given in the hope of dissolving already formed calculi but while these drugs
may succeed in dissolving uric acid in the test-tube it is doubtful if they possess
any distinctly solvent action over uric acid in the kidney or its pelvis. Piper-
azin may be given in doses of 7 J to 15 grains (0.5 to i.o) three times a day
in water, plain or carbonated; its marked hygroscopic properties prevent its
administration in piU or powder. Lysidin may be taken in doses of | to 2^
drachms (2.0 to lo.o) of the 50 percent, alkaline solution in a glassful of car-
bonated water. The dose of lycetol (dimethyl-piperazin tartrate) is from 5
to 10 grains (0.33 to 0.66) three times a day in carbonated water or lemonade.
Hexamethylenamine is considered to have a certain amount of lithontriptic
effect. It certainly is the most effective urinary antiseptic which we possess;
it is particularly indicated in patients with phosphatic calculi and alkaline
urine but is beneficial as well in the other varieties of stone. Given in com-
bination with sodium benzoate — hexamethylenamine gr. viiss (0.5), sodium
benzoate gr. x (0.66) — it will tend to render the urinary tract antiseptic, and
NEOPLASMS OF THE KIDNEY. 703
relieve the pain in the region of the kidney, which is a frequent accompani-
ment of renal stone.
The pain of an attack of renal colic can usually be controlled by nothing
less potent than a considerable dose of morphine — at least \ grain (0.016)
given h}-podermatically and repeated if necessar}^ Suppositories containing
each I grain to 1^ grains (0.065 ^o o.i) of powdered opium and J to ^ grain
(0.016 to 0.032) of extract of belladonna are also useful. For the very severe
paroxysms it may be necessary to give chloroform by inhalation until the effect
of the morphine has taken place. In certain instances the coal tar analgesics,
antipyrine salicylate (salip}Tine) or acetphenetidine (phenacetine) in 10
grain (0.66) doses will relieve the pain to some extent and almost always the
employment of hot compresses or poultices of flaxseed are of benefit; these
and hot bathing may relax the ureteral spasm and render the passage of the
stone more easy. Hot drinks such as lemonade, arrowroot gruel, etc., are
frequently grateful to the patient and changes in position, lowering the head
and raising the buttocks, at times afford a certain amount of relief.
When the calculus has reached the bladder the agonizing pain disappears.
The stone now is usually passed through the urethra or remains in the bladder
to increase in size as a vesical calculus.
In nephrolithiasis, operation and extraction of the stone is necessary if the
latter is too large to enter the ureter, becomes impacted during its passage,
or if any suppurative process is present.
NEOPLASMS OF THE KIDNEY.
The kidney may be the seat of tumorous growth of either benign or malig-
nant type. Of the former the fibroma is the most common; this neoplasm
is usually small and even when multiple may not appreciably increase the
size of the organ. Other benign tumors which may involve the kidney are the
lipoma, the angiofna, the adenoma and the villous papillofna which may have
its origin in the pelvis of the organ. Cystic tumors are frequent and will
be discussed in a separate section. Gumma of the kidney may also occur.
Malignant neoplasms of the kidney are of two varieties — carcinoma and
sarcoma. The latter is the more frequent and is met in one of two forms, the
alveolar sarcoma and the rhabdomyoma; renal sarcoma is often observed in
children. Malignant tumor of the suprarenal body — hypernephroma — often
involves the kidney itself as well, and it is probable that in many instances
apparently primary malignant tmnors of the kidney are in reality primary
in the suprarenal capstile and secondary in the former organ.
The malignant new growths may become so large as to nearly fill the abdom-
inal cavity, they usually increase in size rapidly and are often the seat of
haemorrhage.
704 DISEASES OF THE URINARY SYSTEM.
Symptoms. The smaller benign tumors often give no symptoms; one of
the most t}'pical symptoms of malignant disease of the kidney is hematuria,
it is, however, by no means constant. The blood may be either fluid or
clotted and it may occur in the form of casts of the renal pelvis or lu-eter.
Blood is more common in the urine of carcinoma than in that of sarcoma;
rarely the lurine may contain fragments of the growths from which the diag-
nosis may be made.
Pain is present in certain instances but by no means in all. In character
it may be a dull ache in the region of the kidney or it may be referred to the
hip, thigh or knee because of the pressure of the growth on branches of the
lumbar plexus. Pressure upon and erosion of the vertebrae cause severe
pain and the passage of clots of blood through the ureter is often attended
â– odth symptoms suggestive of renal colic, the pain, however, is rather less
marked. Progressive emaciation with ultimate cancerous cachexia is fre-
quent although in some instances the patient's nutrition may remain in good
condition.
Physical Signs. Bimanual palpation usually detects the presence of a
tumor in the region of the kidney which is not movable from side to side but
moves in a vertical direction with respiration, though less so than do growths
involving the liver. In consistence the tumor may be firm or, if of rapid
growth, soft. In children the enlargement of the abdomen is often marked
and the superficial veins are dilated. The hand may be able to insert itself
between the tumor and the liver on the right side and between it and the
spleen on the left; early in the disease tympany may be elicited upon percus-
sion of this space but later this is likely to become impossible. Renal neo-
plasms enlarge anteriorly rather than backward and push forward the colon,
the presence of which between the growth and the abdominal wall, as evidenced
by obtaining a tympanitic note upon percussion, is an important point in
the differentiation of tumors of the kidney from those of neighboring organs.
The differential diagnosis of sarcoma from carcinoma may be based
upon the following points : the former is more common and is most frequently
seen in young children while carcinoma is usually observed in later life.
In the latter the emaciation is more rapid, hsematuria is more common and
metastatic growths are often observed.
Tumors of the kidney may be differentiated from ovarian tumors by the
more frequent occurrence of urinary^ changes and by the fact that the colon
is usually demonstrable between the growth and the abdominal wall, while
in the latter condition there is tympany in the flanks, the intestines being in
this region, the tumor grows upward from below, there are often symptoms
referable to the genital tract and rectal and vaginal examination reveals gen-
ital abnormalities.
The tumor of retroperitoneal glandular enlargement is not associated
THE CYSTIC KIDNEY. 705
with urinary symptoms and the growth is central instead of being rather upon
one side. A confusing sign may be the presence of tympany upon percussion
due to the position of the intestines in front of the tumor.
Hepatic tumors move more freely diiring respiration than do those of the
kidney; there is often prominence of the right hypochondriac region and the
edge of the liver is often palpable.
Enlargements of the spleen move freely with the descent of the diaphragm
and the tumor extends downward from above; its edge is palpable and the
marginal notch may be demonstrated. The growth is in contact, as a rule,
with the abdominal parietes and consequently percussion yields a dull note.
The prognosis is unfavorable even if the tumor is removed while still small
and before the incidence of metastases. Sarcoma is usually fatal within
a few months while in carcinoma life may be prolonged for a more extended
period.
Treatment, aside from radical surgical measinres, consists merely in render-
ing the patient as comfortable as possible by the employment of hypnotics
when necessary and in the administration of tonics and a nutritious diet in
order that nutrition may be maintained as long as possible.
THE CYSTIC KIDNEY.
Cysts of the kidney may be either congenital or acquired; in the congeni-
tally cystic kidney the condition is usually bilateral, the affected organ con-
taining a number of rounded cysts ranging in size from that of a small pea to
that of a hen's egg. The enclosed fluid may be clear or turbid, brownish-red
or dark brown in color, acid in reaction, and it contains albumin, urinary salts,
blood and more rarely uric acid and m-ea. Usually this affection results
in early death, but in infrequent instances adult life may be reached and
the condition has been found at autopsy, having given no symptoms intra
vitani. Large foetal cystic kidneys may cause obstruction to labor.
Acquired cysts of the kidney are of various types:
a. Retention cysts. These are usually small and contain fluid which
has once been inrine but has become watery; it may contain albumin and
traces of the urinary solids. This condition is observed in chronic nephritis as
a result of stenosis of the tubules by the increased connective tissue. Large
cysts have been observed in kidneys which present no other abnormality.
These may contain blood and probably are also to be classed in this group.
b. Dermoid cysts of the kidney have been reported. These may occur
in otherwise healthy kidneys.
c. Hydronephrotic cysts. Hydronephrosis in which pressure has reduced
the kidney to a mere shell (see p. 695) may be classed among the cystic con-
ditions affecting this organ.
d. Renal cysts occurring with a cystic condition of other organs, partic-
45
706" DISEASES OF THE URINARY SYSTEM.
ularly the liver, spleen and thyroid gland. This form of cystic disease is,
in all likelihood, the result of defective development.
e. Hydatid cyst of the kidney is seldom observed. The diagnosis is made
upon the demonstration of hooklets or bits of the cyst wall in the urine and
upon associated hydatid disease of other organs. Hydronephrosis may
result from ureteral obstruction due to the attempt to pass these fragments.
Symptoms. These consist of the presence of a tumor in the renal region,
the physical signs and differential diagnosis of which have been discussed
in the section upon renal neoplasms (p. 704); of hematuria which is usually
intermittent and, in instances of cysts due to obstruction of the tubules by the
interstitial growth of a chronic nephritis, the symptoms of this primary condi-
tion, such as heightened arterial tension, arteriosclerosis, cardiac hyper-
trophy, a urine increased in amount, of low specific gravity and urea content,
and containing albumin and casts, are present.
The physical signs are those of tumors of the kidney (p. 704) and of hydrone-
phrosis (see p. 696).
The diagnosis is based upon the same general points as that of tumor.
The prognosis in double cystic kidney is unfavorable, operation being
out of the question, and the probability of uraemia or heart failure, especially
when the cysts occiu: in chronic nephritis, being great. Unilateral cystic
disease is amenable to ciure by operation and the possibility of rupture of a
cyst and consequent perinephritis or peritonitis is not to be forgotten.
Treatment, aside from the reHef of pain, maintenance of the patient's nutri-
tion and the management of the chronic nephritis, if this is present, is wholly
within the province of the surgeon. The operation should be adapted to the
condition in hand, it being possible to enucleate single cysts without removal
of the kidney. Nephrectomy may be performed when this is impossible.
IDIOPATHIC HEMATURIA.
Synonyms. Renal Epistaxis; Unilateral Renal Haemorrhage.
Definition. Blood appearing in the urine from unknown cause. The
condition is not a very frequent one and is to be distinguished from the haema-
turia of the kidney lesions previously described, from malarial haematuria
and from renal haemorrhage occurring in anaemia, leukaemia and other diseases
of the blood, from that of traumatism and that of parasitic disease.
Symptoms. Of these the most characteristic is the appearance of blood
in the m-ine. The blood is seldom passed in clots but is usually mixed with
the urine, which is acid and of smoky tinge when passed, becoming brighter
red as alkaline fermentation takes place. Albumin is present in quantity
varying with the amount of blood, and red blood cells, leucocytes and blood
casts are demonstrable by the use of the microscope.
HEMOGLOBINURIA. 707
In typical instances no other symptoms are present, although there may be
complaint of lumbar pain. With the persistence of the haemorrhage, pro-
gressive weakness ensues. The condition may be associated with renal
displacement, pelvic lesions and destructive changes in the kidney.
Treatment consists chiefly in the insistence upon rest in bed and the appli-
cation of cold to the lumbar region, together with the administration of agents
which increase the coagulability of the blood and of astringents. Of the
former the most effective is calcium lactate which may be given in doses of
20 to 30 grains (1.33 to 2.0) three times a day. Rather less efficient is calcium
chloride 20 grains (1.33) three times daily. Gelatin also has a certain action in
the increase of the blood's coagulability and it may be given both hypoder-
matically and by mouth. For purposes of subcutaneous administration 2^
percent, of purified gelatin is dissolved in normal saline solution; of this an
ounce (30.0) or more may be injected at a time. The gelatin when given
internally maybe prescribed in the following formula: Pure gelatin 5 to 10 parts,
distilled water 150 parts, simple syrup 25 parts; of this a dessert spoonful (8.0)
is to be given every two hours. It may be taken, if necessary, in larger quantity
and prescribed in 10 percent, solution of which a pint (500.0) may be taken
daily. Ergot in the form of ergotine injected under the skin in doses of 5 to
ID grains (0.33 to 0.66) or given by mouth in similar dose may be employed.
Other astringents such as lead acetate, alum, gallic and tannic acids, catechu,
hamamelis virginica, and iron persulphate may be tried but little is to be
expected of them. Electric baths may benefit the patient.
The diet should be chiefly of milk. Demulcent and acidulated drinks
may be permitted.
HiEMOGLOBINURIA.
Definition. A condition in which blood-pigment appears in the urine
The coloring matter may be either haemoglobin or methsemoglobin and may
be associated with the presence of a few red blood cells either intact or in a
state of disintegration. Hfemoglobinuric urine is reddish-brown or black
in color if the pigment is present in considerable amount; if only in small
quantity the urine is smoky. Upon standing a heavy brown sediment is
deposited. Albumin is present and the use of the microscope reveals the
presence of blood cells, epithelial cells, urates and pigment granules. Spectro-
scopic examination detects the bands of absorption which characterize the
spectrum of oxyhaemoglobin or that of methaemoglobin. In the former
instance, which is more infrequent than the latter, the bands are two in
number. The spectrum of methsemoglobin exhibits three bands, that in
the red near C being typical.
Haemoglobinuria, clinically, may be divided into two separate varieties.
7o8 DISEASES OF THE URINAE.Y SYSTEM.
TOXIC HEMOGLOBINURIA.
This't)^e of hasmoglobinuria is caused by the presence in the organism of
poisonous substances which separate the hemoglobin from the red cells.
Such poisons are phenol, pyrogallic acid, sulphuretted and arsenuretted hydro-
gen, carbon monoxide, naphthol, nitrobenzol, potassium chlorate and the
toxic substances contained in mushrooms. It also occurs as a result of the
presence of the toxins of the infectious diseases such as enteric fever, scarla-
tina, yellow fever, syphilis and especially malaria (blackwater fever), and has
been observed after excessive muscular exertion, exposure, severe burns and
during pregnancy. The transfusion of blood from one mammal to another
results in hsemoglobinuria and finally, a form of this condition may be met
in newly bom infants where it is accompanied by cerebral symptoms, venous
congestion and jaundice.
The prognosis is usually favorable but is dependent upon the cause and
the severity of the accompanying symptoms.
PAROXYSMAL HEMOGLOBINURLA..
This is a rare condition occurring usually in adults and more frequently in
men than in women. The attacks appear at intervals, are of sudden onset
and are characterized by the passage of urine containing blood pigment.
Chilly feelings, fever, and general pains may be associated with the paroxysm
which rarely lasts more than a day. Several attacks in the course of a day
have been observed. Nausea and vomiting and lumbar pain may character-
ize the seizure and at times the temperature is subnormal. As causes exposure
to cold and wet, excesssive muscular exertion and malaria maj^ be mentioned.
Individuals suffering from Raynaud's disease may be subject to hsmoglo-
binuric attacks but the association of the two conditions has not been
satisfactorily explained.
An associated symptom is jaundice and the condition is always preceded
by the appearance of free haemoglobin in the blood (hsemoglobinsmia) .
No satisfactory explanation of the pathogenesis of hasmoglobinuria has
yet been advanced; the best manner in which we can at present accoimt for
the condition is to say that in some fashion an increased hemolysis is brought
about and the resulting haemoglobin is dissolved in the fluid elements of the
blood and later appears in the urine.
The prognosis is favorable as a rule but the parox}'sms may persist for
considerable periods.
Treatment. Prevention, in both forms of hsemoglobinuria consists in the
avoidance of exposure and of over-exertion. Upon removal to a warm climate
the frequency of the attacks becomes much reduced. In the treatment of
the condition itself we should endeavor to eliminate the causal factor by
stopping the ingestion and aiding the elimination of poisons and by proper
CHYLURIA. 709
treatment of any infectious condition which may be present. If the haemo-
globinuria is the result of syphiHs, mercury and the iodides should be pre-
scribed; if it is due to malarial poisoning, quinine should be ordered. The
latter drug should be given with caution since it is said to increase the tendency
to hcemoglobinuria in some instances. The attack itself may sometimes
be aborted or shortened by means of inhalations of amyl nitrite. During
the seizure the patient should bfe kept in bed and warmly covered; he should
be protected from draughts and may be given hot drinks. The employment
of astringents and of other means suited to the treatment of renal haemor-
rhage has been suggested.
The anemia secondary to the destruction of the red blood cells necessitates
the administration of tonics, iron in particular.
CHYLURIA.
Definition. A rare condition in which the urine is mixed with minute
droplets of fat imparting to this secretion a milky appearance. The chyle
varies in amount from a quantity so small as to render the urine only slightly
opalescent to so large an admixture that this fluid becomes opaque, white and
scarcely to be distinguished by its appearance from milk. With the chyle,
blood is often present and the latter, upon allowing the urine to stand, may
form a clot at the bottom of the vessel whUe the former rises to the surface,
forming a creamy layer. Microscopical examination reveals the presence of
red blood cells in varying number and of granular fatty matter; more seldom
the fat may be visible in droplets as in milk.
JEtiology. The most usual cause of chyluria is the parasitic disease caused
by the -filaria sanguinis hominis or filaria Bancrofti (see the section upon para-
sitic diseases) but even in this affection chyle is not always present in the
urine. Other instances of chyluria are difl&cult of explanation but must
occur as a result of a communication between the chyle vessels and the urinary
tract, although this condition has not been reported as a post mortem finding.
Certain it is, however, that chyluria may exist when careful blood examina-
tion during life and thorough search after death reveal the presence of no
embryo filariae or eggs.
Symptoms other than the condition of the urine, which contains chyle con-
stantly or intermittently, are usually wanting. In certain instances there is loss
of flesh and strength, lumbar pain or occasional discomfort in urination resulting
from obstruction to the passage of coagulated material through the urethra.
The prognosis as to life is favorable but the passage of chyle in the urine
may persist continuously or intermittently for years. In some instances
it may cease spontaneously.
Treatment consists merely in making the patient as comfortable as possible
and in the employment of measures calculated to maintain nutrition.
7IO DISEASES OF THE NERVOUS SYSTEM.
CHAPTER X.
DISEASES OF THE NERVOUS SYSTEM.
DISEASES INVOLVING CHIEFLY THE BRAIN AND ITS
MEMBRANES.
ACUTE ENCEPHALITIS.
Synonym. Acute Cerebritis.
Definition. A primary acute inflammation of the cerebral tissue.
etiology. This condition is the result of microbic infection. It is predis-
posed to by any cause which lowers the body resistance, such as acute alco-
holism. As a primary disease it seldom if ever occurs but it is seen in most
instances as a complication or sequela of the acute infection^ diseases, such
as scarlet fever, variola, measles, influenza, infectious endocarditis or other
septic conditions.
Pathology. The portions of the brain most often involved are the base,
the temporal lobes and the corpus striatum. There is intense inflammation
and congestion with serous exudation, migration of leucocytes and minute
haemorrhages; the neighboring cerebral substance may become softened.
In mild cases the inflammatory process may subside with absorption of the
exudate and small sclerosed areas may result, permanently impairing the
brain function. In cases of severe type the areas of softening and the haemor-
rhages are of greater extent.
Symptoms. The onset of the disease is usually sudden, with headache,
dizziness, nausea, vomiting and a chill followed by a rise in temperatiire to
103° to 105° F. (39.5° to 40.5° C). The pulse and respiration are accelerated
and symptoms of cerebral irritation, such as convulsions, photophobia and
delirium, may occur; later these disappear and the patient becomes stuporous
or relapses into a state of partial coma from which he can, however, be
aroused. The neck is not stifl nor are the pupils contracted. The patient
may lie in this condition for a number of days, the symptoms may abate and
gradually disappear, recovery supervening or he may relapse into a state of
coma and finally die.
Focal symptoms depending upon the part of the brain affected are common;
these may be paralyses of an arm or leg, hemipelgia, hemianopsia, aphasia,
optic paralysis, nystagmus, speech disturbances, etc.
After recovery permanent disabilities of brain function often remain.
CEREBRAL MENINGITIS. 7II
The prognosis is serious but by no means do all cases result fatally or in
permanent cerebral impairment.
Treatment. The patient should be confined to bed in a darkened room;
the bowels should be moved by means of repeated small doses of calomel —
gr. ^ (0.016) — or a saline. Aconite in doses of from 5 to 10 drops (0.33-
0.66) every two to four hours should be given to lessen the fever and the cir-
culatory excitement. An ice cap should be applied to the head and leeches
to the nuchal region and the temples. The restlessness may be relieved
by the bromides or chloral; opium and morphine seem to be ineffectual.
In the later stages cardiac weakness may be combated by the use of
strychnine.
During convalescence general tonic treatment is indicated with the addition
of the syrup of hydriodic acid, one drachm (4.0) or potassium iodide, gr. x
(0.66) three times a day in order, if possible, to aid the absorption of the ex-
udate and lessen the tendency to sclerosis.
The diet during the acuity of the attack should be entirely fluid and feeding
by gavage or per rectum may be necessary.
CEREBRAL MENINGITIS.
PACHYMENINGITIS.
EXTERNAL PACHYMENINGITIS.
Definition. An inflammation of the external surface of the dura mater
of the brain.
.Etiology. This condition results from necrosis of the bones of the skull,