A system of practical medicine. By American authors. Vol. 4

Chapter I: Front Matter (1)

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A SYSTEM OF PRACTICAL MEDICINE.

BY AMERICAN AUTHORS.

EDITED BY WILLIAM PEPPER, M.D., LL.D.,

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.

ASSISTED BY LOUIS STARR, M.D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA.

VOLUME IV.

DISEASES OF THE GENITO-URINARY AND CUTANEOUS SYSTEMS.--MEDICAL OPHTHALMOLOGY, AND OTOLOGY.

PHILADELPHIA: LEA BROTHERS & CO. 1886.

Entered according to Act of Congress, in the year 1886, by

LEA BROTHERS & CO.,

WESTCOTT & THOMSON, _Stereotypers and Electrotypers, Philada._

WILLIAM J. DORNAN, _Printer, Philada._

CONTENTS OF VOLUME IV.

DISEASES OF THE GENITO-URINARY SYSTEM.
PAGE
DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS. By
ROBERT T. EDES, M.D. . . . . . . . . . . . . . . . . . . . . . . 19

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS. By
FRANCIS DELAFIELD, M.D. . . . . . . . . . . . . . . . . . . . . 69

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA. By JAMES TYSON,
A.M., M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

CHYLURIA. By JAMES TYSON, A.M., M.D. . . . . . . . . . . . . . . . 114

DISEASES OF THE MALE BLADDER. By EDWARD L. KEYES, A.M., M.D. . . . 123

SEMINAL INCONTINENCE. By SAMUEL W. GROSS, A.M., M.D. . . . . . . . 137

DISPLACEMENTS OF THE UTERUS. By EDWARD C. DUDLEY, A.B., M.D. . . . 147

DISORDERS OF THE UTERINE FUNCTIONS, INCLUDING AMENORRHOEA,
DYSMENORRHOEA, AND MENORRHAGIA. By J. C. REEVE, M.D. . . . . . . 182

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.
By B. F. BAER, M.D. . . . . . . . . . . . . . . . . . . . . . . 208

PELVIC HÆMATOCELE. By T. GAILLARD THOMAS, M.D. . . . . . . . . . . 239

FIBROUS TUMORS OF THE UTERUS. By WILLIAM H. BYFORD, M.D. . . . . . 245

SARCOMA OF THE UTERUS. By WILLIAM H. BYFORD, M.D. . . . . . . . . 271

CARCINOMA OR CANCER OF THE UTERUS. By WILLIAM H. BYFORD, M.D. . . 274

DISEASES OF THE OVARIES AND OVIDUCTS. By WILLIAM GOODELL, M.D. . . 282

DISEASES OF THE URINARY ORGANS IN WOMEN. By ALEXANDER J. C.
SKENE, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . 339

DISEASES OF THE VAGINA AND VULVA. By EDWARD W. JENKS, M.D., LL.D. 367

DISORDERS OF PREGNANCY. By W. W. JAGGARD, A.M., M.D. . . . . . . . 405

FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE. By W. W.
JAGGARD, A.M., M.D. . . . . . . . . . . . . . . . . . . . . . . 432

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND
ENDOMETRITIS, INCLUDING LEUCORRHOEA. By W. W. JAGGARD, A.M.,
M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

ABORTION. By GEORGE J. ENGELMANN, M.D. (Berlin) . . . . . . . . . 467

DISEASES OF THE MUSCULAR SYSTEM.[1]

[Footnote 1: Though properly belonging in Vol. V., with Diseases of the Nervous System, this section has been placed here for convenience.]

MYALGIA. By JAMES C. WILSON, A.M., M.D. . . . . . . . . . . . . . 529

PROGRESSIVE MUSCULAR ATROPHY. By JAMES TYSON, A.M., M.D. . . . . . 540

PSEUDO-HYPERTROPHIC PARALYSIS. By MARY PUTNAM JACOBI, M.D. . . . . 557

DISEASES OF THE SKIN.

DISEASES OF THE SKIN. By LOUIS A. DUHRING, M.D., and HENRY W.
STELWAGON, M.D. . . . . . . . . . . . . . . . . . . . . . . . . 583

MEDICAL OPHTHALMOLOGY.

MEDICAL OPHTHALMOLOGY. By WILLIAM F. NORRIS, A.M., M.D. . . . . . 737

MEDICAL OTOLOGY.

MEDICAL OTOLOGY. By GEORGE STRAWBRIDGE, M.D. . . . . . . . . . . . 807

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 843

CONTRIBUTORS TO VOLUME IV.

BAER, B. F., M.D.,
Professor of Obstetrics and Gynæcology in the Philadelphia Polyclinic
and College for Graduates in Medicine, and Dean of the Faculty;
Obstetrician to Maternity Hospital; President of the Obstetrical
Society of Philadelphia, etc.

BYFORD, WILLIAM H., M.D.,
Professor of Gynæcology in the Rush Medical College, Chicago.

DELAFIELD, FRANCIS, M.D.,
Professor of Pathology and Practical Medicine in the College of
Physicians and Surgeons, New York.

DUDLEY, EDWARD C., A.B., M.D.,
Professor of Gynæcology in the Chicago Medical College, Chicago.

DUHRING, LOUIS A., M.D.,
Professor of Skin Diseases in the University of Pennsylvania,
Philadelphia.

EDES, ROBERT T., M.D.,
Jackson Professor of Clinical Medicine in Harvard University, Boston,
Mass.

ENGELMANN, GEORGE J., M.D. (Berlin),
Professor of Obstetrics and Gynæcology in the St. Louis Polyclinic
and Post-Graduate School of Medicine.

GOODELL, WILLIAM, M.D.,
Professor of Clinical Gynæcology in the University of Pennsylvania,
Philadelphia.

GROSS, SAMUEL W., A.M., M.D.,
Professor of the Principles of Surgery and of Clinical Surgery in the
Jefferson Medical College of Philadelphia.

JACOBI, MARY PUTNAM, M.D.,
Professor of Materia Medica and Therapeutics in the Women's Medical
College, New York, and Professor of Diseases of Children at the New
York Post-Graduate School.

JAGGARD, W. W., A.M., M.D.,
Professor of Obstetrics in the Chicago Medical College, Medical
Department Northwestern University; Obstetrician to Mercy Hospital,
Chicago.

JENKS, EDWARD W., M.D., LL.D., Detroit, Michigan,
Formerly Professor of Medical and Surgical Diseases of Women and
Clinical Gynæcology in the Chicago Medical College, and in the
Post-Graduate Medical School of New York.

KEYES, EDWARD L., A.M., M.D.,
Professor of Genito-Urinary Surgery and Syphilis in the Bellevue
Hospital Medical College, New York; Surgeon to Bellevue Hospital;
Consulting Surgeon to the Charity Hospital.

NORRIS, WILLIAM F., A.M., M.D.,
Clinical Professor of Ophthalmology in the University of
Pennsylvania, Surgeon to Wills Ophthalmic Hospital, Philadelphia.

REEVE, J. C., M.D., Dayton, Ohio,
Formerly Professor of Materia Medica and Therapeutics in the Medical
College of Ohio.

SKENE, ALEXANDER J. C., M.D.,
Professor of Gynæcology in the Long Island College Hospital,
Brooklyn, and in the Post-Graduate Medical School of New York.

STELWAGON, HENRY W., M.D.,
Physician to the Philadelphia Dispensary for Skin Diseases; Chief of
the Skin Dispensary of the Hospital of the University of
Pennsylvania, Philadelphia.

STRAWBRIDGE, GEORGE, M.D.,
Clinical Professor of Otology in the University of Pennsylvania,
Philadelphia.

THOMAS, T. GAILLARD, M.D.,
Clinical Professor of Diseases of Women in the College of Physicians
and Surgeons, New York; Surgeon to the New York State Woman's
Hospital.

TYSON, JAMES, A.M., M.D.,
Professor of General Pathology and Morbid Anatomy in the University
of Pennsylvania; Physician to the Philadelphia Hospital,
Philadelphia.

WILSON, JAMES C., A.M., M.D.,
Physician to the Philadelphia Hospital, and to the Hospital of the
Jefferson College; President of the Pathological Society of
Philadelphia.

ILLUSTRATIONS.

FIGURE PAGE 1. THE CLASSICAL REPRESENTATION OF THE PELVIC ORGANS . . . . . . 148

2. THE CORRECT REPRESENTATION OF THE PELVIC ORGANS . . . . . . . 149

3. FIRST DEGREE OF PROLAPSE OF THE POST-PARTUM UTERUS . . . . . . 155

4. SHOWING EXTREME DESCENT OF THE UTERUS AND OF THE PELVIC FLOOR,
AND THE HERNIAL CHARACTER OF THE LESION . . . . . . . . . . 156

5. DESCENT OF THE VIRGIN UTERUS INTO THE VAGINAL CANAL, SHOWING
THE REDUPLICATED VAGINAL WALLS . . . . . . . . . . . . . . . 157

6. DESCENT OF THE UTERUS, SHOWING EXCESSIVE CIRCULAR ENLARGEMENT
OF THE LACERATED CERVIX, CONSEQUENT UPON REDUPLICATION OF
THE VAGINAL WALLS AND OUT-ROLLING OF INTRACERVICAL TISSUES . 158

7. THE EMMET CURVES (PESSARY) . . . . . . . . . . . . . . . . . . 160

8. THE ALBERT SMITH CURVES (PESSARY) . . . . . . . . . . . . . . 160

9. THE FIRST SUTURE BEFORE TWISTING IN EMMET'S OPERATION IN
PROCIDENTIA . . . . . . . . . . . . . . . . . . . . . . . . 162

10. FOLDS ON THE ANTERIOR VAGINAL WALL FORMED AFTER TWISTING THE
FIRST SUTURE . . . . . . . . . . . . . . . . . . . . . . . . 162

11. EMMET'S OPERATION FOR PROCIDENTIA AND URETHROCELE COMPLETED . 163

12. DIAGRAM OF EMMET'S OPERATION . . . . . . . . . . . . . . . . . 164

13. THE SUTURES IN PLACE . . . . . . . . . . . . . . . . . . . . . 165

14. THE VAGINAL SUTURES TWISTED . . . . . . . . . . . . . . . . . 165

15. EXTREME RETROFLEXION, WITH HYPERTROPHY OF THE CORPUS . . . . . 167

16. COMMENCING REPOSITION OF THE RETROVERTED OR RETROFLEXED UTERUS
BY CONJOINED MANIPULATION . . . . . . . . . . . . . . . . . 170

17. COMPLETED REPOSITION OF THE RETROVERTED OR RETROFLEXED UTERUS
BY CONJOINED MANIPULATION . . . . . . . . . . . . . . . . . 171

18. SHOWING THE PELVIC ORGANS SUSTAINED BY THE EMMET PESSARY AFTER
REPOSITION OF THE PROLAPSED, RETROVERTED, OR RETROFLEXED
UTERUS . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

19. SCHULTZE'S SLEIGH PESSARY IN PLACE . . . . . . . . . . . . . . 173

20. FRONT VIEW OF SCHULTZE'S FIGURE-OF-EIGHT PESSARY . . . . . . . 174

21. THOMAS'S RETROFLEXION PESSARY . . . . . . . . . . . . . . . . 174

22. PATHOLOGICAL ANTEVERSION . . . . . . . . . . . . . . . . . . . 175

23. CONGENITAL ANTEFLEXION . . . . . . . . . . . . . . . . . . . . 176

24. ANTEFLEXION WITH POST-UTERINE FIXATION . . . . . . . . . . . . 177

25. DIAGRAM SHOWING MUSCULAR STRATA OF UTERUS, AS DIVIDED FOR
CLINICAL PURPOSES . . . . . . . . . . . . . . . . . . . . . 249

26. IMPERFORATE HYMEN . . . . . . . . . . . . . . . . . . . . . . 374

27. SIMS'S VAGINAL DILATOR . . . . . . . . . . . . . . . . . . . . 387

28. FOLLICULAR VULVITIS (HUGINER) . . . . . . . . . . . . . . . . 390

29. ABSCESS OF GLANDS OF BARTHOLINI . . . . . . . . . . . . . . . 397

30. ELEPHANTIASIS OF VULVA . . . . . . . . . . . . . . . . . . . . 400

31. ELEPHANTIASIS OF VULVA . . . . . . . . . . . . . . . . . . . . 400

32. DEFORMITY OF HAND IN PROGRESSIVE MUSCULAR ATROPHY . . . . . . 548

33. SHOWING ATROPHY OF THE RIGHT DELTOID AND ARM, AND OF THE LEFT
ARM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549

34. SHOWING ATROPHY OF THE DELTOID, POSTERIOR ASPECT, AND OF THE
SCAPULAR MUSCLES . . . . . . . . . . . . . . . . . . . . . . 549

{17}

DISEASES OF THE GENITO-URINARY SYSTEM.

{19}

DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS.

BY ROBERT T. EDES, M.D.

Anomalies of Shape, Size, Number, and Position.

The kidneys are two glandular organs, of a concavo-convex shape so characteristic as to be frequently used as a term of comparison, situated on each side of the vertebral column, with the longer diameters nearly parallel thereto, but slightly convergent toward the upper extremity, and extending from about the upper border of the eleventh rib on the left side and the middle of the corresponding rib on the right to the second or third lumbar vertebra. Hence they are somewhat less than half covered by the last two ribs.

The upper extremity is a little the wider and the thinner, and by this peculiarity and a recollection of the position of the vessels (from the front, vein, artery, ureter) the two kidneys may be assigned to their proper sides after removal from the body.

They are behind, and at their upper extremities nearly in contact with, the peritoneum, resting, with their more or less voluminous envelope of adipose tissue, upon the great muscles of the loins. The fat which in the normal condition surrounds the kidneys varies, as might be supposed, within wide limits, and is by no means devoid of importance, since its deficiency is undoubtedly a predisposing cause for some of the displacements hereafter to be described. In this fatty mass may also be situated perinephritic abscesses, and into it spread with considerable facility morbid growths originating in the kidney itself.

At the middle of the inner borders of the kidneys are situated the hiluses into which enter veins, arteries, ureters, nerves, and lymphatics, united by connective tissue and forming a sort of pedicle.

The normal weight of each kidney is to be expressed by a rough average as from four and a quarter avoirdupois ounces, or one hundred and twenty grammes, on the one hand, to seven ounces, or two hundred grammes, on the other; but since a deficiency in the size of one is not unfrequently compensated by an increase in the other, it would be safer to give the weight of the pair as from two hundred and forty to four hundred grammes, the lesser number representing those organs which are not only small but anæmic, and the larger those which are either distinctly hypertrophied or much congested: many diseased kidneys will also be found within these limits.

The size of the kidney is in a general way proportioned to the size of {20} the body: the proportion is stated as 1 to about 240. A disproportionate change in the size of both kidneys without any change in structure is a true hypertrophy, and may be met with in persons whose habits as regards the ingestion of fluids (especially such as are freely secreted by the kidneys--for instance, beer or other forms of dilute alcohol) tend toward excess, or where a disease like diabetes throws a large amount of diuretic material into the circulation.

The deep position of the kidneys makes them usually inaccessible to physical exploration to any practical extent. In stout persons they are so entirely covered by their own immediate envelope of fat, by the adipose tissue of the mesentery, and by the thick abdominal walls as to be completely indistinguishable. In thinner persons deep palpation with both hands may enable us to say that there is a diminished resistance to pressure, as in the case of movable kidney, or that there is or is not any decided enlargement. Slighter changes in size cannot be accurately determined, although Bartels[1] states that he was once enabled to detect a considerable enlargement in a case of parenchymatous nephritis by double palpation. In moderately thin persons the lower end of the kidney can be more or less distinctly felt.

[Footnote 1: _Ziemssen_, vol. xv.]

A position upon the hands and knees (not the gynecological semi-prone position), allowing the whole abdomen to gravitate directly away from the backbone, is said to afford, by the varying concavity of the lumbar region on the two sides, information as to the absence of either kidney from its usual place. When the kidney, however, is displaced, and when it comes decidedly forward from increase in its own size or from the pressure of a tumor behind it, it may very often become extremely accessible.

Percussion gives even less information than palpation, since the dulness of the lumbar muscles extends laterally beyond that of the kidneys, and is of itself so complete as to offer no change from the addition or subtraction of the resistance of the underlying organ.[2]

[Footnote 2: It is probable that Simon's method of thrusting the hand into the rectum and large intestine might be made available by a person with a small hand and arm for diagnosis in doubtful cases where the value of the information to be obtained would be sufficient to compensate for the risk of serious injury.

The removal of the kidneys may be accomplished through the rectum--and has been effected many times by myself and assistants--in cases where a complete autopsy is refused. The manoeuvre is not very difficult through a large and especially a female pelvis, but under other circumstances may be somewhat fatiguing. Considerable post-mortem information in regard to other organs may be obtained in the same way.]

The most marked anomaly in the shape of the kidneys when both are present, and the only one which possesses a clinical interest, is that known as the horseshoe kidney, being a more or less complete fusion of the organs of each side in front of the vertebral column and the great vessels. This fusion is usually at the lower end, but may be in the middle or at the upper end. Sometimes there is a portion lying directly in front of the vertebral column so large and thick as to appear almost like a middle lobe or a third kidney. In a few rare instances this portion has formed a pulsating enlargement mistaken for an aortic aneurism or other abdominal tumor. In others compression of the great vessels has given rise to phlebitis, or the abnormal position of the ureters has obstructed the passage of the urine, with the results, as regards the secondary affection of the kidneys, to be described below. {21} These instances are, however, among the curiosities of medicine, and no rule for their diagnosis can be laid down. A horseshoe kidney is usually discovered only after death, and with no special frequency in cases of renal disease.

Variations in the number of the kidneys possess this point of practical interest, that diseases affecting a single organ are more dangerous than if another exists which can take upon itself extra duty. Apparent absence of one kidney may be due to atrophy, attended with very small size of the renal vessels; in which case a small mass of connective tissue is found at the upper end of the ureter, which is usually illy developed. The other kidney is usually hypertrophied.

The kidney may fail to be developed. In this case there are no vessels corresponding to the renal artery and vein, and the ureter is stated to be invariably absent, but the writer has seen a specimen where the left ureter terminated superiorly in a rounded cul-de-sac, no kidney or suprarenal capsule being present. The other kidney was of rather large size in proportion to the size of the patient, but of the usual form. This defect is apt to be associated with some anomaly of the genital organs.

Another condition, apparently similar, but really due to a fusion of the two embryonic kidneys, is sometimes found. In this the single organ, situated upon one side, is irregular in form and in the number and origin of its vessels. There are usually two ureters, arising one above or beside the other, and directed to their proper positions in the floor of the bladder. A single ureter arising from a single kidney has been seen to empty upon the opposite side of the bladder.

Supernumerary kidneys have been noted. In one case an extra pair, situated below the others, were intensely inflamed, while the normal organs were not so.

A position of one kidney has been noticed considerably higher than normal, so as to push the spleen from its place. A more common anomaly, however, is the situation of one kidney at a point much below the usual, most commonly at the brim of the pelvis. When this happens the kidney itself is usually more or less distorted in form, and receives its blood-supply from several small arteries which enter it at irregular points, forming as it were several small hiluses. They may originate from the aorta or from one or both iliacs. The ureter is correspondingly short. This position is of some importance, since a pelvic tumor is formed which has in one instance proved an obstacle in childbirth, while in another the misplaced kidney itself underwent an acute nephritis from the pressure of the foetal head. The kidney tumor has in a few instances been felt in this position during life, but its nature has not been diagnosticated.

Floating Kidney.

The most clinically important change in the position of the kidney is not a permanent one, but varies from time to time with the posture of the patient and the altered conditions of pressure--externally by dress or apparatus, or internally by the other abdominal organs. It is known as floating or wandering kidney. In this affection the kidney ceases to {22} be firmly imbedded in the fat usually found in the lumbar region, constituting a support and packing for these organs as well as for the suprarenal capsules, and is allowed more or less liberty of movement, which is restrained by a pedicle consisting of the ureter, vessels, and nerves, with more or less connective tissue. As it passes downward and forward it comes into more intimate relations with the peritoneum, which usually covers only the anterior surface, often with an intervening layer of fat, so that it may even gain a sort of special investment or meso-nephron.

The extent of the excursions of which the tumor thus formed is capable must naturally vary considerably. Sometimes the organ can be pushed or make its own way forward so as to come into contact with the anterior abdominal wall on the same side, and not much lower than the normal position, or it may pass considerably downward, and thus be confounded with tumors arising from the pelvis.

This affection is much more frequent among women than in men, and the right kidney is more frequently movable than the left: both, however, are sometimes dislocated. It is observed in a much larger proportion of cases in the laboring classes than in those whose work is less severe and carried on in less constrained attitudes. Judging from the relative amount of the literature of the subject, it would appear to be much less frequently observed in this country than among the lower classes of Germany, where so large a proportion of the severest outdoor labor is carried on by women.

Various causes are assigned for this displacement. It is stated to be usually congenital, but is not described as found post-mortem in children with at all the frequency that it occurs in adults; and it is certainly possible in adults to fix in many cases the beginning of the disease with a reasonable degree of certainty. That a certain amount of predisposition, or peculiarly favorable position of the kidney, or an unusual laxity of connective tissue, exists in a certain number of cases is undoubtedly true.

The next most important factor is undoubtedly a laxity of the abdominal walls, affording a less firm and unyielding support to the contained viscera, and a deficiency, usually an acquired one, of the fat surrounding the kidney, which enables it in the normal condition to be supported by the layer of peritoneum passing across its front from the spinal column to the flank. This is seen in a certain set of cases where the trouble dates from an acute disease or a rapid emaciation. The well-known influence of repeated pregnancies is undoubtedly exerted in this way.

Another set, especially those exceptional cases which occur in strongly-built and not thin persons, are referable to severe shocks received in gymnastic exercises, hard riding, or falls from a horse.

One of the most frequent causes, and one which accounts for the fact of the affection being most prevalent among the working classes, is the use of a tight strap or cord to support the garments. Corsets, which exercise a more even pressure over a larger surface, do not have this effect. The right kidney, from the position of its superior extremity in front of the liver and its slightly higher place in the abdomen, appears to be more influenced by this pressure than the left. The movements of respiration, especially when reinforced by the forced inspiration and {23} compression of the abdominal viscera accompanying violent exertion, appear to assist in the dislodgment already favored by the pressure of the girdle.

According to Müller Warnek,[3] who has laid especial stress on this method of causation, a slighter degree of displacement is possible in this way without or preceding the full development of wandering kidney. A pressure is exercised upon the descending duodenum with which the right kidney is brought into intimate relations behind, and bound down by, the peritoneum; which leads, as Bartels supposes, to a hindrance in the passage of food from the stomach, and consequent dyspeptic phenomena. In these cases, when the kidney has become a more freely movable one and has dropped farther down in the abdominal cavity, the pressure on the duodenum ceases, the consequent symptoms disappear, and give place to the dragging sensations and severe colicky attacks which are apt to characterize an older case.

[Footnote 3: _Berl. klin. Woch._, 1877, 38.]

SYMPTOMATOLOGY.--There is great variety in the kind and amount of effect which the movable kidney exercises on the general organism and the local effects it produces. Neither the local nor the general symptoms are necessarily proportionate in severity to the amount of the displacement.

It may be said in advance that, contrary to what might be expected, the symptoms are not usually connected with any disturbance in the urinary function, and, although exceptions are not unknown, the rule is for a displaced kidney to be an otherwise healthy one. Cystitis and uterine affections have been observed in this connection, but it is doubtful if any relation other than coincidence or a mutual dependence upon impaired general nutrition and overwork exists between them. The partial stoppages which might be supposed to arise from the twisting of the ureters are not frequently observed.

Hysteria and hypochondriasis have been frequently attributed to this lesion, and might undoubtedly find their exciting cause in anxiety about a tumor of unknown character and origin; but there seems no good reason to connect them in any other relation of causation. It is undoubtedly true that many pains and discomforts exist in these cases which are neither satisfactorily explained nor gotten rid of by being called hysterical. These abdominal pains, especially of a dragging character, and also the sensation as of something falling or moving about in the abdomen, particularly when the patient assumes the upright posture or makes unusual exertions, are very naturally connected with the existence of the actual condition which is likely to give rise to them. Müller Warnek has recorded the frequent coincidence of flatulent dyspepsia and dilatation of the stomach depending on retention, and its consequent fermentation, in connection with the movable kidney and its supposed pressure on the duodenum. It is not probable, however, that all the symptoms are to be explained so simply, but it is quite as likely that the dragging and tension of the pedicle may have a remoter effect through the renal and sympathetic nerves.

Severer attacks occasionally occur with violent colic and inflammatory symptoms, the tumor formed by the misplaced organ becoming exceedingly sensitive to pressure. These have been attributed to some {24} incarceration, but there is no evidence that this accident occurs, and it has not been found after death. They are probably due to a localized peritonitis of the investment of the kidney, or perhaps to simple neuralgia. Icterus and hepatitis, consequent upon a circumscribed peritonitis set up by the pressure of the movable kidney upon the liver, have been observed.

Death is not one of the usual results of this affection, but a recent surgical writer (Keppler[4]) has called attention to cases where long-continued dyspeptic symptoms, with constant pain and the chagrin and melancholy due to inability to work, have been followed by death from exhaustion, and nothing except a movable kidney has been found at the autopsy.

[Footnote 4: _Arch. für Klin. Chirurg._, 1879.]

There can be no doubt that in many cases the symptoms are more severe than might be supposed from the ordinary descriptions, and are very unfairly characterized as hysterical. On the other hand, many cases are attended with but the mildest form of the symptoms just described, and the patients, ignorant of any tumor either from its discomfort or from having felt it, live in health and comfort for many years.

DIAGNOSIS.--The diagnosis of this condition, if the physician keeps in mind the possibility of its occurrence, is usually not difficult. In many cases a tumor has been felt by the patient which when called to the attention of the physician is recognized by its shape. In some cases in thin persons the form of the kidney, even to its hilus with the strongly-beating artery, can be made out. It glides easily from between the fingers, and can be moved more or less remotely from its normal position, to which, however, it returns without difficulty, especially when the patient assumes the recumbent position. The excursions are of course limited to a certain length of radius, of which the origin of the renal vessels is the centre, and seldom go much beyond the median line toward the side opposite to that on which the movable organ belongs.

The usual statement of text-books, that a depression or lessened resistance is to be felt in the loins of the side from which the kidney is absent, and a diminution of the normal dulness, which returns again when the organ is replaced, rests, as regards the majority of cases, rather upon theoretical considerations than on actual observation. The thickness of the lumbar muscles, upon which the kidney rests, is such that the dulness on percussion is not capable of much change. In most persons the outer limit of dulness in this region is not that of the outer edge of the kidney, but of the extensor dorsi communis. Palpation and percussion therefore in the renal region are not likely to be of much value in diagnosis, although an occasional case appears to justify the ordinary statement. The hand-and-knee position described above would be more likely than any other to show an existing depression.

Palpation for the purpose of finding the tumor, if it be not at once evident, or for examining it after it is found, should be bimanual, one hand being placed in the space between the ribs and the crest of the ilium of the supine patient and pressed strongly upward, while the surface rather than the points of the fingers of the other hand should be carried and pressed with some firmness into the relaxed abdominal parietes. In this way the kidney may be caught between the two hands and examined more or less completely according to the thickness of the abdominal walls. Sometimes the kidney can be partly grasped between the {25} finger and thumb of one hand. In this way the size, shape, and sensitiveness of the tumor can be determined, as well as its position and movability.

A movable kidney may of course present some difficulties of diagnosis from other abdominal tumors. The liver is sometimes, though very rarely, movable, and never to the same extent as a wandering kidney, and as it is pushed downward discloses its much greater bulk. The base of the gall-bladder may occasionally be quite movable, but its excursions are of a more limited radius, being of course executed only by the base and not the whole organ.

The spleen, when it descends so as to be distinctly felt below the ribs, is much less movable, and if it descends deeply without great enlargement, its absence from its proper place is demonstrable by percussion. The splenic tumor is also larger, firmer, and more closely applied to the abdominal walls than the floating kidney. The left kidney, it should be remembered, is less frequently movable than the right.

A small ovarian tumor might be mistaken for a movable kidney low down in the abdomen, or vice versâ. The latter error has actually been committed, and has led to an attempted removal of the supposed cyst. The more easy movability of the kidney upward and of the ovary downward or laterally, as well as the shape, and in many cases the result of a vaginal examination, should be sufficient to make the distinction, which, if an exact diagnosis be absolutely necessary, may be confirmed by aspiratory puncture.

A malignant omental tumor might at the first examination present points of difficulty in diagnosis, but even if it were single and counterfeited with considerable accuracy the shape of the kidney, neither of these conditions would be likely to continue for any length of time.

TREATMENT.--The treatment usually suggested for this affection is based partly on the fact that many cases are hysterical, and also on that other more important one, that very little can be done to restrain the vagaries of the offending organ.

A correct diagnosis, it has been frequently remarked, is often sufficient to relieve the patient's mind, and secondarily her body, and may be all that is necessary in cases where the symptoms are all psychical and have arisen from the discovery of a tumor of unknown nature.

As a relief from the more serious annoyances the avoidance of certain disturbing causes may be of value, and such will consist in a proper regulation of the bowels and consequent avoidance of straining, and the choice of an occupation as little laborious and involving as little work in the upright posture as possible. No tight, narrow girdle should be worn about the upper part of the abdomen.

On the other hand, the use of a tight bandage over the whole abdomen is usually recommended, and seems to be useful in a small proportion of cases. It can of course act only by rendering the whole abdomen a little more tightly packed, and cannot exercise much restraint on any special portion of its contents. Pads of various shapes worn under the bandage may bring a little more local pressure to bear. One shaped like a carpenter's square, with an ascending branch to check the lateral movements, and a horizontal one to prevent the descent of the tumor, has been proposed. A truss with pads adapted to the loins and a front pad over the kidney has also been used.

{26} It is impossible to read the history of many cases of this affection without becoming convinced that while the majority need but the mental assurance of the harmlessness of the tumor to restore their mental equilibrium, and others find their troubles bearable or capable of relief by mechanical appliances, no inconsiderable number are incapacitated from labor and the enjoyment of life by the necessity for great care in their movements, or suffer from severe symptoms, as pain and dyspepsia, which demand a more active treatment.

This has been afforded by operative surgery in two ways. Of these the most obvious is removal of the offending organ. It has now been clearly shown, by the number of nephrectomies that have been performed, that one healthy kidney is sufficient to support the function of urinary elimination; and if one kidney can be clearly shown to be healthy, the other can be safely removed. Such an operation undoubtedly adds to a patient's risks, since any subsequent renal affection is likely to prove fatal; but it has been now done a considerable number of times for the relief of the affection in question, and with good results. R. P. Harris[5] has collected 16 cases with 10 recoveries, the organ removed in 3 out of the 6 fatal cases being diseased. Only 2 of these operations were by the lumbar incision, both being saved. They have since been reported.

[Footnote 5: _Am. Journ. Med. Sci._, July, 1882.]

The operation has usually been done by the abdominal incision, which offers the advantages of greater accessibility of the pedicle for the purpose of ligating the arteries, and also greater ease in getting at the kidney itself, since it has often formed a partly separate pouch in the peritoneum, from which it would not be so easy to dislodge it by the lumbar incision. The latter operation is, as just stated, by no means impracticable nor specially dangerous. Of course it is desirable to avoid for some time after the operation anything which, like the use of diuretics or the excessive secretion of water, will throw any increased work upon the remaining kidney until it has had time to accommodate itself to them.

A singular case of attempted excision of a tumor supposed to be a wandering kidney, which could not be found after the incision was made, is recorded.[6] In this case the symptoms, which, as well as the physical signs, had pointed distinctly to a movable kidney, disappeared after the operation. The author compares this case to another, in which great relief was experienced from a pretended operation for the removal of normal ovaries.

[Footnote 6: _Hygeia_, 11, 12, 1880, Svensson.]

The other operation consists in the fixation of the movable organ. In one case a curved needle bearing a strong tape ligature was passed into the abdominal muscles, through the kidney, and out again. The ligature remained for some time, giving a certain amount of relief from the distressing symptoms, but maintaining a constant discharge until it came away without having accomplished any permanent benefit. The kidney was afterward removed by a lumbar incision, and a deep cicatrix found running longitudinally along the otherwise healthy organ.[7]

[Footnote 7: A. W. Smyth, _New Orleans Med. and Surg. Journal_, Aug., 1879.]

In other cases[8] a dissection has been made until the kidney was reached, which was then, with its adipose capsule, stitched firmly into {27} the wound. In one of these cases the kidney became somewhat loosened again, but it is possible that the risk of this accident might be avoided by some modification in the operative procedure. If this operation can be made a successful one, and generally accepted, of which as yet the paucity of cases hardly permits us to judge, it is manifestly far preferable to removal, since it leaves in its place an organ usually perfectly capable of performing its functions.

[Footnote 8: Hahn, "Fixation of Movable Kidney," _Am. Journ. of Med. Sci._, April, 1882, from _Cbl. für Chirurgie_, 1881.]

Polyuria; Diabetes Insipidus.

Polyuria is the name of a symptom the presence of which may be easily ascertained beyond a doubt, but which is notwithstanding occasionally overlooked. Its existence is to be determined by measuring the urine. In extreme cases this may be unnecessary, but slighter forms may easily escape notice if this is not done. The quantity of urine normally secreted varies considerably, owing to many causes, of which the principal are--the quantity of fluid ingested, not necessarily in the form of beverages, but of food more or less succulent; the activity of the other secretions, especially those of the skin and the intestines, and the presence of substances which increase the rapidity of its flow through the kidney or stimulate the glandular cells; and, to a certain extent also, individual peculiarities.

The quantity of water furnished by the kidneys depends largely upon the excess of pressure in the vessels, and especially in the Malpighian coils, over that in the interior of the tubes, and is consequently influenced by the general blood-tension.

The second factor of importance is the calibre of the renal vessels, especially the arterioles; and the third, the freedom of exit of the formed secretion from the uriniferous tubes. A certain amount of back pressure, so far from diminishing the amount of urine, seems to increase it, as shown in some of the cases of surgical polyuria, where the normal amount is considerably exceeded, while the renal parenchyma is being gradually destroyed.

The arterioles of the kidney being, like all other arterioles in the body, under the control of the nervous system through the vaso-motor nerves, it is easy to see how the various affections of this controlling element may act upon the secretion of urine; neither is it possible to deny (although by far the most important factor in the rapidity of the urinary secretion has been shown to be the blood-pressure) that the nervous system may have a direct effect upon the secreting renal parenchyma.

The normal quantity of urine for an adult of medium height and weight and ordinary habits as regards the ingestion of liquids may be stated as fifty fluidounces, or a liter and a half, which is of course to be considered as only a very rough approximation. One liter on the one hand, and two liters on the other, can hardly be considered pathological limits, unless the increase or decrease takes place under circumstances which ought to produce the opposite effect.

Frequency of micturition, especially if nocturnal, is often considered almost a proof of polyuria, but can at most only justify a presumption of it, which is to be confirmed or not by exact measurement. Any {28} existing polyuria is likely to be greater during the night. Frequency of micturition may mean polyuria, or, on the contrary, may coexist with a considerably diminished total amount of urine; in which case it means only increased irritability of the bladder, and is then a purely nervous symptom; assuming, of course, the absence of inflammatory trouble. The rapidity with which the secretion accumulates in the bladder has a certain influence in determining the need for micturition; that is, a bladder containing five ounces of urine which has been gradually accumulating for some hours retains it with greater ease than if the same amount had been rapidly secreted, as, for instance, after a full meal with an abundant supply of fluids.

Polyuria is often, or always if persistent, an important symptom, and the suggestions made by it can easily be added to and confirmed by a more minute examination of the urine. Thus we may have the following combinations indicating important diseases:

Polyuria, moderate, with diminished specific gravity, albumen usually in small amount, and some casts; in chronic interstitial nephritis;

Polyuria, with pus and mucus and débris from the urinary passages, usually turbid and often alkaline and offensive; in irritation of the kidneys depending on lesions of the deeper urinary passages, prostate, or bladder (surgical polyuria);

Polyuria, with increase of urea (azoturia);

Polyuria, with increase of phosphates (phosphaturia);

Polyuria, with increased specific gravity and sugar; in diabetes mellitus;

Polyuria, with decreased specific gravity and diminished or normal solids; in diabetes insipidus.

These conditions have many points of mutual contact and resemblance, but the affection which is the subject of the present essay is diabetes insipidus--_i.e._ that form of polyuria which is accompanied by no abnormal constituents except occasionally inosite, a very little sugar, or a very small amount of albumen. In the cases where these constituents might lead to difficulties in the way of diagnosis the absence of other symptoms of the disease likely to be mistaken will suffice to mark off the affection as entirely distinct.

The normal elements may be decreased, normal, or increased. The disease thus defined includes not only diabetes insipidus, but many cases of so-called phosphaturia and azoturia, which, if not exactly coinciding, have many points in common.

In some cases which, from the character of the urine as well as from the other symptoms, should evidently be classed as diabetes insipidus, the quantity of urine, although somewhat increased, is not very excessive, reaching perhaps two liters, but in the great majority is discharged in much larger quantity. In a case which came under the observation of the writer by the kindness of H. E. Marion the amount of urine gradually rose from two or three gallons to five or six and seven, and on one occasion the patient, a girl of fifteen, after some unusual excitement is supposed to have passed eight gallons in the course of twenty-four hours. Of this eleven quarts was by actual measurement, and passed in the presence of her mother in the course of the afternoon.

The urine in these cases is, as would naturally be supposed, of a very {29} pale color and of low specific gravity, which from 1005 to 1010, representing the usual range, may in extreme cases fall to or even below 1001 as measured by the ordinary urinometer. I have seen no case recorded where the specific gravity of such a urine has been determined by instruments of greater delicacy. Its odor is comparatively faint, but it is somewhat prone to decomposition. The solid constituents are often somewhat increased in the twenty-four hours, especially the urea, which may be present in double the usual amount. This is probably the result of an increased metamorphosis from the passage of so large an amount of water through the tissues.

It is not always true, however, that the solids are increased, and the difference in the amount of destructive metamorphosis taking place in different cases is probably closely connected with the clinical differences which may be observed in regard to the amount of wasting and affection of the general health. The phosphates are frequently increased, as found by Dickenson and Teissier; and such an increase has probably about the same meaning as the increase in urea. In other cases, however, they take part in the general diminution of solids, as in the case of Marion just alluded to, where they were reported as absent, which undoubtedly means simply present in so small amount as to escape the usual clinical tests.

Among the concomitant symptoms the most necessarily and closely connected with the increased discharge of fluid is its increased ingestion, so that the disease has been called polydipsia instead of polyuria, it being assumed that the thirst is the initial and important symptom upon which the diuresis naturally depends. It has been observed in many cases, however, that the quantity of water drunk is very much below that which is passed. In the case last spoken of the water ingested in the form of drink was but a small fraction of the quantity of the urine, so that the patient drank but two or three pints while passing many gallons. In cases where the beginning of the disease has been carefully observed patients have distinctly stated that the increased discharge began before they felt increased thirst. This of course takes no account of the quantity of water contained in solid or semi-solid food. Polyphagia is occasionally seen, as in the oft-quoted case of Trousseau, the terror of restaurant-keepers. So intense is the craving for water that in several instances where attempts have been made to limit its amount the unfortunate patient has drained the chamber-pot. Emaciation is probably connected with increased metamorphosis, as indicated by the increased secretion of urea and phosphates. Dryness of the skin has been frequently noted, and has been said to mark the distinction between polyuria and polydipsia, in the former the skin being dry, and in the latter moist. In one case, however, where copious perspirations were noted, the patient stated positively that the polyuria began a number of days before increased thirst was experienced. In another very extreme case, attended, however, with no wasting, night-sweats occurred. Pruritus has been mentioned as affording another point in the resemblance which undoubtedly exists between the severer cases of this disease and diabetes mellitus. Dyspeptic symptoms have been noted in some cases, and oedema may take place, as in many wasting diseases.

The nervous symptoms are perhaps the most important in the severer {30} cases. In some which have been examined post-mortem distinct nervous lesions have been found, such as the remains of tubercular meningitis, tumors involving the cerebellum, and softening of the floor of the fourth ventricle; in others the patients are known to have been syphilitic.

Severe headache is a symptom of some importance, occurring in a considerable number, but not the majority, of cases. Atrophy of the optic nerve was present in two reported cases, to which the writer can add a third, where failing vision, headache, and emaciation were the principal and earliest phenomena, while at a later period the atrophy was demonstrable by the ophthalmoscope. The polyuria in this case, though marked, was not excessive, and the patient, a young man, after remaining for some years in a condition of chronic invalidism, died. Chronic interstitial nephritis had of course been suspected and sought for, but no evidence of it found beyond the symptoms already stated; neither were there any more definite cerebral symptoms.

Finally, it should be stated that a great many cases of this kind have no marked symptoms at all except the essential one, and so long as they are supplied with a sufficient amount of fluid live in comfort with their single inconvenience.

The diabète phosphatique of Teissier[9] should be cited in this connection. In only a small proportion of his cases where an excess of phosphates was noted was the quantity of the urine also increased, and in these the symptoms seem as appropriate to the polyuria as to the phosphaturia. It is worthy of note, however, that one series of his cases is connected with disease of the nervous system; another alternates or coexists, as does also diabetes insipidus, with diabetes mellitus; and his fourth class closely resembles, with the exception of the increase of phosphates (if this can be looked upon, after what has been said above of the increase of solid urinary constituents, as an exception at all), the affection last named--_i.e._ diabetes mellitus. In fact, many of these cases of Teissier read like what would have evidently been called, without a quantitative analysis, simply polyuria or diabetes insipidus.

[Footnote 9: _Du Diabète phosphatique_, par L. S. Teissier, Paris, 1877.]

According to Teissier, the presence of an excess of phosphates in the blood is sufficient to determine a polyuria. It is possible that in many cases where a polyuria accompanies phthisis, as noted in many of his cases, the symptom may be really due to actual organic (perhaps amyloid) disease of the kidney.

The COURSE AND TERMINATION naturally vary greatly with its etiology and the diseases with which it is associated. In some cases where nutrition is but little affected, and no attempt is made to check the natural appetite for water, the disease may go on for years with no essential change or impairment of the general health, as in the remarkable one quoted by Dickenson, where a French infant had at the age of three impoverished her family by her demand for water, which seems to have been an expensive luxury, and at a later period kept her husband--to whom, however, she bore eleven children--in a constant state of impecuniosity by the same depraved appetite. At the age of forty she drank in the presence of a scientific commission within ten hours fourteen quarts of water, of which she returned through her kidneys ten to their astonished gaze.

{31} When polyuria is merely a symptom of cerebral inflammation, of central tumor, of syphilis, or of phthisis, the course and prognosis will of course be that of the primary disease. It occasionally comes on during pregnancy, and in one such case it is stated to have ceased two days after delivery, and in another the secretion, uninfluenced by parturition, resumed its normal quantity when lactation was fully established.

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A system of practical medicine. By American authors. Vol. 4Chapter I: Front Matter (1)

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