Volume 4 — DISEASES OF THE GENITO-URINARY SYSTEM. (continued 2)

The amount of local disturbance produced in the pelvis of the kidney by the presence of a foreign body seems to depend somewhat upon the character of its surface. Rough and uneven calculi, such as oxalate of lime, are apt to produce inflammation much more rapidly than smooth and polished ones, but it is seldom that any calculus remains without some pyelitis. At first only a loss of polish of the mucous membrane, with a little increase of mucus, may be observed, to which succeed roughening and suppuration with occasional fibrinous deposit. The pelvis, more or less dilated, may then contain a quantity of mucopurulent urine, with perhaps some blood, in which are concealed the stones which have given rise to this condition, and often phosphatic deposits not converted into calculi.

Pyelitis is divided by some foreign writers into catarrhal and diphtheritic—a distinction rather of degree than of kind. The mucous membrane of the pelvis may, like other mucous membranes rarely, and like serous membranes often, throw out a fibrinous exudation which takes the form of false membrane. This indicates intensity of inflammation, but has no necessary connection with diphtheria. A true diphtheritic pyelitis, that is, connected with the general disease known as diphtheria, is of course a conceivable lesion, but certainly not a common one.

The renal symptoms—especially true albuminuria, so common and of such grave import in this disease—are due to lesions of the secreting substance, and not of the pelvis. It is important, but not always easy, to decide whether there is more albumen present than is to be accounted for by the pus. The pyelitis may be acute or chronic, being characterized by the intensity of the attack and the rapidity with which the symptoms subside. The prospect of a given attack being acute is decided largely by the supposed cause: a small calculus passing into the ureter undoubtedly gives rise in most instances to a localized pyelitis, which subsides after the cause of irritation has disappeared. An inflammation from a larger one remaining is naturally of slower development, but may be more acute while the calculus remains rough and irritating, and partially subside when it becomes covered with a smoother coating of phosphates. The mucous membrane, however, is not likely to regain a completely healthy condition.

The mucous membrane in severe pyelitis may be deeply eroded, and even perforated, so that the contents of the pelvis escape and give rise to abscess in the perinephritic or prevertebral cellular tissue, which may be discharged through the loins with resulting cure, or the establishment of a fistula, from which issues pus and at times calculi. Among the rarer results of perforation may be mentioned gastro-nephric and duodeno-nephric fistulæ. These might be diagnosticated by the presence of food and other intestinal contents in the urine, provided that the ureter were still pervious. Vomiting of calculi and urine has been reported by the older writers.

The writer is indebted to J. R. Chadwick for references to two modern cases—one where such a fistula was diagnosticated during life;¹⁶ and another where a gastro-nephric fistula was found after death.¹⁷ In the latter case a diagnosis would have been impossible, as the kidney was disorganized and the ureter occluded. The extent to which the renal secreting substance suffers in calculous pyelitis varies considerably, and is very probably connected with the amount of pressure exercised either by the calculus itself when it attains a large size or by the urine in cases of obstruction. It is rare for either pyelitis or hydro-nephrosis to exist entirely independently.

¹⁶ Giornale di Anat. e Fis. path., iii. p. 370.

¹⁷ Marquezy, Thèse de Paris, 1856.

The changes which take place are those of atrophy. Interstitial suppurative nephritis seems to follow this form of pyelitis much less frequently than that which is due to extension upward of disease in the lower urinary passages.

Corresponding to the pressure of solid or fluid, the papillæ are eroded and the straight tubes shortened. In the cortical substance, which soon becomes diminished in thickness, the interstitial tissue is hypertrophied, dense, and hard, while the tubes become smaller or in time disappear. The Malpighian bodies are changed to dense masses of connective tissue, but are still plainly recognizable, irregularly crowded together instead of being arranged as usual in more or less symmetrical double rows. The cortex of the kidney may thus become but little more than a mere skin stretched over a large stone, with perhaps here and there a piece of renal structure recognizable and in a comparatively normal condition.

The extremer grades of hydro-nephrosis do not seem to be met with in this form of atrophy, but the pelvis is considerably dilated, while its internal capacity is also added to by the atrophy of the renal substance. The interior of the cyst thus formed usually retains distinct traces of its original division into infundibula, and may be, as already stated, almost filled by the calculus. Kidneys undergoing this process of degeneration often furnish up to a short time before death a normal, or even more than normal, amount of urine, and one is often astonished to find how little disturbance of elimination has been caused in cases where the true kidney-structure seems to the naked eye to have been almost entirely destroyed.

The DIAGNOSIS of a calculus remaining in the pelvis of the kidney depends chiefly on the determination of hæmaturia and pyelitis for which no other cause can be found, and upon the presence of pain in one loin. It is naturally greatly assisted by the presence or history of renal colic. An aching pain in the loins, more or less permanent, is a frequent but not invariable symptom. It may be such as to prevent the patient from standing upright, and cause him to assume an habitually stooping posture in standing or walking. A careful examination of the urine in conjunction with this symptom, especially if an unusually abnormal condition has been preceded by an exacerbation of the pain, may make the diagnosis almost certain. In the beginning of a case occasional not severe hæmaturia, with some increase of mucus or a little pus, may be all that can lead to the suspicion of calculus as the cause of pain. At a later period an increase of these symptoms, with a considerable quantity of the peculiar irregular epithelium lining the pelvis, may be observed. The latter constituent, however, can hardly be looked upon as entirely conclusive of pyelitis, since the lower urinary passages may give rise to cells of about the same form and size, and the irregularity is likely to be increased beyond recognition by the presence of inflammation. They may also undergo change of form in the urine. The presence of transparent or other casts denotes the irritation of the renal parenchyma.

The point of chief difficulty in the diagnosis of pyelitis is the determination of the origin of the pus, whether from the kidney or the bladder. Cystitis may be only partly excluded by the absence of dysuria. A point of considerable weight is the reaction of the urine, that from the kidneys being usually acid, while that from the bladder, when cystitis of much severity exists, is alkaline or rapidly becomes so. The pus coming from the kidneys is more intimately mixed with the often profuse urine than when formed in the bladder. The whole of it does not in the former case completely subside, but remains in sufficient quantity to form a turbid or opalescent mixture—the polyuric trouble of Felix Guyon, according to whom this condition in an acid urine is strongly indicative of renal as distinguished from vesical lesion. In cystitis the pus subsides in more or less distinct masses, but if the urine is alkaline, or when it becomes so, is altered to a ropy consistency usually spoken of as muco-purulent.

The procedure recommended by Thompson may be resorted to in order to determine whether the urine comes from the kidneys loaded with cellular detritus, or whether the addition is made in the bladder. This consists in washing out thoroughly the bladder with several successive quantities of water through a single catheter, until the water comes away clear and the bladder has contracted itself around the instrument, when the urine from the kidneys will for a time come through direct and comparatively uncontaminated.

In cases where the urine is alkaline in the kidney, which may happen, distinctions founded on the reaction cannot be of value, and the same may be said of cases where cystitis is known to exist, but where there is in addition a possibility of a renal calculus. In these some such mechanical procedure as that just described must be resorted to.

The presence of a calculus as a cause of pyelitis cannot always be demonstrated, but may be more or less strongly suspected according to the conclusiveness with which any other cause can be excluded, by the definiteness and character of the local pain, the history of renal colic, the presence of uric-acid crystals in the urine, and perhaps in some cases the results of palpation. The exploring-needle may be used, and may of course, if reaching the calculus and giving a characteristic grating feeling and sound, give absolutely positive results; but a failure to strike a stone could hardly be regarded as proof positive of its absence.

The diagnosis of renal calculus from lumbago or neuralgia should rest, in case the pain is severe enough or long-continued enough to really cause the question to arise, upon an examination of the urine.

A very important point in diagnosis, especially when the question of operative procedure arises, is that of the soundness of the other kidney. Accidental circumstances will sometimes permit this to be determined; as, for instance, when one ureter is suddenly blocked by a calculus, and at the same time the urine, which has previously been found purulent, bloody, and containing renal cells and casts, becomes clear and normal until the obstruction is removed and the abnormal ingredients reappear. Cases of exstrophied bladder, where of course it is possible easily to separate the urine of the two kidneys, may be, from their rarity, practically left out of the account. Various proposals for obtaining the separate urine of the two kidneys have been made. A small catheter has been passed into the female ureter through the dilated urethra. In the female also a finger in the vagina may succeed in temporarily blocking one ureter, while the secretion of the other alone is filling the bladder, a catheter with a bent portion at the end being used for making counter-pressure from the inside. It would probably remain doubtful in most cases how successful this manoeuvre had been in completely stopping the flow of urine, although experiments upon the dead body have been made by Polk,¹⁸ who proposes the method, with entire success. The male bladder offers greater difficulties, which are at present insurmountable. A point opposite the lower end of the ureter can, it is true, be reached with some difficulty in the rectum, and it is possible that a catheter might be so adjusted as to make counter-pressure to the finger in this position, but there could be no certainty that the occlusion was complete.

¹⁸ New York Med. Journ., Feb. 17, 1883.

The whole hand in the rectum, after Simon's method, would enable the object to be accomplished with more certainty, but this procedure has risks of its own. A staff with flattened extremity, as suggested by Weir,¹⁹ may more conveniently, though with somewhat less certainty, be used for pressing from within the rectum on the ureter where it passes over the brim of the pelvis. A compressorium consisting of an empty and folded bag, to be introduced into the bladder and there expanded by the introduction of metallic mercury, has been described and used, with the result of partly checking the flow of urine.²⁰ The proposition to pinch up the extremity of one ureter in the bladder by means of the lithotrite is still more open to the objection of great uncertainty, and would, to say the least, demand very special skill to obtain even a chance of success.

¹⁹ Ibid., Dec. 27, 1884.

²⁰ See Weir's article, just quoted.

None of these procedures have as yet been put to practical use, and it is doubtful whether any of them, unless we except perhaps the use of a staff in the rectum, would be justified for purely diagnostic purposes, considering the great risks involved. For the present, at least, the possibility of separating the secretion of one kidney from that of the other must be looked upon as depending chiefly upon accident, and in case of contemplated operation it is not possible to assure one's self of the integrity of the other kidney before the abdomen is opened. In many cases after opening the abdomen both kidneys may be examined before deciding upon further steps. Lawson Tait considers an exploratory incision distinctly indicated whenever abdominal disease not malignant threatens the life of the patient. The soundness of the other kidney, however, may be considered highly probable if in spite of demonstrated extensive disease of one kidney a sufficient quantity of urine with a normal amount of urea and salts continues to be formed.

The SYMPTOMS arising from a large calculus producing destruction of the renal substance, when both kidneys are affected or one is insufficient to supplement the partial or total loss of the other, may closely resemble those of diffuse nephritis, either interstitial or parenchymatous, or perhaps it would be more correct to say that these forms of nephritis are the symptoms of such a change. Thus we may have polyuria, albumen, and casts, dyspnoea, dropsy, and uræmia. The enormous calculus described above as resembling a hippopotamus had given rise to no marked symptoms until palpitation, dyspnoea, and oedema were complained of; the heart was hypertrophied.

The TREATMENT of calculi remaining in the kidney is, so far as medical means are concerned, that which has been already described, and, to say the least, is not a high degree of efficiency. Rest, diuretics, and solvents of the kind already spoken of, and narcotics, may afford relief, and in the case of quite small calculi, such as sometimes remain in the kidney even when not too large to pass through the ureter, solution is possible; but there is even less reason to suppose that large calculi can be dissolved in the kidney than that the tendency to their formation can be counteracted.

Surgery, however, offers in some cases complete relief. Two operations have been undertaken for this purpose, of which the surgical details are here inappropriate, but the indications for which may very properly be discussed from a medical point of view. These are nephrotomy or nephro-lithotomy, the removal of the stone through an incision in the pelvis or secreting substance of the kidney; and nephrectomy, or the removal of the whole gland with its contents. It is obvious that the indications for these two operations are quite different, although cases are likely to arise where it will be well to change the plan from the former to the latter during the operation.

When a sinus exists from the inflamed and perforated pelvis, or an abscess connected with the kidney has been recently opened, it may be dilated or enlarged by incision sufficiently to allow the passage of an exploring finger and forceps. The large arterial and venous branches which surround the pelvis make it safer to trust rather to dilatation or tearing to get through to its interior than to incision, which must, if necessary, be practised with great care. Experience has shown that an incision can be made through the renal substance without great danger, the hemorrhage being chiefly venous. This incision has been made in several cases, and where the secreting portion is much atrophied is obviously of still less consequence than in the healthy kidney. After the removal of the calculus, drainage may be established for a time until the pelvis has resumed its normal condition or the purulent discharge has diminished.

If no sinus exists, but a diagnosis has been clearly made, or even if symptoms of sufficient severity exist to justify a strong suspicion and decisive treatment, an incision may be made along the edge of the erector spinæ or the great mass of muscle attached to the spinal column and passing through the quadratus lumborum. An incision outside of the quadratus lumborum will come upon the kidney, but too far outside to make a direct access to the pelvis practicable. If it be known, however, that the cut must be made through the kidney itself, then the primary incision through the skin may be made in the exterior line, and will be less deep. Measuring along the last rib two inches from its extremity, and then at right angles an inch and a half downward and inward, will indicate a point at which a puncture will reach the renal pelvis. This may be made the central point of an incision, though it is often necessary to utilize the whole space from the last rib to the crest of the ilium. After reaching and exploring the kidney with the finger, the incision may be carried cautiously through the pelvis and enlarged by dilatation or tearing.

In order to feel the calculus it may be necessary to have counter-pressure made from the front of the abdomen in order to lift or fix the kidney, and a case has been mentioned where the finger, having failed to reach a calculus behind, was carried around and in front of the kidney with success. If the calculus is too large or too irregular to be removed whole, it may be broken and extracted piecemeal.

This lumbar method is undoubtedly to be preferred when it is known that a simple nephrotomy will be sufficient or when the more or less diseased kidney is to be treated as a cyst or abscess by drainage. It is open to the objection that if it be found desirable to change the operation into an nephrectomy, it is not quite so easy to remove a large mass in this way as by laparotomy, and the pedicle is much less accessible. The objection is not sufficient, however, to contraindicate it in many cases, for additional room can be obtained by resection of the last rib. So far as the writer is aware, laparotomy has never been performed for the simple removal of a calculus.

Nephrectomy, or removal of the kidney, may be required for various conditions, among which is to be reckoned a renal calculus with pyelitis of sufficient severity to threaten life or give rise to constant suffering; but as it is often indicated for other reasons, its consideration will be deferred.

Pyelitis may be excited by the presence of other foreign bodies, among which are coagula and parasites. An acute pyelitis may accompany an acute nephritis. Occasionally also an idiopathic pyelitis is said to be met with, but it must be difficult in such a case to exclude the presence of some irritant which has escaped observation.

Secondary Pyelitis.

Pyelitis is most frequently excited by the propagation of an inflammatory process upward from the bladder, and hence it is, with its resulting effects upon the renal structure, one of the most important complications of chronic cystitis and of surgical affections in the lower urinary passages. Anatomically, a pyelitis of this character differs but little from that of local origin described above, except that the contents of the inflamed cavity do not include deposits of urinary salts unless such have been formed secondarily. It is, however, more likely to be severe, and especially to affect the true renal substance more rapidly and more seriously, and consequently to be attended with constitutional symptoms in an acute form.

Two factors are of especial importance in determining the rate of development and severity of pyelitis supervening on affections of the urinary passages: First, the amount of obstruction which exists to the exit of the urine; and, secondly, the character of the cystitis as regards decomposition of the urine. It is obvious that whatever sends urine back into the ureters, or, what is the same thing, prevents its passage downward, will by keeping it longer in contact with the mucous membrane intensify whatever morbid action such an irritant would have, and of course a putrid or ammoniacal urine will induce inflammatory action, while a normal secretion might remain for a long time innocuous. Hence it is that we may have hydro-nephrosis and pyelitis entirely distinct from each other, but are very likely to have both combined in most cases.

It is especially in surgical affections of the urinary passages, involving, as many of them do, considerable obstruction with a more or less intense cystitis, that we meet with the combination of the two conditions. Such are enlarged prostate with its usual obstruction and frequent chronically-distended bladder, with ammoniacal, purulent, and decomposing urine, or stricture with frequent over-contraction of the bladder, forcing the urine backward as well as forward. In diseases of the female generative organs we are more likely to have the hydro-nephrosis and pyelitis as separate affections, since the compression which so frequently arises in cases of cancer or of pelvic inflammation is likely to be above the bladder, thus preventing the regurgitation of urine as well as its passage downward.

Two conditions of the renal substance seem to result from pyelitis of this kind: one, a chronic nephritis already described, with increased formation of connective tissue, atrophy of the tubes and the Malpighian bodies (the latter, however, remaining recognizable, although crowded together), and a general, and at times extreme, shrinking of the whole organ. The other is more acute, and consists in the formation of abscesses of small size, which in the medullary portion are somewhat elongated and arranged parallel to the tubes, and in the cortical portion preserve a less degree of regularity, though still having some reference to the columnar arrangement of the masses of convoluted tubes. The intervening structure is usually in a marked condition of parenchymatous degeneration. This is the so-called surgical kidney.

Whether the one or the other of these processes shall take place probably depends chiefly on the infectiousness of the cystitis or of the urine contained in the bladder and backing up into the kidneys, although it is not necessary that any degree of dilatation should be present for this condition to arise. Sometimes also the surgical kidney may be found when the original cystitis is not at all severe.

The DIAGNOSIS of a pyelitis supervening on a cystitis is not always easy, but may frequently be inferred, and it is possible that by careful treatment of the cystitis it may be reduced to a very low grade of severity, while the pyelitis still remains, which will permit the diagnosis to be somewhat more conclusive.

If the urine comes acid, but pus-laden, from the kidney, it will soon assume the contrary reaction in the bladder, and the pus will be changed by the ammonia into so-called muco-pus; the cells supposed to be characteristic of the pelvis of the kidney will, like the pus-cells, be so altered by the same causes, and so intermixed with similar cells from the bladder, that the distinction will be difficult or impossible. The presence of a few hyaline casts is very likely to be noticed, and indicates irritation, or perhaps a more decided implication, of the renal substance. Nothing, however, can be inferred from failure to find them. Hæmaturia is not so necessary an accompaniment of this form of pyelitis as of that arising from a mechanical irritant in the kidney. If, however, the urine does not become rapidly altered in the bladder, or if by any of the processes mentioned above the kidney urine can be obtained in a condition of comparative purity, the microscopic indications become more precise.

A dull pain and tenderness in the loins and along the course of the ureters is a symptom of value, though by no mean conclusive, and should lead to a suspicion of pyelitis. A polyuria of short duration may be a purely nervous symptom, but a persistent flow of pale urine, which fails to settle clear, and of which the turbidity is caused by pus, is due in great probability to renal disease, and if it could be shown to come in this condition from the kidney would almost certainly denote pyelitis.

The rational SYMPTOMS are of the greatest value as determining the extent and severity of the disease, although it may be impossible to distribute them with absolute exactness between the various organs involved—that is, bladder, pelvis, and renal substance.

The occurrence of a single chill, or even of several, with rapid subsidence of the fever, is not conclusive, since the ordinary urinary fever supervening on surgical operations, even so slight as passing the catheter, is not necessarily connected with renal disease.

A long-continued fever, not especially intense and of a more or less distinctly intermittent type, especially if becoming at some definite period decidedly more intense, is likely to mean the invasion of a new tract of mucous membrane, such as that of the renal pelves or even of the kidney-substance itself. Continued or remittent urinary fever is of very grave import. With this fever will appear the dry red tongue and the distressing anorexia, nausea, and vomiting, with either constipation or diarrhoea.

The TREATMENT of this form of pyelitis, so far as it differs from that of the calculous variety, depends largely upon that of the causative cystitis, though not entirely, since if it has once assumed the chronic condition it does not necessarily subside even if the cystitis be cured. The essentials of treatment may be said to be drainage from below and washing from below and from above. The measures for carrying the first of these indications are those which are also required for the causative cystitis, and, being chiefly surgical, a minute description of them does not come within the scope of this article. They may be simply catheterization, dilatation, divulsion or section of a stricture of the urethra, drainage of the bladder through the rectum or through the perineum.

It is not out of place, however, even in a strictly medical essay, to point out the extreme importance, not only in the way of treatment, but of prophylaxis, of securing a free exit for the urine. Even that small degree of obstruction or hindrance which leads a person to habitually put a little extra strain upon the bladder in order to expel its contents, especially if it be allowed occasionally to become dilated, may gradually lead to dilatation of the ureters, and thus make an easy passage upward for inflammatory and decomposed urine if such should afterward be formed as a consequence of cystitis by retention. The washing of the bladder from the urethra may be done with a great variety of antiseptics and acids: nitric acid in the proportion of 1 per mille may be used to change the reaction of the urine. Carbolic acid should be carefully used, from the danger of its absorption in poisonous amounts. Boric acid is a safe and quite efficient antiseptic.

Washing from above, which is evidently that which alone can directly affect the renal pelvis, must be done with such drugs as can be safely given internally, so that carbolic acid cannot be of much use in this way. Salicylic acid loses a part, but not all, of its antiseptic properties in its passage through the blood and kidneys. Boric acid passes readily into the urine, alters its reaction, and seems to have some antiseptic action. It is unirritating in the stomach, and may be given in doses of 30 centigrammes or 5 grains to the extent of 1 or 2 grammes per diem. Benzoic acid and the benzoate of sodium, ammonium, or lithium have been found to be of value in cystitis, and as they can only reach the bladder by previously passing over the pelvic mucous membrane, they should also have a good effect here. It is obvious that constitutional symptoms arising from cystitis and its consequent nephritis may demand the most attention, and should evidently be of a decidedly supporting character, the details of which have no special reference to the disease, but to the general condition. Quinine may be called for as an antipyretic.

The question of removal of a kidney for pyo-nephrosis is less likely to arise in this form than the other, since from its causation it is much more likely to be bilateral; but if under any peculiarity of anatomical arrangement, such as greater dilatation of the one ureter, it should be found that one kidney was nearly healthy while the other was in a state of pyelitis, and purulent inflammation was giving rise to serious constitutional disturbance, such an operation might be undertaken.

The operation of nephrectomy, or removal of the kidney, may be required for various lesions, most of which include more or less pyelitis, and it may be considered once for all in this place. It has now been practised more than one hundred times. A table including 100 cases is given by R. P. Harris in the American Journal of the Medical Sciences for July, 1882, and many have been recorded since.²¹ It can, of course, hardly be expected that the removal of one of a pair of vital organs, under circumstances where it is often the case that the other is not completely capable of carrying on the additional work, should present the same favorable array of statistics as ovariotomy; but it gives no small number of recoveries in cases which without it would undoubtedly have proved fatal, and it must be considered as having a legitimate and well-defined place among the major operations.

²¹ Weir, New York Med. Journ., Dec. 27, 1884.

There are two distinct methods, besides, of course, all the minor differences of detail called for in the individual case. The kidney may be reached from the loin by an incision along the outer edge of the erector spinæ, as already described for nephrotomy. It is to be enucleated from its capsule of fat by the fingers, and a ligature or ligatures passed around the pedicle consisting of the veins, arteries, and ureter. The kidney is then cut off, possibly leaving a little renal substance if the pedicle be short and accessible with difficulty. The wound is left partly open for drainage. This method has the advantage of avoiding the peritoneum and the handling of other abdominal organs. Its disadvantages are, in some cases, the want of room, and when undertaken for the relief of floating kidney the difficulty of finding the organ, which is likely to be at the end of a pouch formed of peritoneum. In cases of calculous pyelitis, where it may be at the beginning of the operation uncertain whether merely an incision for the removal of a stone or a total removal of a kidney of normal size may be necessary, this line of approach presents decided advantages.

The other method is by abdominal incision or laparotomy, which is usually made through the linea alba, though in a number of cases the outer edge of the rectus abdominis on the side corresponding to the organ to be removed has been taken as the guide. The steps of the operation are similar to those of ovariotomy where the pedicle is tied and returned to the abdominal cavity. This operation may be one of choice, from the greater ease with which the pedicle can be reached and the possibility of increasing the length of the incision in case of necessity for the removal of a very large tumor. In one case a crucial incision was made. When the kidney to be removed is a wandering one, and especially when a kidney has become fixed in an anomalous position, this is by far the easiest, and sometimes the only practicable, method.

Antiseptic precautions are of course to be used.

Hydro-nephrosis.

Obstruction to the discharge of urine from the body naturally produces special disorders in the secreting and discharging organs. If the obstruction exist below the neck of the bladder, as in stricture of the urethra or enlarged prostate, then the bladder is the organ primarily affected, and it may become distended, sacculated, its muscular coat hypertrophied, its mucous membrane affected with catarrhal inflammation, and its contents changed from the normal by the addition of mucus, of pus, of bacteria, or a deposit of earthy phosphates from the ammoniacal reaction produced by decomposition of the urea.

The effects of distension of the bladder will sooner or later make themselves felt in the upper urinary passages, and will then give rise to the same dilatation of the ureters and the renal pelvis as occurs when the obstruction is higher up. As regards the rapidity with which such changes progress, much depends upon the degree of obstruction as well as upon the amount of urine secreted. It probably, however, never takes place suddenly.

In a case which came under the observation of the writer a partial paralysis of the bladder, probably existing from infancy, had in the course of three or four years, during which large quantities of light urine were passed, given rise to dilatation of the ureters, slight dilatation of the pelvis of the kidneys, atrophy of the parenchyma, and hypertrophy of the left ventricle.

Obstructions in the course of the ureters may exist at their opening into the bladder, which may be contracted by chronic cystitis; at a point immediately above this from compression by morbid growths, especially of the uterus, one of the most common causes of hydro-nephrosis, or even from retroflexion of the uterus when pregnant; at any point in its course by a twisting or sharp angle, as in movable kidney, although this is a much rarer accident than might be supposed; or at the brim of the pelvis, where it may be bound down by old peritoneal adhesions, and at its junction with the renal pelvis, which may be formed in such a manner as to constitute a valve, so that the urine escapes slowly or with great difficulty; or where it may be blocked by a calculus or other deposit in the cavity of the pelvis.

Obstructions by a twist or angle or by a valvular opening may, it is obvious, be temporary or intermittent in their action, and probably some arrangement of this kind was present in the cases which have been reported of relief of hydro-nephrosis by gentle massage of the abdomen.

Above the point of obstruction the ureter and pelvis are found dilated and the walls somewhat thinned. The kidney and its pelvis form a more or less irregular rounded pouch, with the tense cylindrical tube of the ureter attached to it below. The kidney itself becomes in various degrees atrophied. In some cases it retains nearly all its secreting structure, and is merely spread out upon the surface of the sac; in others, while the pelvis is but little dilated, the true kidney substance atrophies almost completely, and becomes a mere shell enclosing a cavity continuous with the pelvis and broken up by fibrous septa into subordinate cavities representing the original calices. A partial hydro-nephrosis is sometimes observed affecting only the calices.

Whether the one or the other of these conditions shall result depends, as has already been remarked, upon the completeness and suddenness of the obstruction. If the ureter of a rabbit is ligatured, the second condition—that is, atrophy of the kidney with but little dilatation—is observed. The pressure of urine soon puts a stop to further secretion, and there is no time for a slow and gradual dilatation of the pelvis and ureter. When, as is much more frequently the case in the human subject, the obstruction is more gradual or incomplete, the back pressure is for a long time insufficient to completely stop the passage of fluid through the renal capillaries, so that the pelvis and ureter, though allowing their contents to pass out only under a considerable vis-a-tergo, have time to accommodate themselves to the change, and dilate gradually, attaining sometimes enormous dimensions. The size of a hydro-nephrotic sac varies greatly: 60 liters of contents is certainly a very extreme case.

The sac is usually white and glistening, thinner at some places than at others, and lined with a smooth, pale, and atrophied mucous membrane. The muscular layer has degenerated, and perhaps partly disappeared. The liquid contained in the sac, supposing no inflammatory products to have been mingled therewith, is at first nearly identical with urine, and always contains urea. Afterward its character changes from the absorption of the urinary salts and the secretion of mucus. The contents may be dark-colored from hemorrhage or somewhat gelatinous. At a later period again they become serous and may contain cholesterin.

The description just given, as well as that of the symptoms, applies to simple hydro-nephrosis. When the sac has become inflamed we have the very common combination with pyelitis, and the affection is called pyo-nephrosis. The progress of a case of hydro-nephrosis may be in rare cases to recovery by spontaneous re-establishment of the permeability of the ureter. In others it persists a long time without giving rise to trouble. If inflammation supervene, it is obvious that fever, either simply irritative or of pyæmic character, may be a severe or even a fatal concomitant, or that in this condition a perforation may take place. When the tumor is large it may from its bulk alone produce disturbance of the circulation, dyspnoea, palpitation, and oedema of the lower limbs.

As regards the influence of this lesion on the secretion of urine, everything must depend on the amount of renal atrophy. A single kidney may undoubtedly be completely atrophied by this as by any other lesion without producing serious symptoms, since, as has been repeatedly demonstrated, the other is sufficient to carry on the work under ordinary circumstances; but if, as very frequently happens, both kidneys are involved, there must come a time when the renal substance no longer suffices, and the usual results of suppression of urine follow. It is possible, however, for extensive changes to take place in both kidneys before symptoms of insufficient secretion arise.

Hydro-nephrosis, in the entire absence of inflammatory symptoms and in the presence of conditions likely to cause it known to exist in the lower urinary passages, may be rather suspected than diagnosticated until the appearance of a tumor. Some dull pain in the loins without irradiations in any direction may exist, but so common a symptom can have but little weight in diagnosis. For an early recognition of swelling in suspected cases where nothing can be felt anteriorly, it has been recommended that the patient be placed upon the hands and knees, when the flank upon the affected side, instead of falling slightly forward and leaving a shallow depression outside of the erector spinæ, will remain full or protuberant. When an enlargement evidently connected with the kidney makes its appearance after obstruction to the passage of urine is known to exist, the diagnosis may often be very simple; but if the tumor be the first phenomenon observed, as may easily happen when the obstruction is situated high up or even at the commencement of the ureter, it may require to be distinguished from several other kinds of tumor occupying the lumbar region, or, since hydro-nephrosis of a movable or misplaced kidney sometimes takes place, from tumors of the abdomen in general. From solid malignant tumors of the kidney the feeling of comparative elasticity and fluctuation will in most cases distinguish it, though an encephaloid kidney may be so soft as to render the second of these points of comparatively little value. Absence of hæmaturia and of the cancerous cachexia, though not conclusive, would have much weight.

A hydatid cyst might counterfeit a hydro-nephrosis, but instances of this affection having its primary seat in the kidney are of extreme rarity. An ordinary cystic kidney is most likely to be connected with chronic diffuse interstitial nephritis, which will have made itself manifest by the usual symptoms, and is moreover unlikely to attain the dimensions of a large or even moderate hydro-nephrosis. In a thin person the ureter might, if felt dilated through the abdominal walls, clear up the diagnosis. Extreme cases of cystic kidney with comparatively little nephritis may, however, present great similarity and cause difficulty in diagnosis.

From most other tumors of the abdominal cavity those of the kidney present the important distinction that they are situated behind the peritoneum, and consequently behind the intestines, so that the surface of a renal tumor is likely to be crossed by a more or less extensive area of percussion resonance, representing usually the large intestine. This criterion is, however, not absolute, since a renal tumor may push the colon completely to one side, or, on the other hand, tumors not connected with the kidney may allow the intestine to come between themselves and the abdominal wall.

An ovarian cyst is more manifestly attached to the pelvis, and its history will disclose the fact of its having arisen from below. A gravid uterus should also, when small, be manifestly connected with the pelvis, and when larger be accompanied by the usual symptoms of pregnancy. The same may be said of extra-uterine pregnancy, which may be mentioned as among the conditions possibly giving rise to difficulties in diagnosis.

The most efficient aid to diagnosis, when it is of importance that such should be accurately made, is the aspirator-needle, which will procure a fluid more or less characteristic of the tumor into which it is thrust. In hydro-nephrosis the contents are a somewhat dilute urine, with perhaps mucus; in a solid tumor, blood, with pieces of tissue recognizable by the microscope; in a cystic tumor, fluid which is perhaps somewhat urinous, but much more changed than in simple hydro-nephrosis, and perhaps containing solid-looking bodies with concentric and radiating striation; in hydatid cysts, hooks and fragments of scolices; in ovarian cysts, the various contents, fluid and semi-fluid, but not urinous, generally found therein.

With all these means, however, cases will occasionally arise in which expert diagnosticians may be lead astray, and the difficulties become considerably greater when the dilated pelvis is that of a displaced or unusually-placed kidney. Such cases have been subjected to operation under the impression that an ovarian cyst was present.

The medical TREATMENT of hydro-nephrosis is nil. In many cases nothing is demanded by the immediate necessities of the case, and atrophy, if it be probable that only one kidney is involved, may be allowed to take place without interference. It is possible that in some instances manipulation of the tumor might relieve the obstruction and allow the tumor to subside when a slight twist or angle in the ureter is the cause. The fact of an occasional spontaneous subsidence of such a tumor shows that something of this kind has taken place.

The surgical treatment of affections of the lower urinary passages, as both a prophylactic and therapeutic measure, has already been spoken of under the head of Pyelitis. It would, however, be only in a minority of cases of pure hydro-nephrosis that the seat of obstruction could be efficiently reached by surgery.

Puncture and aspiration of the sac may very properly be resorted to, and may prove of value—in the first place, as a more or less temporary relief; and secondly, as a means of re-establishing the flow through the natural passages by the relief of pressure and consequent opening of the valvular fold, which has occasionally been observed at the junction of the ureter with the pelvis.

In a case where the obstruction is known to be irremediable, and where the hydro-nephrosis, if existing only on one side, is likely to increase, it is not desirable to make the puncture too early or to repeat it too frequently, since by allowing the pressure to increase the atrophy of the kidney will be more rapidly accomplished, and the need of frequently emptying the sac will not arise so often in the future. On the other hand, if there is a prospect of a restoration, if both kidneys are affected, or if the kidney not involved in the hydro-nephrosis is known to be seriously impaired in function, and it is desirable to preserve the secreting structure as long as possible, the punctures should be so arranged as to keep the pressure at its minimum. This must, however, be regarded as a temporary expedient. The puncture may be made either from the back or front, though in most cases the latter position, if the puncture be made with a small clean needle, would be the more convenient, and equally safe notwithstanding its traversing the peritoneum.

A hydro-nephrosis may be treated either by removal or by drainage. Both of these methods have been resorted to, and are to be employed according to the circumstances of the individual case. A pyo-nephrosis naturally demands interference more peremptorily and more promptly than a simple hydro-nephrosis, because it exposes the patient to the dangers not only of its pressure and of its tendency to destruction of the renal substance, but to those more urgent ones of purulent infection or of perforation and perinephritic abscess. Removal is to be undertaken by the ordinary rules of laparotomy. Drainage has been arranged in cases where removal was impossible or unadvisable by stitching the edges of an opened sac to the external wound. It is possible that the choice between the two operations can be made only after the primary incisions and explorations have advanced sufficiently to enable the extent of adhesions and the amount of healthy renal substance to be approximately determined.

Staples of Dubuque states, on the basis of 71 cases collected by him, that "63 per cent. of patients operated on are cured by lumbar nephrectomy, 68 per cent. by open methods in general, and up to date 100 per cent. by either lumbar incision and drainage or the creation of a fistula."

Malignant Growths.

As pathological rarities only, and having but little clinical interest, may be mentioned, as occurring in the kidneys, fibroma, lipoma, myxoma, anginoma, and adenoma. Malignant growths originating in or involving the kidneys, sarcoma or carcinoma, are, however, more frequent and more important.

Sarcoma, primitive or secondary, of the kidney is a somewhat rare occurrence, but most frequent in children. The whole kidney may be transformed into a mass occupying its place and somewhat resembling it in form, but many times exceeding it in bulk and weight. Such a tumor may largely distend the abdominal cavity and compress its contents. Upon section we often find a substance varying greatly in consistence, from almost fibrous hardness to cavities filled with grumous material broken down by fatty degeneration and often colored by hemorrhage. In the interior may be found remains of the pyramids and cortical substance occupying their usual relative positions, but as it were distended, these portions being surrounded by a much thicker layer of purely abnormal neoplasm, probably connected with the capsule and its surrounding fat. In other cases all traces of normal form and structure may have disappeared. The microscopic structure of such a growth presents no peculiarity except so far as the arrangement of cells in the normal gland may be followed to a certain extent in the less-altered portions of the tumor. Besides this total destruction of the kidney, it is not uncommon to find nodules involving a part of one or both the organs, and more or less distinctly marked off from the healthy portion.

The origin of sarcomata involving the kidneys may be the subperitoneal cellular tissue or the neighboring organs. As a primary disease sarcoma of the kidneys is very rare.

True cancer or carcinoma of the kidney is not a common disease, and is said to have been found 12 times in 447 cases of cancer of various organs. It may be primary or secondary, and a description of the gross appearances would be essentially the same as that of the sarcoma. The tumor does not, however, usually attain so large a size, and the amount of degeneration of neighboring organs and of ulceration is greater. Calculi are often found in cancerous kidneys.

The SYMPTOMS produced by either sarcoma or carcinoma may be none at all for a time. Dull pains in the loins or referred to the hypochondrium—which, however, from their indefiniteness can have but little diagnostic importance—are among the early phenomena. Pains like nephritic colic may appear. The urine usually shows little of importance. There may be sympathetic disturbance of micturition, but unless hemorrhage occurs there is not likely to be anything in the urine discoverable by the microscope to fix the nature of the trouble. Fragments of cancer-structure in the very rare cases in which they are said to have been found would of course be conclusive, but evidence based on the alleged discovery of cancer-cells in the urine must be received with the utmost caution, recollecting the great variety of shapes and sizes assumed by the epithelium of the urinary passages. Hæmaturia is a symptom occurring in only a portion of the cases, its appearance in a given case evidently depending on the way in which the tumor invades the kidney and increases in size. If growing in such a way as to compress the ureter at an early stage before any erosion of the mucous membrane has taken place, blood, even if set free in the pelvis, cannot reach the bladder. If hæmaturia is present before any tumor can be felt, it has only a subordinate value, but if occurring after the discovery of such a tumor, the combination is of the highest significance. At a later period all the symptoms of compression of other abdominal viscera arise—anorexia, vomiting, jaundice, oedema, ascites, emaciation, and death.

When a tumor has become evident, it is to be diagnosticated from cystic disease and from hydro-nephrosis, with which it agrees in position and possibly in form. From the former of these its hardness and rapid growth, the invasion of other organs, and the cachexia will serve to distinguish it. Hæmaturia is not present in cystic disease. From hydro-nephrosis or pyo-nephrosis the diagnosis has already been stated. On the right side it might not in every case be easy to distinguish a morbid growth of the kidney from one affecting the liver, and a similar difficulty might arise on the other side with the spleen. The diagnosis is to be made by a careful location of the tumor by palpation and percussion and the absence of symptoms likely to occur in connection with affections of the organs named. In children psoas abscess and degeneration of the lumbar lymphatic glands should also be considered.

A sarcoma of the kidney has been mistaken and punctured for an empyema. A sarcoma behind the kidney, pushing it forward, is very difficult to distinguish from a similar growth affecting the organ itself, especially as it is likely to give rise to signs of renal irritation discoverable by the microscope. A slight pyelitis, distinguished by pus and the absence of any cellular elements to indicate an origin at a lower point, has been observed in such a case.

The results of exploratory puncture have been before alluded to. If a piece can be brought away large enough to be examined microscopically, it may settle the diagnosis, not only as to a malignant growth, but also as to its kind.

The distinction between carcinoma and sarcoma cannot always be made during life, nor indeed, without a microscopical examination, after death. It is of importance chiefly with reference to prognosis after operation for removal of the organ. A more rapid growth, a greater tendency to invade other organs, and a more marked cachexia would speak in favor of carcinoma, while a tumor gradually attaining a very large size, and not spreading beyond the kidney and its immediate envelopes, is more likely to be a sarcoma.

There is no TREATMENT known to be of value in cancer or sarcoma of the kidney, except so far as it may diminish pain or regulate the secretions. Surgically, removal of the diseased organ is the only expedient to be thought of. Although nephrectomy has been shown to be a perfectly practicable operation, and one that is usually well borne when the other kidney is sound, it has not proved very successful with malignant growths, even as a temporary expedient. This is partly at least to be accounted for by the difficulties lying in the way of diagnosis in the earlier stages, and the reluctance with which so serious an operation would naturally be resorted to until hopes based either on the uncertainties of diagnosis or mistaken reliance on medical treatment have been given up. Cases, however, have been reported where patients have recovered from the operation, and the disease has not returned for some months. When an operation has been resorted to, the tumor has usually become too large to be extracted through the loin, and laparotomy has been the course pursued. According to Billroth,²² out of 33 operations for tumors of the kidney, 13 have been cured.

²² Mittheil. der Aerzte in Nieder Oesterreich, Bd. x. p. 161 et seq.

Cysts.

Three kinds of cysts are met with in the kidney besides those connected with the growth of parasites.

Kidneys congenitally affected with cystic degeneration contain a large number of sacs lined with a vascular membrane, among the partitions of which are found the remains of secreting structure. Both kidneys are equally affected, and are enlarged and more or less lobulated. They are occasionally so large as to constitute an obstacle to labor, and various operative procedures, even evisceration, have been required to accomplish the delivery of the foetus affected. The cysts are filled with fluid of various degrees of darkness of color from almost perfect limpidity to almost black. The fluid in the smaller cysts, at least, contains some of the urinary solids. The slighter degrees of this affection do not render a child necessarily non-viable, but with the larger some accident is likely to happen.

The formation of these cysts has been referred to an intra-uterine chronic nephritis, but another theory accounts for them by a vice of development. The fact that when the lesion is unilateral, as sometimes happens, there is apt to be a deficiency of some other part of the genito-urinary apparatus on the same side, and that several infants with cystic degeneration have been born of the same mother, speaks strongly in favor of the latter theory.

Serous cysts of later origin do not usually attain so large a size, or rather the kidney does not, on account of their smaller number. They are lined with a thinner membrane, and their contents are nearly clear, but coagulable, comprising uric acid, carbonate of lime, and cholesterin. Occasionally a single cyst attains considerable dimensions and produces by its pressure atrophy of part of the kidney. These cysts are supposed to arise in consequence of the blocking of a tube.

The third class of cysts closely resemble the first in appearance and in form, and contain more or less serous or gelatinous fluid, with albumen, blood-corpuscles, and pus, as well as the peculiar colloid bodies previously mentioned. They undoubtedly arise from the distension of tubes and of Malpighian bodies. These cysts are usually associated with chronic interstitial nephritis, and in fact they are rarely absent in cases of this kind, although the extreme degree—that is, where the cysts assume the most prominent position while the contracting nephritis falls into the background—are less common. In these latter cases the organ may be almost transformed into a mass of rounded bodies somewhat resembling a bunch of grapes.

The SYMPTOMS of the first two of these conditions—that is, of the cysts which are not connected with an active nephritis and attract attention simply as tumors—depend on the pressure they exert; and a diagnosis is to be made by a knowledge of their history and by the rules already given. The symptoms and diagnosis of the third variety are involved in those of chronic interstitial nephritis.

There is no reason to suppose that any drug has any therapeutic action on such kidneys, so far as the cysts are concerned. It should always be remembered that a kidney may contain a large number of cysts, and yet scattered portions of secreting substance enough be left to carry on the function indefinitely.

It might under some circumstances be justifiable to remove a cystic kidney on account of the pressure exercised on other organs, but as the cysts do not increase rapidly in size, punctures several times repeated, so as to empty a number of them, would in most cases prove as effectual an operation, and, what is of greater importance, would not involve the loss of any portion, even if small, of secreting structure which may be left.

Tuberculosis.

The tubercles which are found in the kidney in cases of general miliary tuberculosis have usually no clinical interest, since the kidney is not, even in children, one of the points where tubercular localization is most intense, and renal tubercles are consequently but little advanced when death takes place from the extension of the disease in other organs. They present no symptoms which are perceptible among the much graver ones attending the progress of the disease elsewhere.

In the disease known as tubercle of the kidney, caseous nephritis, or nephro-phthisis, masses of caseous material are deposited in the renal parenchyma which may soften, break down, and communicate with each other and with the calices and pelvis. In some cases it is probable that the disease originates in or immediately underneath the mucous membrane of the urinary passages. This process of breaking down continues much in the same way as that of a phthisical lung, until the kidney becomes little more than a hardened, irregular, knobby shell enclosing a ragged, ulcerated cavity with thickened, pus-secreting walls and filled with pus, more or less blood, and débris of kidney-structure and tubercle. In such portions of renal substance as may remain it is not unusual to find miliary tubercle. If obstruction of the ureter exists, a pyo-nephrosis may exist in addition. Rupture into the peritoneal cavity or into the intestine has occurred.

It is probable that in this affection are included two processes, differing in pathology and etiology and to some extent in clinical history. It is probable that true tubercle may originate in the kidney as a result of either tubercle or cheesy inflammation elsewhere, as in the lungs, bodies of the vertebræ, or scrofulous glands. In this case there are no marked symptoms until the process of softening and breaking down has reached the mucous membrane of the pelvis. Besides this, renal phthisis sometimes succeeds, as a more local invasion, to tubercle or cheesy inflammation of the urinary passages, and in this case the symptoms appear simply as aggravations of those already present and depending upon ureteritis and pyelitis. Renal phthisis is seldom if ever an independent disease. It is often associated, besides the affections already named as standing in etiological relationship with it, with cheesy inflammation of the testicle, vesiculæ seminales, and much less frequently of the ovaries and Fallopian tubes.

The DIAGNOSIS of tubercle in the kidney before it has reached the pelvis is probably impossible. Pain in the back or slight albuminuria, as has been already stated, is of no diagnostic value except as pointing to some renal irritation, as to the cause of which it tells nothing. In the presence of tubercle elsewhere it might be regarded as suspicious.

After cavities have become connected with the pelvis or have extended from it, the symptoms become more marked. In the urine are to be found pus, some blood, epithelium of the urinary passages and often of the kidneys, in many cases in the form of casts; and it is claimed that masses of caseous matter as large perhaps as the head of a pin may be found, which will of course make the diagnosis almost a matter of certainty. If the urine containing such a deposit is acid, it is almost certain that the lesion is mainly in the kidney and that the bladder is but slightly if at all affected. It is also stated that the bacillus of tubercle has been found. The presence of this parasite will not only testify as to the presence of the clinical condition known as phthisis of the kidney, but will also make it sure that the affection depends upon tubercle in the strictest pathological sense, and will influence the prognosis accordingly. Inoculation of purulent sediment from the urine of a patient suffering from tuberculosis of the urinary passages has produced tubercle in the iris of the rabbit. This procedure has been suggested as a means of diagnosis as to the character of a chronic catarrh of these passages before the appearance of tubercle elsewhere.²³

²³ Ebstein, Centralblatt für die Med. Wiss., 1882, p. 918, from Deutsch. Arch. f. klin. Med., xxxi. S. 63.

If pyelitis have already been present, the change in the appearance of the urine will be less characteristic, but there may be a marked aggravation of symptoms when the contents of softened masses are added to the secretions of the mucous surface. There is likely to be much fluctuation in the quantity of débris present from day to day. Urinary fever of the hectic or subcontinued type, with anorexia, nausea, dry tongue, and diarrhoea, is present. In some cases the enlarged and irregular kidney may be felt.

The PROGNOSIS of this condition is in the highest degree unfavorable, although the finding of cicatrices in kidneys where symptoms of renal phthisis have been present suggests that it is possible for caseous masses in these organs, as well as in the lungs, to undergo absorption and healing.

The TREATMENT must be, in the first place, constitutional by tonics and reconstituents, and local by the use of such antiseptics as are eliminated through the kidney, as boric or benzoic acid or the benzoates. But little, however, is to be expected from it.

Parasites.

The most important parasite which is known to inhabit the kidney is the immature tapeworm of the dog, or Tænia echinococcus. It is decidedly rare in this country to meet with this affection in any part of the body, and as the kidney is not one of the organs most likely to be chosen as its habitat, the condition is not one which comes often under the observation of physicians.

It is hardly necessary to describe here the structure or contents of the hydatid cyst which forms the home of the parasite, nor its etiology, since these topics belong to general pathology, and the cyst is the same in whatever organ it may be seated. When it affects the kidney, it is usually the left—more frequently that of a man between thirty and forty years of age.

A hydatid cyst may be situated upon any part of the kidney. If small, it may never make its presence known. A larger one may give rise to those vague pains in the back found with so many diseases of the kidney and characteristic of none of them. A cyst may open in any direction, but is more likely to empty into the pelvis of the kidney. When this happens, the smaller cysts or pieces of the larger ones often enter the ureter and give rise to renal colic, and possibly, later, to a pyelitis. Other points of discharge are the intestines, the lungs, or the abdominal walls.

After a hydatid cyst has reached a certain size its presence may be recognized by palpation, but the diagnosis between it and other tumors of the kidney must be very difficult unless characteristic fragments make their appearance in the urine at the same time that the tumor diminishes in size, or unless they can be obtained by puncture. The hydatid thrill, if it can be obtained, will be an important factor in diagnosis.

The TREATMENT of this affection in the kidney presents no special points of difference from that of similar cysts in the liver; with this important exception, that besides punctures with large and small trocars, incisions, electrolysis, etc., the resource of complete extirpation still remains. Cures have been obtained by repeated punctures and subsequent suppuration, and by partial removal through the abdominal walls and subsequent drainage.

Among the parasites of the kidney it is customary to mention the Strongylus gigas, which is a worm somewhat resembling the ascaris and inhabiting the pelvis. It is not very infrequent among the Carnivora, but since only seven cases have been described in the human subject since the seventeenth century, and only a part of these are admitted as genuine by certain authors, its diagnosis, prognosis, and treatment must depend more upon theory than upon experience. The diagnosis is to be made, if at all, on the basis of a pyelitis and the discovery of the eggs of the parasite in the urine.

The Distoma hæmatobium is a parasite found chiefly in the blood-vessels, and especially those of the portal system. It is occasionally, however, met with in the veins of the kidney and also in the urinary passages. Its eggs pass into the pelvis and ureters, and there begin their development, which, however, is soon arrested, as they rapidly perish in the urine.

These parasites appear to produce either by a direct action or by the occlusion of vessels, ulceration, and hemorrhages from the urinary mucous membrane, including that of the bladder. These effects are supposed to be due to the blocking of the smaller vessels by the worms themselves. An adherent deposit consisting of masses of distoma eggs and grains of uric acid sometimes forms in grayish-yellow patches within the ureter, and gives rise to stricture, with dilatation and hydro-nephrosis above. This parasite has been considered the cause of the endemic hæmaturia of hot countries, but as cases of this affection have been carefully examined for the distoma with negative results, it must be considered as only one among several causes. Strongyli are said to have been found in some of the cases.

Nothing is known of an appropriate TREATMENT for the distoma. An abundant flow of urine might perhaps carry off more rapidly such individuals as have found their way into the urinary passages, and, considering the character of the deposit described above as causing stoppage of the ureter, treatment directed against the uric-acid diathesis might diminish the risk of this particular form of trouble.

Diseases of the Ureters.

Absence of the ureter may take place when one kidney is congenitally absent, though this is not an absolute rule, since the ureter may terminate above in a rounded sac. When a single kidney exists, consisting of the fusion of two, there are usually two ureters opening in the usual position. In one instance, in which only one kidney and one ureter were present, the ureter opened into the bladder on the side opposite to that upon which the kidney was situated.

Not very infrequently two ureters exist in connection with a normal kidney, remaining separate for the whole or a part of their course to the bladder. This condition is merely a sort of exaggeration of the separation between the two branches of the renal pelvis.

A few instances have been noted where a ureter or a fistula connected therewith has opened outside of the bladder at a point near the urethra. This malformation gave rise to symptoms of incontinence of urine, and in one case was remedied by operation.

Abnormal openings of the ureter into the uterus and vagina as the results of pelvic inflammations, and upon the external surface as the result of wounds, have occurred. They are more or less amenable to surgical treatment, and belong to the domain of surgery and gynecology rather than to medicine.

Occlusion of the ureter has already been spoken of in connection with the hydro-nephrosis and pyelitis to which it gives rise. This occlusion results from pressure exerted either at the vesical orifice from cystitis; a little higher up from malignant disease connected with the uterus or a fibroma surrounding the ureter; from contracting adhesions resulting from pelvic inflammation; or from sharp flexions of the tube itself, perhaps also from valvular folds of the mucous membrane. Sometimes its obliteration seems to be the result of old inflammation of the mucous membrane of the ureter itself in connection with that of the renal pelvis. In the latter case the occlusion may be complete at several points, while at others a collection of dry, cheesy, or putty-like material occupies the cavity of the ureter as well as the pelvis of the atrophied kidney.

Cancer is not known primarily to invade the ureter.

Tubercle is not infrequently found in the form of small granulations in cases of general tuberculosis, and it is possible that this deposit may be among the earlier ones; hence a chronic catarrh of the urinary passages without some known cause should be looked upon with suspicion, and the development of phthisis as far as possible guarded against. The presence of these small tubercles in the ureter, if none are present or no ulceration exists in the kidney, are of little or no local importance.

Inflammation of the ureter often exists in connection with cystitis and pyelitis, and in fact constitutes the means by which the higher urinary passages become gradually involved in the diseases below.

The DIAGNOSIS of this condition as a distinct disease is hardly possible, and is besides unnecessary, as the treatment to be directed thereto would be included in that called for by the more extensive and obvious inflammation of the kidney and bladder.

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS.

BY FRANCIS DELAFIELD, M.D.

CHRONIC CONGESTION OF THE KIDNEY.

SYNONYMS.—Passive congestion; Cyanotic induration.

It is now generally recognized that we must separate from the other forms of kidney disease the condition of chronic congestion. Since Traube first called attention to the causation and characters of this lesion, all authors have recognized its special character, although there are still minor differences of opinion concerning it.

ETIOLOGY.—Chronic congestion of the kidney may be produced by any mechanical cause which interferes with the escape of the blood from the renal veins. Thrombi of the veins, tumors pressing on the veins, emphysema of the lungs, hydro-pneumothorax, pericarditis,—all may produce this lesion. As to how often it is produced by the pregnant uterus is still a question. But the most common cause of all is organic disease of the heart. Practically, the lesion comes under consideration as a complication of heart disease, of aneurism of the arch of the aorta, and of emphysema of the lungs.

LESIONS.—If the congestion has not existed for a long time, we find the kidneys increased in size and their weight great in proportion to their size. They are of an unnatural hardness—a hardness which can be imitated by injecting the blood-vessels of a normal kidney with water. The capsules are not adherent, the surfaces of the kidneys are smooth. Both the cortical and pyramidal portions are congested, and this congestion gives the entire organs a peculiar reddish, livid color. No lesions are found in the Malpighian bodies, tubes, stroma, or blood-vessels, except that the epithelium of the convoluted tubes may be a little swollen.

If the congestion has lasted for a longer time, the kidneys may continue to be large or they may be somewhat reduced in size; the weight remains out of proportion to the size. There are the same unnatural color and consistence. The capsules are now often slightly adherent and the surfaces of the kidneys finely nodular. In the cortex there may be patches of new connective tissue enclosing atrophied tubules, or there may be a more diffuse growth of connective tissue separating the tubes from each other. In the convoluted tubules the epithelial cells may be swollen and finely granular, or very much swollen and coarsely granular, so as to nearly fill the tubes, or flattened so that the cavities of the tubes are unnaturally large. The tubes may also contain cast-matter and detached and broken epithelial cells. The capsules of the Malpighian bodies may be a little thickened and the capsular endothelium swollen. In the pyramids the epithelium of the straight tubes may be granular and detached, and there is often cast-matter in the looped tubes. It is difficult to tell whether there is any real change in the veins of the kidney.

As a result of the same interference with the venous circulation, similar changes are found in other parts of the body—in the lungs, liver, spleen, stomach, small intestine, and pia mater. In all these organs there is, first, simply a venous congestion, then after a time structural changes are added. Formation of new connective tissue and of new functional cells of the particular organ, degeneration of these cells, dilatation and tortuousness of the small veins and capillaries, are regularly present. The kidney lesion, therefore, is only one of a number of lesions, all dependent on a common mechanical cause.

SYMPTOMS.—Of the persons who die with chronic congestion of the kidney, a large number present marked symptoms during life, but it is difficult to determine how largely these symptoms are due to the congestion of the kidney.

A congestion of the kidney of only a few days' duration does not seem usually to give rise to any symptoms. Even if such a congestion is prolonged to two or three weeks, as we see in some cases of hydro-pneumothorax from perforation of the lung, there may be no renal symptoms and no changes in the urine. On the other hand, it is extremely rare for organic heart disease or emphysema of the lungs to prove fatal without some disease of the kidneys.

The question is still further complicated by the fact that both in cardiac disease and emphysema there may be either chronic congestion of the kidney or chronic diffuse nephritis with the same symptoms.

After excluding the cases of cardiac hypertrophy secondary to kidney disease and the cardiac diseases with complications, I find in my casebooks 137 cases in which the patients died simply from heart disease, changes in the viscera due to the disturbance of the venous circulation, and kidney disease. Of these cases, 84 presented the lesions of chronic diffuse nephritis; 53 were in the state of chronic congestion. Of the cases of chronic diffuse nephritis, 27 were large white kidneys, 29 atrophied kidneys, 28 could not be classed as either large white or atrophied. In these cases there existed during life certain regular symptoms. There were changes in the urine, dropsy, headache, delirium, convulsions, coma, dyspnoea, vomiting, cough, hæmoptysis, loss of flesh and strength.

As regards the quantity of the urine, there was a very great variety until shortly before the patient's death; then the urine was usually diminished in amount, sometimes suppressed. A very marked decrease in the amount of urine was more constant in the cases of chronic diffuse nephritis than in those of chronic congestion. But in several cases both of chronic diffuse nephritis and of chronic congestion the patients passed from thirty to forty ounces of urine up to the time of their deaths.

Albumen and casts were often present—nearly always with the large white kidneys, not nearly as constantly with atrophied kidneys or with the cases of chronic congestion. In cases of chronic congestion the albumen was usually in small amount and often not accompanied with casts.

The specific gravity of the urine was apt to be low with chronic diffuse nephritis and high with chronic congestion, but there were many exceptions to this rule. With large white kidneys, atrophied kidneys, simple diffuse nephritis, and chronic congestion the specific gravity might be either normal, high, or low up to the time of death.

Transudation of the serum into the subcutaneous connective tissue and the serous cavities was a very constant symptom. It was a little more constant, and perhaps usually reached a greater degree, in the cases of chronic diffuse nephritis than in those of chronic congestion.

Headache, delirium, convulsions, and coma occurred in a moderate number of all the cases.

Dyspnoea was a very frequent symptom in all the cases.

Vomiting was also present in many cases.

Cough, with mucus or muco-purulent sputa, sometimes with hæmoptysis, was a very common symptom.

Many of the patients lost flesh and strength and became anæmic.

COURSE OF THE DISEASE.—There is a great deal of similarity in the histories of patients who suffer from the combination of cardiac and renal disease. There is first the history of the heart disease. A patient goes on for a number of years, sometimes apparently perfectly well and unconscious that his heart is diseased, sometimes more or less troubled with cough, cardiac dyspnoea, and palpitation. But after a longer or shorter time there is a marked change for the worse. Either gradually or rapidly the cough becomes worse, the dyspnoea greater, the functions of the stomach are disturbed, the patient loses flesh and strength, dropsy is developed, and finally cerebral symptoms. Some die suddenly, some with exhaustion, some with dropsy, some with dyspnoea, some comatose. It is always possible for the patient to recover from the first attack of this kind, sometimes even from a second, but eventually there comes an attack which proves fatal.

The most striking cases are those in which cardiac disease exists for many years without giving any symptoms, and then the symptoms are developed rapidly. Such persons, although they have organic disease of the heart, may seem to enjoy perfect health. They may even be able to take long walks, climb mountains, or perform laborious work. On some day they suddenly become sick. Sometimes the exciting cause of the attack is a pleurisy or a pericarditis, sometimes there is no apparent cause. The first symptom is usually dyspnoea, and this is not an ordinary cardiac dyspnoea. It is a very distressing and constant dyspnoea, which does not allow the patients to lie down. They pass days and nights sitting in a chair, fatigued, ready to sleep, but kept awake by the constant dyspnoea. Some of these patients will die at the end of a few days; others live longer and develop dropsy, anæmia, and cerebral symptoms.

When the chronic congestion of the kidneys is secondary to emphysema of the lungs, the course of affairs is much the same. The patient goes on for a number of years with the ordinary symptoms of emphysema, and then gradually or suddenly becomes worse. Dyspnoea, dropsy, anæmia, cerebral symptoms make their appearance, and the case terminates in the same way as the cardiac cases.

DURATION.—How long congestion of the kidneys may exist without producing symptoms it is hard to say. Certainly it may exist for a number of days without any apparent disturbance of the functions of the kidney. Whether it may exist for a time, give symptoms, and then disappear, is uncertain; the rule seems to be that the lesion, when once well established, persists up to the death of the patient.

TREATMENT.—It must be acknowledged that we can hardly hope for a cure of the lesion of the kidneys, and that even alleviation of the symptoms is not always possible. The mechanical cause of the obstruction to the venous circulation cannot be removed, and it is not only the functions of the kidneys that are disturbed, but those of the lungs, liver, spleen, stomach, and small intestine. Still, we can do something. The iodide of potassium, convallaria, caffeine, and digitalis may be of service in equalizing and strengthening the heart's action, and at the same time act as diuretics. Inhalations of the nitrite of amyl dilate the arteries and capillaries, and so unload the veins. Opium is the great remedy for the dyspnoea, although it must be given with caution. Inhalations of ether may render the patient's last days more comfortable.

BRIGHT'S DISEASE OF THE KIDNEYS.

After considering separately the condition of chronic congestion of the kidney, we find that there are a group of kidney diseases characterized by certain rational symptoms, changes in the urine, and alterations in the structure of the kidneys which are popularly known by the name of Bright's disease.

Various attempts have been made to classify these cases.

1. All the kidney lesions have been supposed to correspond to the stages of an inflammatory process—a stage of congestion, a second stage of exudation, and a third stage of contraction.

2. The disease has been divided, according to its clinical symptoms, simply into acute and chronic Bright's disease.

3. The gross appearances have been taken as a standard, and the cases are classed as examples of large white kidney, atrophied kidney, waxy kidney, etc.

4. The kidneys have been compared to mucous membranes, and authors speak of catarrhal and croupous nephritis.

5. The disease has been classified, according to the particular part of the kidney affected, into parenchymatous, tubular, glomerular, interstitial, and diffuse nephritis.

With our present knowledge of the subject it seems to me most convenient to speak of acute and chronic parenchymatous nephritis and acute and chronic diffuse nephritis. I include under the head of parenchymatous nephritis all those kidneys in which the lesions are strictly confined to the epithelial cells lining the tubules and the capsules of the glomeruli; under the head of diffuse nephritis, those kidneys in which the lesions involve the tubes, stroma, glomeruli, and arteries; under the head of interstitial nephritis, those kidneys in which the essential morbid changes are in the stroma.

This classification seems to me to be theoretically correct, but yet I must admit that from a clinical standpoint nearly all the cases may be conveniently arranged into the two classes of acute and chronic Bright's disease.

GENERAL SYMPTOMS OF BRIGHT'S DISEASE.—There are a certain number of symptoms common to all the varieties of Bright's disease, and it is convenient to consider them before going on to the special description of each of these varieties. These symptoms are—

Changes in the Urine.—Healthy adults usually secrete during the twenty-four hours from 40 to 50 ounces of urine of a light-yellow color, of acid reaction, of a specific gravity of 1015 to 1025, and holding in solution a number of excrementitious substances. Small amounts of albumen and of sugar seem to be, in some persons, physiological ingredients of the urine.

In most cases of Bright's disease the quantity of the urine at some time in the course of the disease deviates from the normal standard. Either the urine is increased in amount or diminished or suppressed, and in the course of the same case the urine may be at one time increased, at another diminished.

We find in healthy persons that the quantity of urine varies with the amount of fluids that are imbibed and with the condition of the skin and the bowels—that nervous influences and certain drugs will increase or diminish the amount of urine. Physiologists teach us that the amount of urine excreted varies with the degree of the blood-pressure in the renal arteries or with the rapidity with which the blood circulates through these arteries.

The urine may be very much increased or diminished in amount as the result of various morbid conditions. Scanty urine or suppression of urine is observed in the course of acute parenchymatous and acute diffuse nephritis and in the early stages of the development of the large white kidney. During the course of any case of chronic Bright's disease there are usually periods during which the urine is scanty or suppressed, especially toward the close of the disease. The kidney lesions which complicate scarlet fever, yellow fever, and cholera are often attended with suppression of urine. Any diseases accompanied by a well-marked rise of temperature are apt to be associated with a diminution in the amount of urine. Injuries to the urethra, even very slight ones, may be followed by complete suppression of urine, without any changes in the kidneys except congestion.

Marked diminution in the amount of urine occurring in the course of acute and chronic Bright's disease is usually associated with the development of cerebral symptoms—headache, restlessness, delirium, muscular twitchings, convulsions, stupor, and coma. Such a change in the amount of the urine usually lasts only a few days and may terminate fatally, or the quantity of urine will increase and the patient get better. There are, however, cases in which the suppression of urine lasts for several days without the development of uræmic symptoms. Whitelaw¹ relates a case of suppression of urine lasting for twenty-five days in a boy eight years old. The suppression began twelve weeks after an attack of scarlatina. There were no uræmic symptoms, and the child recovered completely.

¹ Lancet, September, 1877.

The suppression of urine due to injuries of the urethra gives rise to symptoms of great prostration—rigors, vomiting, and collapse—rather than to uræmic symptoms.

Suppression of urine is also produced by occlusion of the ureters by calculi, new growths, etc. It is a curious fact that in these cases the patients continue to live for a number of days (9 to 11, Roberts), and no uræmic symptoms are developed until a few hours before death.

The most marked examples of persistent increase in the quantity of urine are afforded by cases of diabetes mellitus and diabetes insipidus. But a daily excretion of from 70 to 100 ounces is common enough with atrophied kidneys, with large white kidneys, and with waxy kidneys.

It is exceedingly difficult to form any rational idea of the causes of the variations in the amount of urine in the course of the same case, and in different cases with similar kidney lesions. Various explanations have been attempted, ascribing these changes to the hypertrophy of the left ventricle of the heart, to changes in blood-pressure, to lesions of the arteries, to changes in the composition of the blood, to lesions in particular portions of the kidneys. But any one who tries to apply these explanations to any number of actual cases will find many difficulties.

The most evident causes of diminution in the amount of urine seem to be an abnormal condition of the circulation of the blood and either congestion or structural changes of the kidneys.

The specific gravity of the urine varies from day to day and from hour to hour in the same person, having a regular relation to the quantity of urine passed. But a long-continued deviation from the normal specific gravity is usually an evidence of disease. The highest specific gravities obtain with saccharine diabetes. Abnormally high specific gravities also often occur in the urine of patients with a high temperature, with chronic congestion of the kidneys, and in some cases of acute and chronic parenchymatous nephritis.

Low specific gravities are the rule in diabetes insipidus and with acute and chronic diffuse nephritis. In chronic diffuse nephritis the specific gravity remains low even if the quantity of urine passed is very small. When there is almost suppression of urine from occlusion of the ureters the urine that is passed is of low specific gravity.

These changes in specific gravity correspond of course to the amount of solid matter in solution in the urine, and may depend upon a change in the relative proportion of the fluid and solid constituents of the urine, or upon an absolute increase or decrease of the solid portions.

Any change in the absolute amount of solid matter excreted in the urine must depend upon changes in the composition of the blood, or in the circulation of the blood through the kidneys, or in the structure of the kidneys themselves. All these three conditions seem to exist in Bright's disease, and either together or separately may diminish the daily excretion of solid matter.

It is not necessary here to enumerate the different solid constituents of the urine. A change in the amount of many of them merely indicates disorders of the digestive process. Urea seems to be the most important of the excretory substances, and its quantity is regularly diminished both in acute and chronic Bright's disease.

Blood is found in the urine in a considerable number of cases of Bright's disease. If it is present in large quantities, the urine will be of a reddish color; if in smaller quantities, of a smoky color; and if in still smaller quantities, the color will not be changed. Blood is found regularly with acute diffuse nephritis, with the more severe cases of acute parenchymatous nephritis, with the exacerbations of chronic diffuse nephritis, and with suppurative nephritis. The blood seems to be derived from the tufts of vessels in the Malpighian bodies.

Albumen in the urine is a very common symptom of renal disease, but it is not confined to such cases. It is also found without any structural lesions of the kidneys.

1. There are some individuals whose urine, for many years, will contain small quantities of albumen, and yet their general health is good and they never develop any renal symptoms. In some of these cases the urine is always somewhat diminished in quantity, and in some there is also a little sugar in the urine.

2. In a large number of perfectly healthy persons small amounts of albumen will appear as a temporary condition after muscular exercise, sea-bathing, eating certain kinds of food, etc.

3. Albumen may be present in considerable amount for weeks or months in the urine of young persons, and then disappear altogether. The general health may continue good or be somewhat depreciated. After a time the albumen disappears and the patients have no further trouble.

4. General convulsions, concussion of the brain, and transfusion of blood often produce a temporary albuminuria.

Some observers believe that albumen is always present in the urine, but in such small amounts as to elude the ordinary tests.

Both physiological and pathological albuminuria is most constant and abundant after eating.

The albumen is not all of the same character. Most of it is serum-albumen, but with it is a smaller amount of globulin and sometimes of peptones. As yet the serum-albumen seems to be of the principal practical importance.

Pathological albuminuria is most constant and the albumen is most abundant with acute and chronic parenchymatous nephritis, with acute diffuse nephritis, and with the large white variety of chronic diffuse nephritis. It is least constant and least abundant with the atrophic variety of chronic diffuse nephritis, with some waxy kidneys, with interstitial nephritis, and with chronic congestion of the kidney. A variety of explanations have been given to account for the production of albumen by diseased kidneys, but none of them are very satisfactory.

The albuminuria has been ascribed to disease of the epithelium of the Malpighian bodies; to increase of the blood-pressure within the renal arteries, either with or without disease of the arterial walls; to slowing of the blood-current in the arteries; to diminution of the blood-pressure in the arteries; to congestion of the renal veins; to changes in the composition of the blood; to changes in the epithelium of the renal tubules.

For practical purposes it is to be remembered that large amounts of albumen regularly indicate structural changes in the kidneys; that small amounts of albumen are found without any kidney lesions, with chronic congestion of the kidney, and with chronic diffuse nephritis; that chronic diffuse nephritis may exist without albuminuria for a long time.

In many cases of kidney disease we find in the urine bodies of cylindrical shape called casts. The same bodies are also found within the tubules of diseased kidneys. Concerning the nature and origin of these bodies we are still ignorant. We only know that they are formed within the kidney tubules and are carried thence into the urine. With the exception of the blood-casts, which are composed simply of a number of blood-globules pressed together, all casts seem to be formed of a peculiar homogeneous hyaline substance to which other elements may be added. Hyaline casts are composed entirely of such material. Waxy casts are formed of the same substance, which becomes denser. Epithelial casts are made by the adhesion of epithelial cells to the surface of hyaline casts. Nucleated, granular, and fatty casts are hyaline casts with the fragments of degenerated epithelium incorporated in them.

Occasionally hyaline casts are found in the urine of healthy persons. They also occur as a temporary condition after severe muscular exertion, with typhlitis, with renal calculi, and with jaundice. Most frequently, however, they are associated with structural disease of the kidneys. Usually they are found in albuminous urine, and in proportion to the amount of albumen, but we may find casts without albumen and albumen without casts.

With chronic congestion of the kidney the casts are hyaline and few in number. With acute parenchymatous nephritis there are hyaline, granular, nucleated, and epithelial casts. With chronic parenchymatous nephritis there are hyaline, granular, and nucleated casts. With acute diffuse nephritis there are blood, epithelial, hyaline, granular, nucleated, and fatty casts. With chronic diffuse nephritis there are hyaline, waxy, granular, fatty, nucleated, and epithelial casts.

An accumulation of serum in the subcutaneous connective tissue, in the serous cavities, and in the lungs is one of the regular symptoms of Bright's disease. It usually appears first in the feet or in the face. Such dropsy is said to be due to a low specific gravity of the blood-serum; to the loss of albumen; to the scanty elimination of urine; to hydræmia plethora; or to changes in the walls of the blood-vessels.

The functions of the stomach are often disordered, either with or without the existence of chronic gastritis. Loss of appetite, nausea and vomiting, oppression after eating, etc. continue and grow worse throughout the disease. Vomiting is also a frequent concomitant of the so-called uræmic attacks.

Diarrhoea often occurs with dropsy and a scanty excretion of urine, and may then be of service to the patient, but it sometimes becomes very profuse, rebellious to treatment, and is of positive injury.

Dyspnoea associated with Bright's disease seems to occur in several different ways. It may be of mechanical origin from oedema of the lungs or from hydrothorax. It may be a purely nervous phenomenon, or it may depend upon a complicating heart lesion. The nervous dyspnoea seems to be allied to the uræmic vomiting and cerebral symptoms; it is often most distressing.

In the course of chronic Bright's disease disturbances of vision occur dependent on three different conditions: (1) There may be a loss of vision, usually temporary, without any discoverable lesion of the eye. (2) There may be simple neuro-retinitis. (3) There may be the characteristic nephritic retinitis with hemorrhages and fatty degeneration of the retina. These two forms of retinitis are often the first symptoms of renal disease.

Neuralgic pains, most frequently referred to some part of the head or face, but also to other parts of the body, are prominent symptoms in some cases.

The Blood.—Both in acute and chronic Bright's disease the patients often become markedly anæmic and pale. This change in the color of the patient corresponds to an alteration of the composition of the blood with the details of which we are not as yet fully acquainted. The blood seems to be thinner and more watery.

Cerebral Symptoms.—Headache, drowsiness, stupor, sleeplessness, delirium, coma, muscular twitchings, and general convulsions are of frequent occurrence. The headache and drowsiness may continue during the course of the disease for many months. The stupor, sleeplessness, delirium, coma, muscular twitchings, and general convulsions are apt to occur in attacks which last for several days, and then pass away or terminate in the death of the patient. With such cerebral symptoms are often associated dyspnoea, vomiting, increased temperature, and diminution in the excretion of urine. The entire group of symptoms is commonly known by the name of uræmia.