174 relation to the lower rib, 3 removal of one, 4 slight attachment, 1 symptoms and course of amyloid de- generation, 178 ; of ischaemia, 174 symptoms of embolism, 181 ; of ve- nous congestion, 172 treatment of amyloid degeneration, 180; of venous congestion of kid- ney, 173 venous congestion, 171 Kupfer's researches, 7 Lange, removal of one kidney, 4 Leptothrix in urine, 157 Lesions of urethra or bladder, 51 Leucin and tyrosin, 141 Lipuria, 133 Lithotomy, 6 Local inflammations in the genital organB, 325 treatment in chronic prostatitis, 312 Malpighian tufts, 97 Masculine sterility more frequent than feminine, 342 Masturbation, 322-324 Mechanical irritation of rectum and vagi- na, 55 in cystitis, 268 Method of applying electricity in enuresis, 303 Microscopic examination of urine for tu- mor of the bladder, 290 Mineral waters for renal calculi, 239 Morbid anatomy in acute nephritis, 177 in amyloid degeneration of kidney, 177 in cancer of the kidney, 255 in chronic nephritis, 199 in chronic prostatitis. 307 in cirrhosis of the kidney, 209 in cystitis, 270 ' in embolism of the kidney, 181 in hydatids of the'kidney, 260 in hydronephrosis, 246 in perinephritis, 265 in pyelitis, 226 in suppurative nephritis, 222 in tuberculosis ot the kidney. 251 of the kidney in ischaemia, 174 of the kidney in venous conges-tion, 171 Morbid conditions affecting other than the genital organs, 317 growths, fragments of, in urine, 153 Mucous casts in urine, 151 Myomata of the bladder, 284 Necrotic fragments of vesicnl tumor con- taining crystals of hematoidin, 289 Nephritis, acute. 182-184 chronic pare nchymatous, 182 etiology of acute, 184 ; suppurative, 221 of diphtheria, 192 Nerve supply to the bladder, 11 Neurosis of the bladder, 293 Nitrogen equilibrium, 102 Nocturnal pollutions, 321 Obstruction of ureter from displacement or enlargment of uterus. 8 Obstructive albuminuria, 124 Origin of tube-casts in urine, 150 Otis' urethrometer, 85 Oxalate calculi, 240 of calcium, 140 Oxaluria, 140 Patn, symptoms in tumor of the bladder, 286 Parasites in the urinary organs, 154 INDEX. 349 Paresis of the bladder, 297 treatment, 298 Pathology of the urine, 100 Pelvis and ureter, 6 Perinephritis, 264 diagnosis, 26(5 morbid anatomy, 265 symptoms, 265 Perityphlitis, 267 Physiology of the urine, 95 Pollutions, 320-J.22 clinical history, 326 diagnosis, 328 from certain constitutional diseases, 326 from organic disease of the spinal cord, 326 local treatment, 330 treatment, 328 Polyps of the bladder, 284 Position of the vesical orifice of the ure- thra, 13 Precaution in vesical paresis, 299 Preventive treatment in renal calculi, 238 in acute nephritis, 194 in amyloid degeneration of the kid- ney, 180 in cancer of the kidney, 260 in chronic nephritis, 205 in chronic prostatitis, 309 in cystitis, 274 in ischaemia of kidney. 174 in pollutions, 328 in pyelitis, 229 in renal calculi, 237 in renal cirrhosis, 218 in tuberculosis of the kidney, 254 Propeptone in urine, 114 Prostatic casts, 153 discharge, 310 disorders, 304 hyperaesthesia, 339 urethra, 16 Prostatitis, acute form, 304 chronic, 307 diagnosis, 306 symptoms, 304 treatment, 306 Prostatorrhoea, 308 Psychrophor of Winternitz, 312 Puncture in hydronephrosis, 250 Pus in urine, 147 Pyelitis, acute, 226 diagnosis of, 229 etiology, 225 morbid anatomy, 226 or pyelo-nephritis. 221-224 sediment from, 227 symptoms, 226 treatment, 230 Pyelo-nephritis, sediment in urine, 228 Quantity of urea excreted, 103-159 Ratio between tissue metamorphosis and urea, 101 Reaction of the urine, 136 Rectum, examination of urinary organs per, 34 Renal calculi, 231 alkalies, 240 alkaline remedies, 242 causes and conditions, 232 cylinders of ammonium urate, 243 diagnosis, 236 mineral waters, 239 preventive treatment, 238 prognosis, 237 symptoms, 234 treatment, 238 vegetable acids, 240 Renal cirrhosis, diagnosis, 217 diet, 219 prognosis, 218 treatment, 218 sediment in urine, 216 Renal colic, 234 abortive, 236, 237 Renal cysts, 263 haematuria, 145 tuberculosis, primary, 251 Sarcoma of the kidney, 255 Sarcomata of the bladder, 285 Scarlatinal nephritis, duration, 192 Scarlet fever as cause of acute nephritis, 185-187 Sediment from acute cystitis, 272, 273 from chronic nephritis, 203 in urine from acute nephritis, 189; from acute pyelitis, 227; from cal- culous pyelitis, 236 ; from pyelo- nephritis, 228; from renal calculi, 243 ; from renal cirrhosis, 216 Sediments in urine, 143 peculiar to alkaline urine, 142 Seminal ejaculations, 321 incontinence, 320 Sexual act, analyzed, 321 excesses, 324 organs, defective, 337 Solution for injection in chronic prosta- titis, 313 Sound used in chronic prostatitis, 312 Spasm of the bladder, 294 Spermatic crystal, 310 Spermatorrhoea, 320-330 clinical history, 331 diagnosis, 331 importance of correct diagnosis, 332 prognosis, 333 treatment, 333 Spermatozoa, 153 causes of absence, 342 vitality impaired, 343 Sphincters of the bladder, 11 Sterility, 340 compared in male and female, 340 Strictures, urethral, 38 Strongylus gigas, 154 Suppurative nephritis, .221 morbid anatomy, 222 350 INDEX. Suppurative nephritis, symptoms, 223 Symptoms and course of acute nephritis, 188 and course of amyloid degeneration of kidney, 178 and course of ischaemia of the kid- ney, 174 of cancer of the kidney, 256 of cirrhosis of the kidney, 212 of chronic nephritis, 200 of chronic prostatitis, 307 of cystitis, 271 of disease of the kidney, 172 of embolism of the kidney, 181 of hydatids of the kidney, 261 of hydronephrosis, 246 of perinephritis, 265 of prostatitis, 304 of pyelitis, 226 of renal calculi, 234 of suppurative nephritis, 223 of tuberculosis of the kidney, 252 of tumor of the bladder, 285 Syphilis of the kidney, 250 Tampon, 81 Tests for sugar in urine, 162-169 The chlorides in urine, 110 phosphates in urine, 110 sulphates in urine, 111 trigonum, 13 Therapeutics with the endoscope, 81 Treatment in acute nephritis, 194 in acute prostatitis, 306 in amyloid degeneration of the kid- ney, 180 in cancer of the kidney, 260 of chronic cystitis, 277 of chronic nephritis, 206 in cystitis, 275 in chronic prostatitis, 311 of hydatids of the kidney, 263 in hydronephrosis, 249 in impotence, 338 of incontinence of urine, 301 of paresis of the bladder, 298. in pollutions, 328 in pyelitis, 230 in renal calculi, 238 in renal cirrhosis, 218 of renal colic, 242 in spermatorrhoea, 333 of tuberculosis of the kidney, 254 of tumors of the bladder, 291 in venous congestion of the kidney, 173 of vesical spasm, 296 Tube-casts, clinical significance of, 151 in urine, 147 Tubercular cystitis, 282 Tubercu osis of the kidney, 251 diagnosis, 253 morbid anatomy, 251 prognosis. 254 symptoms, 252 treatment, 254 Tumor of the bladder, 9, 283 benignant, 284 course and duration, 291 diagnosis, 285 irritability, 285 symptoms, 285 treatment, 291 Tumors of the urethra, 75 removed Irorn the male bladder, 293 Twelfth rib, absence and abnormal brev- ity, 3 Urea, 101 artificial elevation of temperature, 105 as an index to the secretory activity of the kidneys, 104 as to the amount of tissue change, 104 consumption of animal food, 105 clinical estimation, 103 excretion in disease, 106 factors which influence the production and excretion, 104 limitation of the oxygen inspired, 105 poisoning with, carbonic acid, 105 quantitative estimation of, 165 quantity excreted, 103 Ureter, catheterization, 92 Urethra. 17 bleeding from the, 144 congenita] organic strictures, 20 cases of constriction, 86 chronic inflammation of the mucous membrane, 74 dilatation of, 63 erosions and ulcers, 79 hyperaesthesia, 40 inspection of, 69 # intimate association with nerve cen- tres, 54 laceration of the mucous membrane, 57 lesions from instruments, 51 muscles of, 21 polyp, 76 simple granulation, 78 s-pasmodic contraction of muscles, 22 thickening of the epithelium, 74 tumors, 75 Urethral fever, 49 Urethrometer, 84 Uric acid, 139 infarcts, 244 excessive excretion, 1S9 acids and urates, 138, 139, 152 Urinary channel, simple adhesion of op- posing mucous surfaces, 19 hemorrhage from the entire tract, 145 organs, aggravation of pre-existing in- flammation, 51 sediment of blood, 143 sediment of epithelial cells, 143 sediments, 138 tract, congestion from sudden evacua- tion, 57 Urination, frequency, suddenness, pain, 30 manner of, 31 INDEX. 351 Urine, albumen in, 112 accidental ingredients of, 157 acidity of, 136 ammonia, 111 amyloid casts in, 151 appearance of the triple phosphate, 142 bacteria in, 155 bedside tests lor, 166 blood-casts in, 118 blood-clots in, 146 chlorides, 110 clinical examination of the, 158 colors as a test on examination, 161 color of, 146, 160 condition, admixture of blood, man- ner of urination, 31 cooling of the, 139 daily amount of, 135 Dr. Fowler's test, 165 epithelial casts in, 149 examination by heat, 161 excessive acidity of, 139 fatal syncope from too rapid removal of, 52 Fehling's test. 163 fungi in, 155 Gmelin's test, 163 granular casts in, 149 Heller's test, 164 hyaline-casts in, 148 increased by an abundant supply of animal food, 135; arterial pressure, 135; presence in the blood of sub- stance exciting activity in kidney, 135 ; psychical influences, 135 inorganic constituents, 109 leptothrix in, 157 microscopic examination, 146 mucous casts in, 151 nocturnal incontinence, 12 normal ingredients, 100 le, Oliver's test-papers, 168 organized sediments, 143 phosphates, 110 physiology of, 95 picric acid tests, 162 propeptone, 114 pus, 147 quantity of, 159 reaction of the, 136-146 renal cirrhosis, 215 scantiness of, 139 sediments peculiar to alkaline, 142 specific gravity, 146 sulphates, 111 tests for biliary pigment, 163; for chlorides, 164 ; for indican, 164 ; for peptone, 163 ; for sugar, 162-169 too sudden evacuation, 60 traces of fat in, 132 tube-casts in, 147 Ultzmann's test, 164 Urobilin, 109 Use of the sound to discover tumor of the bladder, 287 Ultzmann's discoveries in renal calculi, 232 test in examination of urine, 164 Valves in renal orifice or ureter, 7 Variations in the normal ingredients of the urine, 100 Vascular supply of the bladder, 9 Vegetable acids for renal calculi, 240 Venereal excesses, 316 Vesical calculus, 287 neuralgia, 294 spasm, diagnosis, 296 ; treatment, 296 tumor, 287 tumors in females removed, 292 Villous polyps of the bladder, 284 WAsniNG out the bladder, 277-279 ia3w,, | ✓xs^ J r^%''^K | aan ivnouvn snidicisw do Aavaan tvnouvn snidic i it 3NAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIOh / p- jiaaw do Aavaan tvnouvn snidiqsw do Aavaan tvnouvn 3Niom3w do Aavaan tvnouvn snidk ONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIOr- iiasw do Aavaan tvnouvn 3nidiq3w do Aavaan tvnouvn snidiqsw do Aavaan tvnouvn snidic IONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIOr Diasw do Aavaan tvnouvn snidicjsw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn snidk IONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIOr 3I03W do Aavaan tvnouvn snoiosw do Aavaan tvnouvn 3NiDia3w do Aavaan tvnouvn snidi onal library of medicine national library of medicine national library of medicine natioi * ' JotL C D laaw jo Aavaan ivnouvn 3NiDia3w jo Aavaan ivnouvn 3nidiq3w jo Aavaan ivnouvn snidi TJ^~^ IT - p j o V £i Sf3 '0? 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