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William Henry Porter.

A practical treatise on renal diseases and urinary analysis online

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A



PRACTICAL TREATISE



ON



EENAL DISEASES



URINARY ANALYSIS



WILLIAM HENRY PORTER, M.D.,

PROFESSOR OP CLINICAL MEDICINE AND PATHOLOGY IN THE NEW YORK POST-GRADUATE MEDICAL.

SCHOOL AND HOSPITAL ; CURATOR TO THE PRESBYTERIAN HOSPITAL ; ACTING CURATOR TO

BELLEVUE HOSPITAL ; MEMBER OF THE NEW YORK PATHOLOGICAL SOCIETY ; OF THE

CLINICAL SOCIETY OF THE NEW YORK POST-GRADUATE MEDICAL SCHOOL

AND HOSPITAL, AND OF THE NEW YORK NEUROLOGICAL SOCIETY



CONTAINING ONE HUNDRED ILLUSTRATIONS



NEW YORK

WILLIAM WOOD & COMPANY

56 & 58 Lafayette Place

1887



Copyright
WILLIAM WOOD & COMPANY

1887



PRESS OF

STETTINER, LAMBERT 4 CO.,

22, 24 & 2« READE ST.*

NEW TORK.



THE FOLLOWING PAGES

AEE DEDICATED TO

MY FATHER,

FREDERICK EDWARD PORTER,

AS A TOKEN" OF RESPECT
AND AFFECTION.



PREFACE.



Dukikg the past ten years, the author has had ample opportunity
for studying the various lesions of the kidneys, as they are found in
human and animal subjects. The essential ideas advanced in this
book, if any originality can be claimed, are based upon the statistics
gathered from over one thousand post-mortems.

Attention was devoted specially, during the course of studies in
comparative medicine, to the class of lesions commonly known as
Bright's disease, and it was from these observations, taken in con-
nection with the opportunities that have offered since of watching
these conditions from their inception in the human being, through
the different phases of the disease, until finally they came to the post-
mortem table, that the deductions employed throughout the work
were obtained.

Among the lower animals, the necropsies were made immediately
after death, and consequently accurate results were obtained in regard
to the morbid changes in the epithelial protoplasm, and the exam-
iner was enabled to judge how much of the metamorphotic change
was due to the disturbed physiological condition prior to death, and
how much was more directly due to the post-mortem alterations.

Eenal diseases have been studied chiefly from the clinical and.
pathological point of view, but we have tried to present them not
only from this standard, but also from the physiological standpoint,
deducing the methods of treatment not only from the physiological,
but from the pathological phenomena.

Preceding the group of diseases usually classed as Bright's disease,
a brief resume of the anatomy and physiology of the kidneys has been
inserted, in order that the reader, by refreshing his memory, may be



VI PREFACE.

enabled to obtain a clear understanding of the various lesions; and in
connection with this, the various pathological conditions found are
described at some length.

A chapter is also devoted to the consideration of diabetes.

The second portion of the book is devoted to a study of urinary-
analysis; not simply the chemical or microscopical examination of
samples of urine, but also the physiological indications, with their
bearings on clinical medicine. A more accurate interpretation of the
exact conditions of the diseased organs may be obtained, and a more
definite prognosis pronounced, when these considerations receive full
weight, than can be the case if only the chemical and microscopical
results, as usually noted, are borne in mind.

An extended bibliography has been omitted purposely, in order
that the work might be kept within bounds; but the author takes this
opportunity of acknowledging the assistance obtained by a perusal of
the chief authorities upon both renal diseases and urinary analysis.

The original drawings, some fifty in number, have been made by
his clinical assistant, Dr. George G. Van Schaick, from sections in the
author's possession, and the credit is due him for their accuracy and
perfection.

Through the courtesy of Dr. Francis Delafield and the kind co-
operation of the publishers, Messrs. William Wood & Co., a large
number of plates have been employed in illustrating different por-
tions of the book, that have appeared in other works on this subject.

It gives me much pleasure, also, to testify to the valuable aid 1 have
received from two of my former students, Dr. William C. Carroll and
the late Dr. William Hustace Hubbard.

Before closing, the author wishes to extend his sincere thanks to

his friend, Dr. Samuel Lloyd, who has rendered most valuable aid in

the final revision of the manuscript and in the correction of the

proofs.

W. II. P.
STRATHMORE, 1674 Broadway, cor. 52d st.
April 20lh, 1887.



CONTENTS.



PART I.

DISEASES OF THE KIDNEYS.

CHAPTER I.

PAGE

Anatomy of the Kidney 1

CHAPTER II.

Physiology of the Kidney ; Inflammation and its Bearings on the Pathol-
ogy and Treatment of Acute Parenchymatous Metamorphosis of the
Kidney , 12

CHAPTER III.

Chronic Parenchymatous Metamorphosis of the Kidneys; Parenchymatous
Metamorphosis of the Kidneys Associated with Pregnancy; Parenchy-
matous Infiltration of the Kidneys associated with Wasting Disease. . 2?

CHAPTER IV.

Acute Diffuse Nephritis ; Chronic Diffuse Nephritis, First, Second, and
Third Forms. 45

CHAPTER V.
Complications of Renal Lesions ; Treatment of Chronic Diffuse Variety. . . 62

CHAPTER VI.

Acute and Chronic Sclerosis of the Kidneys ; Gouty Kidneys ; Hyalin e,

Albuminoid, or "Waxy Kidneys ; Summary 92

CHAPTER VII.
Renal Hemorrhage ; Hsematoglobinuria ; Anaemia 105

CHAPTER VIII.
Acute Congestion ; Chronic Congestion Ill



vi 11 CONTENTS.

CHAPTER IX.

PAGE

Pyelonephritis ; Pyelitis ; Pyonephrosis 118

CHAPTER X.
Hydronephrosis ; Renal Calculi 127

CHAPTER XL
Acute and Chronic Atrophy of the Kidneys ; Cysts of the Kidneys 132

CHAPTER XII.
Tuberculosis of the Kidneys 136

CHAPTER XIII.

Infarction of the Kidneys : Fat Embolisms of the Kidneys ; Pysemic Em-
boli of the Kidneys 141

CHAPTER XIV.

Tumors of the Kidneys: Sarcoma; Carcinoma; Adenoma; Fibroma;
Congenital Rhabdo-Sarcoma ; Angioma ; Lipoma ; Lymphoma ; Os-
teoma ; Angioma or Cavernous Neoplasms 146

CHAPTER XV.

Parasites : Echinococcus; Bilharzia Hasmatobia ; Strongylus seu Eustron-
gylus Gigas; Ascaris Renalis 157

CHAPTER XVI.

Glycosuria or Diabetes Mellitus— Its Etiology, Pathology, Clinical History,

and Treatment 165



PART II

UEINAEY ANALYSIS.

CHAPTER I.
Introductory Remarks 195

CHAPTER II.
C inical Examination 202

CHAPTER III.
Albumin ; Tests for Albumin ; Clinical Significance 217



CONTENTS. IX

CHAPTER IV.

PAOK

Glucose or Grape Sugar ; Tests for Glucose 234

CHAPTER V.
Nitrogenous Excretory Substances .... 254

CHAPTER VI.
Urates, Phosphates, and Chlorides 275

CHAPTER VII.

Adventitious Coloring Matters ; Bile Pigment ; Fat ; Mucus ; Blood or
Haemoglobin 279

CHAPTER VIII.
How to use the Microscope ; Red Blood Corpuscles ; Leucocytes; Mucus.. 285

CHAPTER IX.
Uric Acid ; Oxalates ; Urates ; Phosphates ; Microscopic Pigments 294

CHAPTER X.
Epithelial Cells ; Spermatozoa 802

OHAPTER XI.
Vegetable Organisms ; Fungi 308

CHAPTER XII.
Casts 317

CHAPTER XIII.

Sediments of Doubtful Origin : Lime Carbonate ; Fatty Matters ; Choles-

terin; Cystin ; Leucin ; Tyrosin ; Xanthin ; Foreign Matter 324

CHAPTER XIV.;

Animal Organisms : Echinococcus ; Filaria Sanguinis Hominis ; Bilhar-
zia Haematobia ; Trachinas Cystica ; Eustrongylus seu Strongylus
Gigas ; Tetrastoma Renalis ; Spurious Entozoa ; Pediculus Pubis 332

CHAPTER XV.
Analysis of the Case ; Indications as to Diagnosis and Treatment 338



LIST OF ILLUSTRATIONS.



FIG.
1.
2.

3.
4.

5.
6.

7.



10.
11.

12.
13.
14.
15.
16.

17.
18.
19.

20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.



Cross section of kidney, .....

Markings of the cortex, .....

Diagram of uriniferous tubules, ....

Malpighian tuft, ....••

Section from snake's kidney, showing rods of Heidenhain,
Looped tube of Henle, ......

Prickle cells taken from kidney of dog, .
Section showing vascular arrangement of the kidney,
Kidney of dog, natural injection of secreting portion,
Rods of Heidenhain, .....

Acute parenchymatous metamorphosis of the kidney,
Chronic parenchymatous metamorphosis of the kidney,
Chronic parenchymatous metamorphosis of wasting disease.
Acute diffuse nephritis, .....

Chronic diffuse nephritis, .....

Section from cortical portion showing thickened and expanded

afferent vessel, ....
Chonic diffuse nephritis, atrophied kidney,
Miliary aneurism of the brain,
Acute parenchymatous metamorphosis of the kidney following a

surgical operation, .....

Acute interstitial nephritis, ....

Chronic interstitial nephritis, ....
Chronic interstitial nephritis with thickened blood-vessels,
Section from a typical gouty kidney,
Waxy degeneration of blood-vessels of glomerulus,
Early stage of waxy metamorphosis of the kidneys, .
Acute renal congestion with infarctions,
Pyelo-nephritis or surgical kidney,
Bacillus tuberculosis,

Acute congestion of the kidneys, with multiple infarctions,
Fat embolism of the kidney,
Round-cell sarcoma of the kidney,
Medullary carcinoma,
Lipoma of kidney, ....
Tsenia echinococcus complete,



PAGE

3

4

6

7

8

9

9

10

14

15

19

30

42

46

53

56
59
63

77

93

94

95

97

99

100

112

119

138

142

144

147

149

154

157



Xll



LIST oV ILLUSTRATIONS.



FIG.

35. Cuticula of echinococcus cyst,

36. Endocyst of Huxley,

37. Scolices of Taenia echinococcus, .

38. Hooklets from scolex of taenia echinococcus,

39. Bilharzia hannatobia,

40. Strongylus seu Eustrongylus gigas,

41. Miliary gumma, ....

42. Large gumma, ....

43. Syphilitic pneumonia,

44. Chronic parenchymatous metamorphosis of the kidney,

45. Diabetic parenchymatous metamorphosis of the kidneys, medullary

portion, .....

46. Diabetic parenchymatous metamorphosis of the kidneys, cortical

portion, .....

47. Diabetic metamorphosis of the liver,

48. Glass cylinder graduated,

49. Conical glass, ....
Vogel's test-plate of colors,

50. Crystals of ammonia magnesium phosphate,

51. Uric acid crystals, ....

52. Urinometer, ....

53. Fermentation saccharometer,

54. Graduated cylinder,

55. Urometer of Doremus, . ,

56. Blood-corpuscles as seen with the square ocular micrometer,

57. Human blood-corpuscles, .

58. Human red blood-globules,

59. Human blood-corpuscles crenated,

60. Pus-corpuscles, ....

61. Pus in various stages of development,

62. Highly magnified leucocytes,

63. Uric acid crystals, ....

64. Uric acid crystals, ....

65. Uric acid crystals, ....

66. Uric acid crystals, ....

67. Oxalate of lime crystals, ordinary forms,

68. Oxalate of lime crystals, typical forms, .

69. Oxalate of lime crystals, rare forms,

70. Urate of soda, ....

71. Stellar phosphate of lime,

72. Epithelial cells found in urine, .

73. Epithelial cells found in urine,

74. Epithelial cells found in urine,

75. Human spermatozoa,

76. Sphero-bacteria, ....

77. Micro-bacteria, ....

78. Leptothrix buccalis,

79. Bacillus tuberculosis,



LIST OF ILLUSTRATIONS.



XIII



80. Desmo-bacteria

81. Penicillium glaucum,

82. Yeast and sugar fungi,

83. Casts,

84. Casts,

85. Casts,

86. Conical glass,

87. Cystin,

88. Leucin,

89. Tyrosin,

90. Whetstone-shaped crystals of xanthin, .

91. Hydrochlorate of xanthin,

92. Foreign matter, ....

93. Hooklets from scolex of taenia echinococcus,

94. Scolices of the taenia echinococcus,

95. Filaria sanguinis hominis,

96. Filaria in human blood,

97. Bilharzia haematobia,

98. Stronyglus seu Eustrongylus gigas,

99. Pediculus pubis found in urine, .



PAGE
314

315
316
318
319
320
323
326
327
328
328
329
330
332
333
334
335
336
336
337



RENAL DISEASES.

PAET I.



CHAPTER I.

ANATOMY OF THE KIDNEY.

The kidneys, the two largest glandular organs in the body, are in-
tended for the excretion of urine, and are situated in the lumbar re-
gion, on either side of the vertebral column; the left on a level with
the last dorsal and two upper lumbar vertebrae, the right lying some-
what lower, on account of the large space occupied by the liver. They
rest upon the crura of the diaphragm, behind the peritoneum, the
upper end approaching nearer the vertebral column than the lower;
and they have a quantity of connective tissue and fat called the tunica
adiposa surrounding them, which, together with their blood-ves-
sels, nerves, lymphatics, and ureters, holds them in proper position,
and through which they receive their nutriment and discharge their
excretions. They are about four inches (10 centimetres) in length
and one inch (2.5 centimetres) in thickness, but these dimension
vary in individual cases. The left is usually larger and narrower than
the right, and weighs one and a half drachms more. The average
weight of the kidney in the adult male is from four and a half to live
ounces (125.572-141.747 grams); and in the adult female from four
to four and a half ounces (113.398-127.572 grams). The specific
gravity of the kidney tissue is about 1.052.

Regional Relations and Topography. — The anterior surface of the
left kidney is in contact with the inferior extremity of the spleen and
the tail of the pancreas; covered in by the cardiac extremity of the
stomach, and is immediately behind the descending colon. The an-
terior surface of the right kidney is in contact with the liver and de-
1



'1 ANATOMY OF THE KIDNEY.

scending portion of the duodenum, and is immediately behind the
ascending colon. Both are covered anteriorly by the peritoneum, the
tunica adiposa intervening.

The posterior surface of each kidney rests against the corresponding
eras of the diaphragm and the anterior lamella of the transversalis
fascia which covers the quadratus lumborum muscle ; the superior
extremity is in contact with the corresponding suprarenal capsule.

Variations. — From the normal standard above described, the kid-
neys occasionally vary as regards form, position, size, and number.
Sometimes they are long and narrow, sometimes short and broad; one
or both may be situated in the pelvic region or any other part of the
abdominal cavity; the vessels may^e elongated, the peritoneum form-
ing as it were, a mesentery, and thus allowing them to float freely in
the peritoneal cavity, giving rise to the condition known as a " floating
kidney." which is most frequently met with in women, and usually on
the right side.

One kidney may be large and the other proportionately small; or
the two may be united by a band of renal tissue, passing over the
vertebra? and connecting their inferior extremities; this condition is
known as a "'horse-shoe" kidney; and when it occurs, both glands are
usually situated lower than normal.

One kidney and its ureter may be entirely absent, the opposite
organ being normal or increased in size; and in rare instances three
have been found in one body, the third occupying a position in front
of the vertebral column, or at the side of the normally located
glands. There is one case on record in which there were four with
their accompanying vessels and ureters; ' all four ureters opening
separately into the bladder. The two kidneys have also been found
upon the same side, and in such cases they are usually located lower
than normal.

The surface may be traversed by numerous moderately deep fur-
rows which give the organ a distinctly lobulated appearance; this
condition is always present in the foetal kidney, and may be found in
organs removed from the bodies of those who die during the first few
years of life; but this is not usually the case in those removed from
adults, the external surface being then perfectly smooth. When
traces of these furrows and lobules are found in the adult organ, they
are called traces of or festal mar kings. This condition is not infre-
quently met with, and indicates only a divergence from the general
rule, having no pathological significance.

Macroscopic Appearance. — The kidney is shaped somewhat like a
1 Indiana Medical Gazette, Jan., 1874.



ANATOMY OF THE KIDNEY.

" Haricot " or " Kidneybean." The anterior surface is convex, the
posterior nearly flat; the superior extremity is thick and rounded, and
is larger than the inferior, which is thinner and more pointed. The ex-
ternal border is convex, the internal concave, presenting a deep fissure,
about an inch (2.5 centimetres) in length, called the hilum, through
which pass the vessels, nerves, and lymphatics, and the excretory duct
or ureter. The hilum opens into a cavity in the substance of the
gland which is called the sinus renalis.

The relations of the vessels and ureter to each other in the hilum
are as follows: from above downwards, artery, vein, and ureter; from




Fig. 1.— Cross Section of Kidney.
1, Malpighian pyramid; 2, arterio-venous arcade of Flint; 3, striations of the pyramid; 4,
base of pyramids of Ferrein; 5, calices; 6, columns of Bertini; 7, pelvis and infundibuli ; 8
ureter. (From Sappey's Anatomy.)

before backward, vein, artery, and ureter; but this arrangement occa-
sionally varies. The whole gland is covered by a thin, smooth,
fibrillated connective-tissue membrane, called the capsule, which, in
the normal state, is not adherent to the underlying surface, and, upon
removal, leaves it perfectly smooth, although the foetal markings may
occasionally be observed. By making a longitudinal section, the cor-
tex, medullary substance, and sinus renalis are exposed. Tlie sinus



* ANATOMY OF THE KIDNEY.

mialis is the deep fossa in the kidney proper in which the pelvis (the
expanded portion of the ureter) joins the renal substance, and through
which the vessels pass to reach the nephritic tissue. The hilum is
the perceptible notch; the sinus is deep in the gland proper. The
medullary substance consists of from eight to eighteen conical masses
called the Pyramids of Malph igij their apices being known as papilla,
which converge and are invaginated in the ultimate divisions of the
pelvis known as the calices. The calices, seven to thirteen in number,
converge to form the three primary divisions of the pelvis, which in
turn have been termed infundibula; and these join to form the pelvis
of the kidney, which is the funnel-shaped extremity of the dilated
ureter. The ureter is the excretory duct, and opens into the posterior
surface of the bladder. The pyramids are distinctly striated, these




Fig. 2. — Markings of the Cortex.
r, Cortical layer; m, medullary rays or pyramids of Ferrein; c, arterise recta?, with attached
Malpighian corpuscles; g, base of Malpigian pyramid; h, bundle of collecting tubes; 6, vascular
area between the bundles; p, apex of Malpighian pyramid.

striations always being straight in the normal kidney, and consisting of
diverging blood-vessels and straight or collecting uriniferous tubules,
the arrangement of which will be explained hereafter. This striated
appearance is prolonged into the cortex, where it is more prominent
than in the pyramids. This is accounted for by the greater paleness
of the epithelium. The red lines indicate the position of the nutrient
vessels; the pale lines indicate the straight tubules prolonged into the
cortex, and are known as the Pyramids of Ferrein. These alternating
colors are called the markings of the cortex; when straight, they indi-
cate a normal kidney, or one in which the lesion is confined to the
epithelial cells only; when wavy or tortuous, they indicate a lesion in-



ANATOMY OF THE KIDNEY. 5

volving the intertubular tissue, which by contraction has caused the
vessels to deviate from a straight course. By these striations and
their changes, we are enabled, in a measure, to differentiate between
a parenchymatous and a diffuse or sclerotic change. This will be
fully appreciated later on, when studying the morbid appearances.

The cortical layer lies immediately beneath the renal capsule; it
is about one-quarter of an inch (6.25 mm.) in thickness, and sur-
mounts the base of the pyramids, sending prolongations between
them as far as the sinus. These interpyramidal portions are known
as the " Septa vel Column® Bertini," and mark the original divisions
of the kidneys into lobules. That portion of the cortical substance
which stretches from one column to another, and which surrounds
the base of the pyramids, is called the cortical arch. The columns
of Bertini and the cortical arches taken together form the "Laby-
rinth of Ludwig." 1

Microscopic Appearances. — The capsule is composed of fibrous
tissue, in which a few elastic fibres are intermingled.

It is connected with the organ by fine fibrillated connective tissue
and minute blood-vessels. An inflammatory thickening and an in-
crease in these connecting fibres account for the adhesion of the
capsule and the roughening and detachment of small fragments of
the renal surface in the intertubular varieties of renal disease.

The capsule may be divided into two layers : an outer one about
y-^-j of an inch (0.143 mm.) in thickness, which becomes continu-
ous with the connective tissue surrounding the blood-vessels and
the ureter at the hilum ; and an inner, about T oVo" °f an inch (0.025
mm.) in thickness, terminating where the papillae join the calices in
the sinus renalis. Beneath the latter is a wide-meshed, delicate
framework of smooth muscle fibres, some of which traverse the cor-
tical substance.

The uriniferous tubules begin in the cortical substance in small
spherical bodies called the Malpighian corpuscles, beyond which they
are markedly convoluted, and are known as the convoluted tubes of the
first order.

At the junction of the capsules with the tubes, there is a marked
constriction or neck, and beyond this convoluted portion they become
straight and pass directly down into or between the pyramids, forming
the descending limb, then turning upon themselves they form a loop
and pass straight upwards to the cortical arches or substance, thus
forming the ascending limb; and these, taken together, form the
looped tube of Henle. In the cortical substance, the tubules again be-
1 Ludwig : Strieker's Manual, p. 461.



6



ANATOMY OF T1IK KIDNEY.



come convoluted ami are called junctional tubes, intercalated tubes,
or convoluted tubes of the second order. They now become straight
and pass down through the pyramids toward the papilla, being




Fig. 3.— Diagram of Uriniferous Tubules.

7?, Cortical Portion. 1, Malpighian tuft; 2, convoluted tube of first order showing neck;
3 c, convoluted tube of second order; d, straight portion of tube between convoluted tube of
second order and collecting tube; 4, collecting tube near surface of kidney; 4 e. collecting
tube entering cortico-medullary portion. Or, Cortieo-Medullary Portion. 3, loop of Henle;
(a), descending arm; (b), ascending arm. .1/, Medullary Portion. 4. converging collecting
tiilx^; e, collecting tubes; /. intertubular space; g, opening of uriniferous tubule at apex of
Malpighian pyramid.



ANATOMY OF THE KIDNEV. I

called the straight or collecting tubes, and, after uniting at very acute
angles, form the excretory tubes or ducts of Bertini. These empty
into the calices on the surface of the papillae, sometimes at the
bottom of a slight depression, known as the foveola, but more often
their open mouths are dotted over the surface. The straight or
collecting tubes, just before leaving the cortical substance, are arranged
in bundles, the central tubes of which are the longest, while the
most external are the shortest; this difference in length gives the
bundles a pyramidal appearance, from which they have been called
the pyramidal prolongations, medullary rays, or pyramids of Ferrein.
They are found only in the cortical arches, and are also known as
lobules of the kidney.




Fig. 4— Malpighian Tuft (Highly Magnified).

«, Afferent artery; b, efferent vein; c, neck of uriniferous tubule; d, space within the capsule ;
f, capillary network; gr, epithelial lining of Bowman's capsule.



The tubules consist throughout their whole extent of a basement-
membrane lined with epithelium. The Malpighian corpuscles are
small spherical bodies, regularly arranged in rows in the edges of the



Online LibraryWilliam Henry PorterA practical treatise on renal diseases and urinary analysis → online text (page 1 of 32)