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A TEXT-BOOK OF MEDICINE



VOL. II



A TEXT- BOOK OF
MEDICINE



BY



G. DIEULAFOY



PROFESSOR OF CLINICAL MEDICINE AT THE FACULTE DE MEDECINE DE PARIS; PHYSICIAN
TO THE HOTEL DIEU ; MEMBRE DE L'ACADEMIE DE MEDECINE



AUTHORIZED ENGLISH TRANSLATION FROM THE

FIFTEENTH EDITION OF "MANUEL DE

PATHOLOG1E INTERNE"

BY

V. E. COLLINS, M.D. Lond., M.R.G.S., L.R.C.P.
J. A. LIEBMANN, Ph.D., M.A., LL.D.



IN TWO VOLUMES
VOL. II



NEW YORK
D. APPLETON AND COMPANY

1911



CONTENTS OF VOL. II



PART III— Continued
DISEASES OF THE URINARY SYSTEM

CHAPTER PAGE

I. DISEASES OF THE KIDNEYS - - 1045

I. ANATOMY AND PHYSIOLOGY OF THE KIDNEYS - 1045

II. CONGESTION OF THE KIDNEYS— CARDIAC KIDNEY - - 1049

III. ACUTE NEPHRITIS - - - - 1050

IV. APPENDICULAR KIDNEY — TOXIC NEPHRITIS — APPENDICULAR ALBU-

MINURIA ...-. - 1058
V. BRIGHT'S DISEASE — CHRONIC NEPHRITIS — PARENCHYMATOUS

NEPHRITIS — INTERSTITIAL NEPHRITIS — MIXED NEPHRITIS - 1066
VI. DISCUSSION ON UNILATERAL NEPHRITIS — SURGICAL TREATMENT

OF NEPHRITIS - - - - - - - 1112

VII. CASES OF ALBUMINURIA NOT DUE TO BRIGHT'S DISEASE - - 1118

VIII. AMYLOID KIDNEY - - - - 1120

IX. TUBERCULOSIS OF THE KIDNEY - - - 1121

X. RENAL SYPHILIS — SECONDARY SYPHILITIC NEPHRITIS — TERTIARY

SYPHILIS OF THE KIDNEY - - - 1133

XI. CYSTS OF THE KIDNEY — ENLARGED POLYCYSTIC KIDNEY - - 1148

XII. HYDATID CYSTS OF THE KIDNEYS - - - - 1152

XIII. CANCER OF THE KIDNEY - - - 1154

XIV. RENAL CALCULI - - - - 1159

XV. PYELITIS — PYELONEPHRITIS ... . 1178

XVI. SUPPURATIVE NEPHRITIS - - - - 1178

XVII. PRIMARY AND SECONDARY PERINEPHRITIC ABSCESS - - 1180

XVIII. HYDRONEPHROSIS - - - - 1185

XIX. HEMATURIA — CHYLURIA ... - - 1186

XX. HEMOGLOBINURIA - - - - 1189

XXI. MOVABLE KIDNEY — COEXISTENT UNILATERAL NEPHRITIS - - 1194

II. DISEASES OF THE SUPRARENAL CAPSULES - - - 1199

i. addison's disease — defaced type of addison's disease - 1199

II. INSUFFICIENCY OF THE SUPRARENAL CAPSULES— HEMORRHAGE—

SUPRABENALITIS ....... 1207



PART IV

DISEASES OF THE NERVOUS SYSTEM

I. DISEASES OF THE SPINAL CORD - - - 1209

I. PROGRESSIVE LOCOMOTOR ATAXY — TABES DORSALIS — DUCHENNE'S

DISEASE ..... - 1209

V



vi CONTENTS OF VOL. II

CHAPTER PAGE

I. DISEASES OF THE SPINAL CORD— Continued !

ii. Friedreich's disease and hereditary cerebellar ataxy —

SPASMODIC FAMILY PARAPLEGIA - - 1232

III. COMBINED SCLEROSIS ...... 1235

IV. SYRINGOMYELIA - - - 1238

V. PROGRESSIVE MUSCULAR ATROPHY - - - 1242

VI. SECONDARY AND PRIMARY LATERAL SCLEROSIS— SPASMODIC TABES

DORSALIS - - - - . - - 1249

VII. AMYOTROPHIC LATERAL SCLEROSIS - - - - 1251
VIII. INSULAR SCLEROSIS - - - - 1253

IX. ACUTE MYELITIS IN GENERAL - - - 1257

X. INFANTILE POLIOMYELITIS — ATROPHIC SPINAL PARALYSIS OF CHILD-
HOOD - - - - 1260

XL POLIOMYELITIS IN THE ADULT — ACUTE SPINAL PARALYSIS IN THE

ADULT - - - - 1264

XII. ACUTE DIFFUSE MYELITIS - ' - - - - - 1268

XIII. CHRONIC DIFFUSE MYELITIS ..... 1271

XIV. SYPHILITIC MYELITIS - - - - - 1273
XV. AFFECTIONS OF THE CAUDA EQUINA AND OF THE FILUM TERMINALE 1277

XVI. HiEMATOMYELIA - ..... 1280

XVII. COMPRESSION OF THE SPINAL CORD .... 1283

XVIII. SPINAL MENINGITIS ...... 1284

II. POLIOENCEPHALITIS — DISEASES OF THE PONS, CRURA, AND BULB - - 1287

I. GLOSSO-LABIO-LARYNGEAL PARALYSIS — INFERIOR CHRONIC POLIO-
ENCEPHALITIS - - - - - - - 1288

II. CHRONIC SUPERIOR POLIOENCEPHALITIS ... - 1293

III. ACUTE AND SUBACUTE POLIOENCEPHALITIS - - - 1296

IV. WEBER'S SYNDROME — BONNIER'S SYNDROME - - - 1297

III. DISEASES OF THE CEREBELLUM - - - 1301

ABSCESS, TUMOURS, AND SYPHILIS OF THE CEREBELLUM - - 1301

IV. DISEASES OF THE BRAIN - - - - - - 1310

I. CEREBRAL CONGESTION - - - - - - 1310

II. CEREBRAL ANEMIA - - - - 1311

III. CEREBRAL HEMORRHAGE - - - 1311

TV. CEREBRAL SOFTENING — EMBOLISM — ATHEROMA - - - 1326

V. APHASIA - .... - 1331

VI. ENCEPHALITIS — ABSCESS OF THE BRAIN • - - - - 1338

VII. CHRONIC ENCEPHALITIS OF CHILDHOOD — HEMORRHAGE — SOFTEN-

ING— PORENCEPHALIA — LOBAR SCLEROSIS — LITTLE'S DISEASE 1340

VIII. CEREBRAL TUMOURS - - - 1346

IX. CEREBRAL SYPHILIS — SYPHILITIC ARTERITIS — GUMMATA AND

SCLERO -GUMMATOUS LESIONS — SYPHILITIC GENERAL PSEUDO-
PARALYSIS ..... 1351
X. GENERAL PARALYSIS — CHRONIC MENINGOENCEPHALITIS - - 1366
XL SYPHILITIC NECROSIS AND PERFORATION OF THE VAULT OF THE SKULL

—DIAGNOSIS FROM TUBERCULOSIS AND FROM CANCER - 1372

XII. CEREBRAL LOCALIZATION - - - 1389

XIII. DISCUSSION ON MEDICO-SURGICAL ERRORS REGARDING CEREBRAL

LOCALIZATION -.... - 1393



CONTENTS OF VOL. II vii

CHAPTER PAGE

IV. diseases OF the brain — continued ;

XIV. TUBERCULAR MENINGITIS - - - 1399

XV. NON-TUBERCULAR MENINGITIS - - 1403

XVI. CEREBRO-SPINAL MENINGITIS - 1406
XVII. CHRONIC MENINGITIS — PACHYMENINGITIS— HEMATOMA OF THE DURA

MATER - - - . 1423

XVIII. MENINGEAL HAEMORRHAGE - - 1425

XIX. HYDROCEPHALUS - - 1426

V. NEURITIS - -... 1429

POLYNEURITIS - - - 1429

vi. neuroses - - - - - 1435

I. ESSENTIAL EPILEPSY — SECONDARY EPILEPSY - - 1435

II. PARTIAL EPILEPSY — JACKSONIAN EPILEPSY - - 1441

III. TRAUMATIC EPILEPSY - .... 1448

IV. HYSTERIA - - - .. 1450

V. HYPNOTISM — LETHARGY — CATALEPSY — SOMNAMBULISM - - 1467

VI. NEURASTHENIA ...... 1471

VII. ASTASIA — ABASIA - ..... 1474

MIL CEREBRO-CARDIAC NEUROPATHY — KRISHABER's DISEASE - - 1476

IX. PARALYSIS AGITANS — PARKINSON'S DISEASE - - - 1477

x. Sydenham's chorea — ST. vitus's dance - - - - 1479

XI. CHOREA GRAVIS — CHOREIC PSYCHOSES - - . . I486

XII. TETANY - - - .. 1491

XIII. OCCUPATION NEUROSES - - - 1493

VII. NEURALGIA - - - - - 1494

I. MIGRAINE - - - - 1494

II. NEURALGIA OF THE TRIFACIAL NERVE — TIC DOULOUREUX - 1496

III. SYPHILITIC NEURALGIA OF THE TRIFACIAL NERVE - - 1501

IV. CERVICO-OCCIPITAL AND CERVICO-BRACHIAL NEURALGIA - - 1503
V. NEURALGIA OF THE PHRENIC NERVE .... 1504

VI. INTERCOSTAL NEURALGIA — ZONA - - - 1505

VII. LUMBAR NEURALGIA - -... 1508

VIII. SCIATIC NEURALGIA — SCOLIOSIS - - - 1508

IX. SYPHILITIC SCIATICA — HOMOLOGOUS SCOLIOSIS - - 1511

X. PAR-ESTHETIC MERALGIA — NEURITIS OF THE EXTERNAL CUTANEOUS

NERVE - - - - 1516

VIII. L'ARALYSES - - - - - 1517

I. FACIAL PARALYSIS - - - - - - - 1517

ii. syphilitic facial paralysis - - - 1525

iii. paralysis of the motor nerves of the eye - - - 1532

iv. ophthalmoplegia - - - - 1540

v. paralysis of the musculo-spiral nerve - - - 1542
vi. radicular paralysis— radicular paralysis of the brachial

plexus - ..... 1546

vii. paralysis of the trigeminal nerve - - - . 1549

ix. trophic and vasomotor troubles - - - 1552

i. trophic troubles in general — dystrophies - - 1552

ii. facial trophoneurosis - - - - - 1555

iii. sclerodermia - ..... i557

iv. local asphyxia — symmetrical gangrene of the extremities 1558

11. 67



viii CONTENTS OF VOL. II



PART V
GENERAL AND INFECTIOUS DISEASES

CHAPTER PAGE

I. ERUPTIVE FEVERS - - - - 1561

I. VARIOLA - - - - 1561

II. VACCINIA - - - - 1569

III. VARICELLA - ...... 1575

IV. SCARLATINA - - - - 1578

V. MEASLES - ...... 1599

VI. RUBELLA - - - - 1612

VII. MILIARY FEVER - - - 1613

VIII. DENGUE - - - - 1616

II. TYPHOID DISEASES - - - - 1619

I. TYPHOID FEVER - - - - 1619

II. TYPHUS FEVER - - - - 1681

III. RELAPSING FEVER - - - - 1684

III. INFECTIOUS DISEASES PROPER TO MAN - - - 1694

I. ERYSIPELAS OF THE FACE — STREPTOCOCCIA - - - 1694

II. MUMPS - - - - 1705

III. CHOLERA - - " - 1710

IV. INFLUENZA - - - - 1720

V. YELLOW FEVER — VOMITO NEGRO - - - 1726

VI. PLAGUE - - - - 1730

VII. TETANUS ... - - 1736

VIII. MALARIA - - - - 1745

IX. SLEEPING SICKNESS ... - - 1768

X. LEPROSY - - - - 1773

IV. INFECTIVE DISEASES COMMON TO MAN AND TO ANIMALS - - - 1781

I. RABIES - - - - 1781

II. ANTHRAX - - - - 1784

III. GLANDERS — FARCY - - - - 1789

IV. ACTINOMYCOSIS - - - - 1792

V. PSITTACOSIS - - - - 1797



PART VI

DISEASES OF THE SPLEEN

HYDATID CYSTS OF THE SPLEEN — DIAGNOSIS OF ENLARGEMENTS OF THE



SPLEEN



1801



PART VII
PATHOLOGY OF THE BLOOD

I. CLINICAL EXAMINATION OF THE BLOOD ... - 1820

II. ANJEMIA - - - - 1824

III. PROGRESSIVE PERNICIOUS ANiEMIA .... 1825



CONTENTS OF VOL. II ix

CHAPTER PAGE

IV. LEUCOCYTH.EMIA - - - 1828

V. CHLOROSIS — CHLORO-BRIGHTISM - - 1837

VI. PURPURA — SCURVY — INFANTILE SCURVY - - - 1850



PART VIII
RHEUMATIC AND DYSTROPHIC DISEASES

I. RHEUMATISM - - - __ 1859

I. ACUTE ARTICULAR RHEUMATISM - - - - - 1859

II. CHRONIC RHEUMATISM ... . Iggg

III. PSEUDO-RHEUMATISM DUE TO GONORRHEA, TUBERCULOSIS, ETC. - 1876

IV. GOUT ........ 1881

v. diabetes mellitus ...... ig92

vi. diabetes insipidus - ... 1926

vii. relations between injury and diabetes - - - 1928

viii. ocesity ........ 1939

ix. diffuse symmetrical lipomatosis .... 1942

x. adiposis dolorosa ...... 1947

xi. myxedema - - .... 1948

xii. scrofula — lymphatism .... . ]95>;

PART IX
PARASITIC INFECTIONS

I. TRICHINOSIS ..... . 195f}

II. FILARIASIS - - -.-. 1958

PART X

DISEASES AFFECTING THE LOCOMOTOR SYSTEM

I. RICKETS .... - - 1962

II. OSTEOMALACIA ... ... 19fi5

III. AGROMEGALY ..... . 19(}6

IV. PAGET'S DISEASE — PROGRESSIVE OSTEITIS DEFORMANS - 1971

v. thomsen's disease .... . 1979

VI. PROGRESSIVE MUSCULAR DYSTROPHIES - 1981

VII. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS - 1983

VIII. PROGRESSIVE ATROPHIC MYOPATHY .... 1986



PART XI

VENEREAL DISEASES

I. GONORRHOEA .... - 1989

II. SOFT CHANCRE - - - - - - -2004

III. HARD OR SYPHILITIC CHANCRE (TREPONEMA PALLIDUM) - - 2007

IV. FULMINANT GANGRENE OF THE PENIS - - - 2015

67—2



x CONTENTS OF VOL. II

PART XII
THE INTOXICATIONS

PAGE

I. ALCOHOLISM - - .... 2025

II. MERCURIAL POISONING — HYDRARGYRISM - - - 2029

III. LEAD-POISONING - - .... 2033

IV. PHOSPHORUS-POISONING - - -.. 2041
V. ARSENICAL-POISONING - - - - 2043

VI. POISONING BY OPIUM, MORPHIA, AND COCAINE - - - 2045

VII. POISONING BY TOBACCO - - - - 2048

VIII. CARBONIC OXIDE POISONING - 2049

IX. INTOXICATION BY CARBON BISULPHIDE - 2050

X. PELLAGRA .... ... 2052

APPENDIX ON THERAPEUTICS

I. MERCURIAL TREATMENT — TREATMENT OF SYPHILIS - - - 2055

II. ARSENICAL TREATMENT — CACODYLATE OF SODA - - - 2058

III. INJECTIONS OF ARTIFICIAL SERUM ..... 2059

INDEX ........ 2062



PART III

DISEASES OF THE URINARY SYSTEM

CHAPTER I
DISEASES OF THE KIDNEYS

I. ANATOMY AND PHYSIOLOGY OF THE KIDNEYS.

Anatomy. — The kidneys are situated on either side of the spine, on a level
with the two upper lumbar vertebrae. They have an average length of
4 inches, a width of 2i inches, and a thickness of 1| inches. They weigh
about 10 ounces. The kidneys have a thin, transparent, fibro-elastic
envelope, which can be detached in the normal condition, but which is
often adherent in diseased states. They are surrounded by a fatty layer,
in which perinephritic abscesses arise.

A cut section, from the convex edge towards the hilum, presents different
parts. In the central or medullary substance ten, twelve, or fifteen striated
bundles are seen. These are the pyramids of Malpighi, the summits of
which converge towards the hilum. The cortical substance, which is more
red and granular, is about § inch thick ; it is not only peripheral, as its name
might seem to indicate, but also central, because it dips in between the
pyramids of Malpighi, and forms prolongations which protrude into the
hilum, and are known as Bertin's columns.

We find, therefore, at the hilum two kinds of alternating projections :
some, red and conoid, are formed by the summit of the pyramids of Malpighi,
and are called papillae ; the others, yellowish and rounded, are formed by
the prolongation of Bertin's columns. They exist only in the central parts
of the hilum, and disappear towards its lateral parts, because Bertin's
columns do not there descend so low.

Each papilla is pierced by ten to thirty orifices. Each orifice, visible
with a lens, is the opening of an excretory canal, and each of these very
short canals is the end of smaller, slightly divergent canals, which are called
Bellini's tubes, and unite to form the pyramids of Malpighi. The tubes of
Bellini, or collecting canals, ascend, whilst branching out, as far as the

1045



1046 TEXT-BOOK OF MEDICINE

cortical substance, where they form straight tubes, called medullary rays,
which are the ends of the uriniferous canaliculi.

The canaliculus has a very complicated path. It arises from the
glomerulus of Malpighi in the cortical substance. The glomerulus is a
small vascular system of a spherical shape, formed by the union of the
winding arterioles, and surrounded by a membrane, known as Bowman's
capsule.

This system is, as it were, suspended from the interlobular arteries. The
afferent arteriole traverses Bowman's capsule, and divides into looped
branches. These branches unite to form the efferent arteriole which leaves
the capsule in close contact with the afferent vessel, and gives rise to a
network of capillaries which envelops the glomeruli, the tubuli contorti,
and the medullary rays. Whereas the afferent arteriole is provided with a
layer of circular muscle fibres as far as its entrance into the capsule, the
efferent arteriole, which is smaller, has only muscular fibres in the neigh-
bourhood of the capsule, and soon loses them, to split up into capillaries.
This arrangement forms a kind of sphincter, which probably serves to
regulate the blood-pressure in the interior of the glomerulus. The structure
of the capillaries in the glomerulus consists of an amorphous wall, lined
internally with an endothelium disposed in the form of a protoplasmic
membrane with nuclei here and there (Hortoles). The vascular tuft is not
free in Bowman's capsule, but has a covering which certain writers look
upon as a flattened epithelium. It appears to be rather a membrane of a
connective nature, emanating from the connective envelope which accom-
panies the afferent arteriole at its entry into Bowman's capsule (Cornil,
Renaut, Hortoles). This protoplasmic pellicule is interposed between the
loops of the vascular tuft.

Bowman's capsule, which surrounds this small vascular apparatus, may
be considered as the origin of the uriniferous canaliculi, and is continuous
with them by a constricted point, called the neck of the capsule, which is
formed by a structureless membrane, provided with flat epithelium.

Immediately after its origin the canaliculus becomes broad and convo-
luted, whence the name of tubuli contorti. The tubuli contorti are situated
in the cortical layer of the kidney, and play a considerable part in the
phenomenon of urinary secretion. After a sinuous path, the convoluted
part of the canaliculus becomes constricted, plunges into the central sub-
stance of the kidney to a variable depth, and is known as Henle's descending
branch. The canaliculus then curves (Henle's loop), increases in size, and
ascends parallel to its descending branch (Henle's ascending branch) ; it
thus reaches nearly to the surface of the kidney, where, under the name of
intercallary tubule and junctional tubule, which is seated in the most
superficial layers of the cortical layer of the kidney, it enters into the



DISEASES OF THE KIDNEYS 1047

prolongation of a medullary ray, which is itself, as we have said, but a
continuation of a collecting tube of Bellini.

The structure of the canaliculus varies much in each of its parts. The
convoluted tubes have a structureless membrane and an epithelium described
by Heidenhain. The epithelial cells are so large that they leave only a
narrow lumen ; their appearance is cloudy and granular, and a portion of
their protoplasm is transformed into fine rods, perpendicular to the axis
of the tube, which give the section a striated appearance. These rods occupy
the part of the cell next to the basement membrane, whilst the protoplasm
and the nucleus are on the side of the lumen. The epithelium of Henle's
descending branch is pavemented and analogous to that of the bloodvessels.
The epithelium of Henle's ascending branch is analogous to that of the
convoluted tubes. The epithelium of the intermediary pieces and of the
first collecting tubes is somewhat like cylindrical epithelium.

In order to understand the relations of the uriniferous canaliculi with
the different elements which enter into the structure of the kidney, it is
useful to study them in transverse sections.

1. In a section made in the region of the papillae we find the large ex-
cretory tubes which divide in this region, and some loops of Henle's tubes.

2. In a section made a little higher, in the portion of Malpighi's pyramid
called the limiting zone, we meet with three varieties of tubes : Bellini's
collecting tubes, Henle's thin or descending branches, and Henle's large or
ascending branches. The vasa recta traverse this zone in order to reach
the cortical substance.

3. Transverse sections of the cortical substance, starting from the
surface of the kidney towards the centre, show the following details : (1) In
the most superficial layer we find the capsule of the kidney, hollowed out
by cavities which are lymphatic spaces. (2) In a somewhat deeper section
we see the sinuous canals, which represent the intercalary and junctional
tubules— that is to say, the end of the uriniferous canaliculi in the medullary
prolongations ; we also see tubuli contorti. (3) In a still deeper section we
see the renal lobule, which is formed of the following elements : In the centre
is Ferrein's pyramid, which is composed of the cortical prolongation of
Bellini's tube (medullary ray) and Henle's ascending branches. Around
Ferrein's pyramid is the labyrinth, and by " labyrinth " must be under-
stood the space between two pyramids with the contents of this space,
tubuli contorti, and interlobular arteries with their glomeruli.

It is important to understand the structure of the renal lobule, because
it is in this region that most of the pathological phenomena of chronic
nephritis take place.

The glomeruli, uriniferous and collecting tubes are embedded in un-
equally distributed connective tissue. " The communication of this con-



1048



TEXT-BOOK OF MEDICINE



nective tissue with the lymphatic vessels shows that here, as elsewhere, it
is made up of lymph spaces, limited by flat cells, and in connection with
the lymphatic vessels."

Physiology. — We know to-day that the role of the kidney consists in
excretion, and not secretion. It does not make the elements of the urine,
but finds them ready-made in the blood, and selects them, rejecting some
and allowing others to pass. An exception must, however, be made in
favour of hippuric acid, which exists in the urine of herbivorous animals,
and appears to be made by the kidney (Koch).

In the normal condition, the urine has a pale yellow colour, an acid
reaction, and a peculiar odour. Its density is from 1018 to 1020, and the
quantity passed by an adult in twenty-four hours varies from 40 to 50 ounces.

Urine is composed of the following elements :



Composition of the Urine.



Passed.



Organic elements
Mineral elements
Total of dissolved matter

Urea/ Men

\ Women . .

Uric acid

Phosphoric acid

Sulphuric acid . .

Chloride of sodium

Lime




Per litre.
Gr.



26-27

3-3-10

34-37

18-24

10-20

0-30-0-40

1-66

2-00

6-6-8-0

0-28-0-30



Per _I4 hours.
Gr.



35-36
12-14
43-52
25-38
20-32

0-50-0-70

2-50

3 00

10-12

0-33-0-45



Urea, which represents the last stage in the oxidation of the albuminoids,
is manufactured in the interior of the tissues, and especially in the liver.
I shall not review the numerous theories of the secretion of the urine. It
is not certain that the glomerulus has only a mechanical role, as was main-
tained by Ludwig ; the glomerular epithelium seems to play a certain part in
the physiological and pathological functions of the glomerulus (Heidenhain).
It is through the glomerulus that the aqueous portion, with the salts of the
plasma, transudes (Bowman). The glomerulus eliminates the sugar in diabetic
patients and the albumin in albuminuric ones. The tubuli contorti and
Henle's ascending branch, which are furnished with a special epithelium (Heid-
enhain), represent the true glandular part of the kidney, and have as their
mission the making of urine, by selecting and excreting its principal products.

Chatin and Guinard would give to the kidney, by analogy with other
glands, an internal secretion, which appears indeed to exist.



DISEASES OF THE KIDNEYS 1049



II. CONGESTION OF THE KIDNEYS— CARDIAC KIDNEY.

Congestion of the kidneys may be active or passive. Active congestion
is associated with inflammation and new growths of the kidneys, and will,
consequently, be described with these various morbid conditions. Passive
congestion will be discussed in this section.

Whenever the blood-pressure increases in the area of the efferent
veins, or in the vena cava, above the mouth of these veins, the kidneys
become congested. Tumours of the abdomen, aneurysms of the abdominal
aorta, and pregnancy, may create a mechanical obstacle to the blood-flow
in the renal veins. Pleuro-pulmonary affections (pleurisy, emphysema,
phthisis) may also form an obstacle to the afflux of the blood from the vena
cava to the right side of the heart, and become an indirect cause of renal
congestion ; but none of these causes can compare with diseases of the
heart. As the result of ill-compensated cardiac lesions and in consequence
of attacks of asystole, the kidneys participate in the chronic congestion
which affects all the viscera, and the cardiac kidney (Jaccoud), which is
analogous to the cardiac liver, results. Post mortem the kidneys are
congested and enlarged ; the capsule strips readily ; the surface of the
organ is red, and streaked with swollen vena? stellatse ; the capillaries and
the veins are congested with blood. On section, the surface is of a deep
red. Small glomerular and intratubular haemorrhages are sometimes
seen. The tissue of the kidney is indurated, and histological examination
shows that the intertubular connective tissue of Malpighi's pyramid is
transformed in places into embryonic tissue forming an early stage of
cirrhosis. Fatty granules are present in the epithelium of the tubuli con-
torti, but the cells do not perish. In short, this congested condition causes
a slight degree of cirrhosis, but the bloodvessels are hardly ever attacked by
endarteritis. The striated epithelium of the convoluted tubes preserves
its integrity, and, consequently, the cardiac kidney does not show chronic
nephritis, and is not the starting-point of Bright' s disease.

This opinion is the most generally accepted, and it must be added that
it is correct. Exceptions must, however, be noted, and Fauquez has col-
lected cases which tend to prove that the cardiac kidney may end in the
interstitial and parenchymatous lesions of B right's kidney.

The cardiac kidney reveals itself during life by evident changes in the
urine. The urine becomes scanty, thick, and high-coloured. Urates, urea,
and uric acid are found in abundance ; but albumin, when it exists, is in
small quantity. Under the microscope white and red corpuscles, epithelial
cells, and sometimes casts of various kinds, are seen.

The insufficiency of urinary depuration, resulting from the lesions
just described, is partially responsible for the symptoms of asystole; but



1050 TEXT-BOOK OF MEDICINE

it very rarely ends in true uraemia. The treatment described under Mitral
Diseases causes the cardiac kidney to resume its functions, and it is, indeed,
through the kidney that asystole is in a large part averted.



III. ACUTE NEPHRITIS.

Discussion. — The history of acute nephritis is still somewhat obscure ; the nature
of the lesions, the aetiology of the disease, and its modes of termination, have been
the subject of such contradictory opinions that it is not possible at the present time
to propose a classification of the acute toxi -infections of the kidney. Not long ago
acute nephritis was divided into catarrhal and parenchymatous. Catarrhal nephritis
had the attributes of being slight and temporary, of limiting its process to the excretory



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