Columbia BanibersJitp COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by lA-S-So^H^^'^* 'Y Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons - http://www.archive.org/details/treatiseonbrightOOmill A TREATISE ON BRIGHT'S Disease of the Kidneys ITS PATHOLOGY, DIAGNOSIS, AND TREATMENT. WITH CHAPTERS ON THE ANATOMY OF THE KIDNEY, ALBU- MINURIA, AND THE URINARY SECRETION. BY HENRY B. MILLARD, M.D., A.M. tDitl) Numerous ©riigiual SUustrations. NEW YORK: WILLIAM WOOD & COMPANY, 56 AND 58 Lafayette Plaoe, 1884. COPYEIGHT, 1883, BY WILLIAM WOOD & COMPANY TROWS ND BOOKBINDING COMPANV NEW YORK TO Dr. J. M. CHARCOT PROFESSOR IN THE FACULTY OF MEDICINE, PARIS ; PHYSICIAN TO THE SALPETRIERE ; MEMBER OP THE ACADEMY OF MEDICINE; OFFICER OF THE LEGION OF HONOR; ETC., ETC. AND TO Dr. M. DEBOVE PHYSICIAN TO THE BIC^TRE AND PROFESSOR AGREGE IN THE FACULTY OF MEDICINE THIS VOLUME IS, WITH THEIR PERMISSION, DEDICATED BY THE AUTHOR AS A TRIBUTE OF RESPECT FOR THEIR PROFOUND ATTAIN- MENTS IN MEDICAL SCIENCE, AND AS A SLIGHT ACKNOWLEDGMENT OF MANY ACTS OF KINDNESS. PREFACE. I HAVE only to say of this volume that it is the result of the experience of nearly twenty-six years of hospital and extensive private practice, and of several years' study in the laboratory, of pathological and healthy kidneys of men and animals. The illustrations were all drawn by myself from kidneys, with the exception of Figures 1, 2, and 7, which are taken from other au- thors, and 4, 5, 6, and 12, which were drawn for me from my own preparations. In perusing the works of many writers upon nephritis, I may in some instances unconsciously have incorpo- rated their ideas without according due credit. I have endeavored, however, carefully to fulfil all obligations of this kind. As I have shown in the context, the term Bright' s disease, as understood by Bright himself, does not comprise every condition of nephritis, but as most of the conditions I have described are generally understood as belonging to Bright's disease, I have given my work this title, though the nomenclature is by no means exact. I have usually employed instead, throughout the book, the word nephritis. I have used exclusively the word albumin instead of VI PEEFACB. albumen, althougli tlie termination en is generally used by medical writers. The word albumen, is, however, simply the Latin word meaning the "white of the Qg^r though it is applied to every variety of albumin ; the latter, however, represents the proximate princi- ple, and I believe chemists now generally distinguish the two by the terminations en and in. In Watts' "Dictionary of Chemistry," ' the most important work of the kind in English, the termination in, is exclusively used. Where, however, I have quoted from other authors, I have not felt justified in changing their spelling. My work has been, at least, conscientiously perform- ed, and with an earnest desire of adding to the knowl- edge*and therapeutics of the subject of which it treats. H. B. MILLARD. 4 East Foety-fikst St. , New York, November 1, 1883. ^Longmans, Green & Co., London, 1870. TABLE OF CONTENTS. PAR T I. CHAPTEE I. PAGE General Anatomy of tlie Kidney 1 CHAPTER n. The Epithelia of the Urinary Tubules 6 CHAPTEE in. The Endothelia of the Urinary Tubules , 18 CHAPTEE TV. The Connective Tissue of the Kidney 23 CHAPTEE V. The Circulation of the Kidney = 25 CHAPTEE VI. Nerves of the Kidney •...,,..... 28 CHAPTEE Vn. Nature and Sources of the Urinary Secretion and Extractives 29 VIU CONTENTS, CHAPTEE Vin. PAGE The Significance of the Existence or Non-existence of Albumin in the Urine, and the General Conditions of its Occurrence in Health and Disease 37 CHAPTEE IX. The Tests for Albumin in the Urine 4:9 CHAPTEE X. The Importance and Significance of Urinary Casts 61 CHAPTEE XI. Nature and Mode of Formation of Urinary Casts 65 CHAPTEE Xn. General Directions for Examining the Urine for Casts and Kidney EpitheHa 73 CHAPTEE Xm. Of Nephritis 75 CHAPTEE XIV. Croujpous Nephritis. — Characteristics. — Acute Croupous Nephritis 79 CHAPTEE XV. Chronic Croupous Nephritis 92 CHAPTEE XVI. Suppurative Nephritis 114 CHAPTEE XVII. Catan'hal or Interstitial Nephritis 117 CONTENTS. IX CHAPTEE XVin. PAGE Actite and Clironic Interstitial Nephritis 119 CHAPTEE XIX. Nephritis without Albuminuria 141 CHAPTEE XX. Chronic Interstitial Nephritis (continued) 155 FART //.—Treatment. CHAPTEE XXI. The Treatment of Acute Nephritis 163 CHAPTEE XXII. Treatment of Chronic Nephritis 203 CHAPTEE XXIII. Treatment of Chronic Interstitial Nephritis 205 CHAPTEE XXIV. Treatment of Chronic Croupous Nephritis 231 CHAPTEE XXV. Treatment of Suppurative Nephritis ,.,..... 238 APPENDIX 239 INDEX. .................................................... 241 LIST OF ILLUSTRATIONS. PAGE Fig. 1. — DiAGKAM SHOwmo the Course and Variations of the Renal Tubules 4 Fig. 2. — Diagram of the Vareettes of Epithelia 7 Fig. 3. — Transverse Section of the Cortical Substance op Dog's Kidney. (500 diameters. ) 8 Fig. 4. —Convoluted Tubule froji the Kidney of a Rabbit. (Longitudinal section— magnified 1,200 diameters.) — Nucleated columnar epitlielium, showing the rods ; endothelia ; interstitial connective tissue, producing the basement layer 13 Fig. 5. — Convoluted Tubule from a Human Kidney affected with Acute Catarrhal (Interstitial) Nephritis. (Ohlique section — magnified 1,200 diameters.) — Inflammatory corpuscle, sprung from the division of an epithelium ; cluster of inflamma- -tory corpuscles, sprung in the same manner ; rods of cuboidal epithelia, still recognizable ; endothelia, increased in size and number 16 Fig. 6. — Convoluted Tubule from a Human Kidney affected WITH Chronic Catarrhal (Desquamative) Nephritis. (Ob- lique section T— magnified 1,200 diameters.) — Calibre, widened by loss of the epithelia ; endothelia, increased in size and number ; interstitial fibrous connective tissue, with augmented plastids ... 20 Xll LIST OF ILLUSTRATIOlSrS. PAGE Fig. 7. — (From Heitzmann.) — Boundary Line bett^een the Cor- tical AND Pyramidal Substance of the Kidney of a Dog. Blood-vessels Injected. — Branch of renal artery ; prolonga- tion of the cortical substance ; tuft ; bundle of straight tubules ; origin of the vasa recta from the capillaries of the cortical sub- stance : bundle of vasa recta. (Magnified 100 diameters.) 26 Fig. 8.— Hyaline Casts. (500 diameters. ) 63 Fig. 9.— Mucous Casts. (500 diameters.) 63 Fig. 10. — Acute Croupous N'ephritis showing Exudate. — Lon- gitudinal section of tubule, showing droplets of exudate. (500 diameters. ) 65 Fig. 11. — Acute Croupous Nephritis. — Longitudinal section of con- voluted tubule, showing formation of casts, endothelia etc. (500 diameters. ) 66 Fig. 12. — Convoluted Tubule from: a Human Kidney affected ■WITH Acute Croupous ISTEPiiRms. (Oblique section — magni- fied 1,200 diameters.) — Hyaline cast; swollen and disintegrated epithelia participating in the formation of the cast ; wreath of endothelia ; interstitial connective tissue 69 Fig. 13. — Various Forms and Kinds of Casts. (Magnified 500 diameters. ) 71 Fig. 14. — Acute Croupous Nephritis. — Transverse section of cor- tical substance, showing cloudy swelling of epithelia. (600 diameters. ) 87 Fig. 15. — Convoluted Tubule from a Human Kidney affected wt^th Acute (Interstitial) Nephritis. (1,200 diameters.) Same as Fig. 5 88 Fig. 16. — Suppurative Nephritis. — Epithelia and masses of living matter, some homogeneous and some having direerentiated into inflammatory corpuscles ; shining lumps of matter and inflam- matory corpuscles ; epithelium dividing ; tubule, with granular LIST OF ILLUSTRATIOlSrS. Xlll PAGE matter greatly enlarged and epithelia enormously swollen ; tubules, witli endothelia and broken-down epithelia and granu- lar matter; tubule filled with pus corpuscles; epithelia: the nuclei, and granular matter undergoing transformation into shin- ing lumps ; thickened connective tissue. (Transverse section, magnified 500 diameters. ) 90 Fig. 17.— (Three illustrations.) — A, Chronic Croupous Nephritis — Straight Tubule. — Granular swelling of the epithelia, showing rods and reticular structure. (Magnified 1,000 diameters.) B, Fatty Degeneration of the Kidney. — Cross-section of convoluted tubule. Cloudy swelling of epithelia, showing rods and fat granules. Connective tissue thickened. (Magnified 600 diameters.) C, Chronic Croupous Nephritis with Waxy Degenera- tion, showing rods rather enlarged. Cross-section of ascending tu- bule. A, droplets of waxy exudation. (Magnified 600 diameters.) 105 Fig. 18. — Chronic Croupous Nephritis. — Cross-section of convoluted tubule filled with nuclei, granular matter from broken-down epithelia, and indifferent elements ; granular cast surrounded by endothelia ; homogeneous lumps of matter formed from the nuclei of the epithelia; hyaline cast surrounded by endothelia ; epithe- lia converted into amyloid or waxy corpuscles ; widened struc- tureless membrane ; atrophied tuft ; space between capsule and tnft filled with connective tissue ; thickened capsule, etc. (Mag- nified 500 diameters.) 106 Fig. 19. — Fatty Degeneration of the Kidney — High Degree (Large White Kidney) — Chronic Croupous Nephritis. Spaces greatly widened. — Fatty cast ; broken-down epithelia, showing fat globules ; fat globules in the connective tissue ; endo- thelia ; nuclei of epithelia, some having undergone the fatty change ; inflammatory C/orpuscles ; tubule with granular matter ; epithelia undergoing the fatty change ; epithelia partly broken down or showing fatty change. (Magnified 500 diameters.) 107 XIV LIST OF ILLrSTEATIONS. PAGE Fig. 20. — Waxt Degeneration of the Kidney — Chronic Croijpoxjs Nephritis. — Waxy cast; capillary with waxy walls; medullary rays with iucipient waxy walls ; artery, transverse section in waxy degeneration ; epithelia and nuclei, part undergoing waxy change. (Magnified 500 diameters. ) 110 Fig. 21. — Chronic Croupous Nephritis. — Columnar epithelia, show- ing cloudy swelling ; tuft full of shining granules ; convoluted tuhule filled with a mass of hyaline and granular matter, (Mag- nified 500 diameters.) Ill Fig. 22.— Suppurative Nephritis (Abscess of Kidney). — Convoluted tubule, filled with pus corpuscles and lined by endothelia; broken-down epithelia ; tubuli nearly obliterated ; pus corpus- cles ; increased and greatly augmented nuclei ; inflammatory cor- puscles ; tubule with nearly unchanged epithelia. (Magnified 500 diameters.) 115 Fig. 23. — Pus Corpuscles, Epithelia from the Straight and the Convoluted Tubules and Pelvis of the Kidney. (Magnified 500 diameters. ) 153 Fig, 24, — Cirrhosis op the Kidney — High Degree. — Striated and hypertrophied connective tissue ; tuft striated and enveloped in connective tissue ; tubule converted into connective tissue ; com- pressed and shrunken tuft ; thickened capsule, etc. (Magnified 500 diameters. ).,,,.,, 159 BRIGHT'S DISEASE AND ALBUMINURIA. PART I. CHAPTER L THE GEJnSRAL ANATOMY OF THE KIDNEY. That what I have to sslj upon the pathology, diagnosis, and treatment of nephritis (Bright' s disease) may be quite clear, I may be permitted to map out and briefly describe the region in which are situated the lesions which exist in this malady. This is necessary to the general reader, because few who do not make pathology and histology a special study, are perfectly familiar with or can call at once to mind the minute anatomy of the kidney. With the general form and position of the kidney we are familiar enough to make it unnecessary to dwell upon them, simply stating, as a guide in autopsies, the average normal weight of the organ to be between four and five ounces. It is covered by a dense, closely adherent capsule, and its bulk is constituted by masses of tubules arranged in a certain order, connective tissue, glomeruli, and blood- vessels, from one portion of which the nutrition of the kidney is derived, and from the other most of the con- stituents peculiar to the urine are eliminated. 1 2 bright' S DISEASE. The whole kidney is diAdded into two principal re- gions, the cortical and medullary ; the latter, again, into the zone of limitation or marginal region, and the papillary region. The cortical region is most vascular, and contains many thousands of small bodies, about ij-ff to ^^0 inch in diameter, known as the Malpighian bodies. Each of these bodies consists of a congeries of blood-vessels, from 0.02 to 0.03 mm. in diameter, and ar- ranged in two main lobes, contained in a membranous sac, known as "Bowman's capsule." This congeries of blood-vessels is composed of a number of small arteries, which are a continuation or blossoming of a small ar- tery proceeding from an interlobular artery, emptying into Bowman's capsule at a point nearly opposite the neck of the capsule, and known as a vas afferens ; the tuft is known as a Malpighian tuft or glomerulus ; it subdivides into seven or eight arteries. These reunite to form a vessel known as a vas efferens, which emerges from the capsule at a point closely adjoining that which the vas afferens enters. The convolutions of the tuft form the lobules, one be- ing slightly larger than the other ; they are both covered by a very thin layer of connective tissue ; this is reflected upon and forms the lining of the capsule. The whole surface of this delicate membrane is covered by a flat epithelial layer whose functions I shall hereafter allude to. The glomerulus is not adherent to the capsule. From the blood thus introduced into Bowman's cap- sule, certain elements, mostly aqueous, are passed out into the capsule, and hence arises the necessity of another outlet than the vas efferens ; this outlet is the commencement of an uriniferous tubule ; it commences as a constricted neck, which quickly dilates into a crooked tube {tubulus contortus). This, with many windings, runs toward the medulla, in reaching which it becomes suddenly attenuated, and descends straight AXATOMY OF THE KIDNEY. 3 down, forming the descending branch of a curve known as '^Henle's loojp^ In the region of the cortex it de- flects from the medullary ray, and is known as an ir- regular tubule. It then becomes convoluted, and again forming a convoluted tubule, of the second order, its con- vexity being directed toward the surface of the kidney, and empties by the junctional part into a collecting tubule ; this latter runs in a straight direction toward the papilla. AYhen several of these tubes have reached the papilla they coalesce. A number of fascicles of col- lecting tubules, constitut'mg the 7?i€duUar 2/ ray, or pyra- mid of Ferrein, form a cone-like body, the base looking toward the surface of the kidney. These cone-like bod- ies are produced by the union of the tubuli uriniferi at about the beginning of the zone of limitation ; they reunite just above the papilla, forming the cone. A number of primitive cones form the pyramids, or ren- culi ; they have a bottle-shaped appearance, owing to the space between what would represent the junction of the neck and body of the bottle. These pyramids are known as i\\Q pyraonids of MalpigM, or medullary pyr- amids. There are from ten to eighteen of these, sep- arated from each other by the prolongations of the cor- tex known as the columns of Berlin ; the apex of these pyramids forms a papilla which projects into the calices, these in turn being formed by the branching and sub- divisions of the pelvis, the latter being a basin formed by the expansion of the ureter. The formation and course of an uriniferous tubule is shown by Fig. 1. . The changes of an independent uriniferous tubule, from its commencement at Bowman's capsule to the time it enters into a medullary ray, are numerous, undergo- ing many variations in direction and diameter. The diameters of the tubules in an adult vary from -^ to ^\-^ of an inch. The space between the medullary rays bright' S DISEASE. Fig. 1. — Diagram showino the Course and Variations of the Renal Tubules. After Ivleiii and Smith (modified). — A, Cortex limited on its free surface by the capsule ; a, subscapsu- lar layer not containing Malpighian corpuscles ; B, boundary layer ; C, medullary substance, or papillary layer ; 1, Bowman's capsule ; 2, proximal convoluted tubule ; 3, descending limb of Henlo's loop ; 4, the loop proper ; 5, ascending limb of Henle's loop ; 6, the irregular tu- bule, and 7, the intercalated tubule, constituting the distal convoluted tubule ; 8, junctional tubule ; 9, 10, straight collecting tubule of medullary ray and boundary layer ; 11, collecting tubule of papillary part. ANATOMY OF THE KIDNEY, O in the cortical substance is known as the labyrinth ; it is here that the Malpigliian bodies and the tubidi con- tortl are found. Bowman's capsule may be regarded as the commence- ment of the uriniferous tubule. The wall of each tubule is formed of a delicate membrane, or tunica propria ; this is absent in the ductus papillaris. Until a comparatively recent time, this membrane has been regarded as wholly homogeneous and structure- less. Ludwig shows, however, that "though," in his own language, " this is as clear as glass, elastic, a nu- cleus can occasionally be brought to view." See Chap- ter III. CHAPTER II. THE EPITHELIA OF THE URESTAEY TUBULES. The membrane of Bowman's capsule and its neck is continuous ; but at tlie commencement of the convo- luted tubule it changes. Here the epithelia are com- posed of a clouded mass of nucleated protoplasm. The epithelial pulp is only loosely attached to the basement membrane. R. Heidenhain first called attention to minute granu- lations in the epithelia in certain of the tubules of ani- mals which he called stabchen, having a long axis di- rected toward the lumen, these epithelia being known as bacillated or rod-like epithelia. As the tubules undergo various changes in their caliber, direction, and form, so do the epithelia lining them vary. The convoluted tubules of the first and second order, the ascending and descending portions of the narrow tu-' bules, are lined by polyhedral or cuboidal epithelia ; as the ascending and descending portions of these become narrower, the epithelia become flat. At the commence- ment of the collecting tubules they are lined with cu- boidal epithelia which soon become columnar, and in the lower portions they are distinctly imbricated. The form and structure of the various epithelia of the kidney are shown in the following figure from Heitzmann.' As the article is pertinent to the subject now under consideration, I subjoin here portions of a paper written '•Microscopical Morphology of tlie Animal Body in Health, and Disease. C. Heitzmann. New York : 1883. EPITHELIA OF THE TITBULES. by me and published in the Neio York Journal of Medicine^ June, 1882, treating also of certain changes the result of intiammation, entitled, " Researches in the Minute Anatomy of the Kidney." ' R. Heidenhain'^ was the first to call attention to the presence of a peculiar rod-like or bacillated structure CVj Fig. % — Diagram of the Varieties of Epithelia. — i^, flat epithelia in front view; S, same in side view ; Cu. cuboidal epithelia ; Co. columnar epithelia in side view ; T, columnar epithelia in top view ; Ci, ciliated columnar epithelia ; 5, bacillated columnar epithelia. existing in the urinif erous tubules. He found this struc- ture in convoluted tubules, in the ascending portions of the looped tubules, and in the intercalated tubules of the kidneys of mammals. According to his view, the rodlets (stabchen) are plainly visible in the outer portions of the epithelia — 1 Read before the New York Medico-Chirurgical Society, May 9, 1882. ^ " Mikrosk. Beitriige zur Anat. und Physiologie der Nieren : " Max Schultze's Arch., f. mikr. Anat., 10 Bd , 1874, 8 beight's disease. that is, in those portions lying next the connective tis- sue, and he sometimes saw in torn epithelia the rods isolated. The same observer' also first demonstrated with accuracy that the secretion of the salts is per- formed only in the tubules, in accordance with the views maintained by Bowman. Char- cot ^ deduces from the experiments of Heidenhain with indigo-blue the conclusion that the secretion or elimination of this coloring matter takes place only in those portions of the tubuli uriniferi which are covered by the epithelia having the rods (epithelium a batonnets). Whether the secre- FiG. 3.-C0BTICA1 Substance OF tiou of the specific principles of Dog's Kidney — Transvekse Sec- . it- • i HON— Blood Vessels Injected.— the UriUe takeS plaCe lU preClSelV A, tuft: B, capsule; C, flat epi- o i • i • • theiia; D, convoluted tubule; E, the Same fashiou as the elimmatiou straight collecting tubule ; F, as- cending limb of narrow tubule ; G, of coloring matters, he regards as descending limb of narrow tubule ; o > o H, irregular tubule : L »a,sa recto, imposslble of demoustratlou ex- Mi^nified 500 diameters. ^ perimentally. In a late monograph \>j Charcot, Legons sur les Con- ditions Pathogeniqices de V Albuminurie, Paris, 1881, he regards the tubuli contorti and the loops of Henle, particularly the ascending branches of the loops, as the real glandular part of the kidney. "They are," he says, "lined by an epithelium, thick, granulated, cloudy — in a word, glandular. They are enveloped in all parts by a dense capillary network, bathed, like themselves, in a lymphatic fluid." " These parts seem, then, in some respects, designed for the selection and concentration of the specific principles of the urine, ' " Versuche iiber den Vorgang der Harnabsonderung : " Pfltiger's Archiv, 9Bd.,p. 1., 1874. ^ Charcot on BrigM's Disease, translated by Millard, p. 28, New York, 1878. EPITHELIA OF TPIE TUBULES. 9 urea, and uric acid ; it is iu these parts, no doubt, that is formed the hippuric acid, which does not pre-exist in the blood." Heidenhain, however, did not associate the rods with the process of secretion, for he observed a similar struc- ture also in the smaller ducts of the parotid and sub- maxillary glands, the same formation in the latter structure being already known to Henle and Ptiiiger. In the acini of the glandula submaxillaris and in the other acinous glands he could not discern them. E. Klein' asserts that he has observed tliat the rods or fibrils of Heidenhain, when looked at from the surface, are connected into a network, so that they are more probably septa of a honey-combed network seen in pro- file. What the intimate nature of these formations is neither of the above-named authors attempts to explain. My own researches, I hope, will prove theu" nature, though as to their significance I have only suggestions to make. Since the reticular stricture of all protoplas- mic formations, including, therefore, epithelium, was demonstrated by C. Heitzmann," the question has been what the reticulum present in the protoplasm is. Un- questionably the two main properties of living matter are motion and production of its own kind. Both these properties are attributes of the reticulum within the protoplasm. As long as a protoplasmic body is alive and endowed with the property of amoeboid motion and locomotion, the reticulum in it is never in a state of per- fect rest. We constantly see changes in the configura- tion of the reticulum. We see that in a portion of the protoplasmic body the reticulum becomes very narrow, while in an opposite portion it is simultaneously wi- dened, especially so when a prolongation of the body, a ' Atlas of Histology, London, 1880. - " Untersucliungen liber das Protoplasma : " Sitznngsbericlite d kaiserl. Akad. d. Wissenscli. in Wien., 1873, 10 beight's disease. pseudopodmm, is pushed out. In such a flat offshoot, or false leg, the reticulum may be stretched to such a degree that the projection looks homogeneous, as if des- titute of any structure. The writer above quoted claims that the narrowing of the reticulum is the state of contraction which is an ac- tive property belonging to it. The stretching, on the contrary, represents the state of extension which is merely passive, due to the pressure of the liquid pushed out from the contracted portion into that at compara- tive rest, this contracted portion being immediately after extended. The foregoing is tenable only if we admit the presence of an investing layer around the protoplasmic body which prevents the liquid filling the meshes from escap- ing outward. The flat investing layer is claimed to be identical in its nature with the mass composing the re- ticulum proper. It is maintained, also, that the reticu- lum at any time, and almost instantaneously, may be transformed into a flat layer, as is the case in the for- mation of an investing layer around a vacuole. Vice versa, the flat layer almost instantaneously may fall back into the reticular structure at the moment of dis- appearance of the vacuole. This continuous change of shape and place of the reticulum is a positive proof of its being living matter. S. Strieker,' among the most recent observers, describes the reticular structure and its changes as follows : "The interior of the cell-bodies undergoes manifold visible variations. One of the most remarkable instances is furnished in the saliva corpuscles. The assumption that a so-called molecular motion takes place in the saliva corpuscles is erroneous. The granules seen with insuflicient amplifications are transverse sections of tra- ' " Mittheilung iiber Zellen und Grundsubstanzen : " Med. Jalirbiiclier, 1880. EPITHELIA OF THE TUBULES. 11 beculse. The saliva corpuscle is traversed by a sharply marked trabecular structure, w^hich, so long as the cor- puscle is fresh, executes lively wavy motions. The vi^aving gradually ceases on addition of solutions of salts in certain concentration, and the reticular structure dis- appears. The waving is now replaced by very slowly formed changes in the interior mass." A second proof of the reticulum being the living mat- ter proper rests upon the fact that, both in normal and in morbid processes, the new formation of corpuscular elements starts from the points of intersection in the reticulum. This so-called endogenous new formation of living matter is especially plain in the inflammatory process invading epithelial formations. Here, it is im- portant to note, the reticulum at first becomes coarse, next it coalesces into lumps, which, being at first homo- geneous, in turn assume a reticular structure themselves, and now represent so-called inflammatory or pus cor- puscles. These corpuscles at first remain in connection with the neighboring reticulum by means of delicate filaments, which are portion and part of the reticulum. Later, when the pus corpuscles which have originated in the interior of an epithelium become extruded from its interior, the newly formed corpuscles represent pus corpuscles. In conducting my researches, I have studied the kid- neys of the rabbit, pig, dog, and man, all of them being preserved and hardened in a solution of chromic acid. I have, therefore, no observations to report upon the form-changes of the epithelia, but have studied the changes in the interior structure of the epithelia in the inflamed human kidney as they appear in chronic croupous, in chronic interstitial nephritis, in waxy de- generation of the kidney, in fatty degeneration, and in chronic interstitial nephritis with acute recurrence. These investigations enable me to maintain that the re- 12 bright' S DISEASE. ticular stracture of the epithelium of the kidney is really a formation of limng matter. Upon closely examining the epifchelia of the tubuli uriniferi in the kidneys of the above-named animals, we readilj'' perceive, with comparatively low powers of the microscope (400 or 500 is sufficient), the presence of rod-like formations in the epithelia of the tubuli con- torti, in the irregular tubules, in the ascending branch of the looped tubules, and in the intercalated tubules, entirely in accordance with Heidenhain's assertions, al- though he does not include the kidneys of the pig. The drawings of the rodlets, as given by Heidenhain in Max Schultze's " Archiv," and copied by Klein and other writers, give an exaggerated idea of the real ap- pearance of the rods. Even under a high power they are never so large as in the drawings, and seldom pre- sent the straight, regular, and symmetrical appearance there represented. The accompanying drawing (Fig. 3) more nearly represents their average appearance under a power of 1,200. I have found them in the healthy kidney as follows : In man, in the ascending tubules, power 1,200. In the rabbit, power 500 to 600, in convoluted, in ascending, and in irregular tubules. Also (never before mentioned) in a portion of the descending tubules. In the pig, in the convoluted and irregular tubules ; and in the same tubules, and narrow tubules, in which the rods are very faintly shown, of the pup. The pale, flat epithelia of the looped tubule proper do not, as a rule, exhibit the rods. The columnar epithelia of the collecting tubules, on the contrary, which are distinctly imbricated, especially in the kidney of the dog, exhibit the rods more or less plainly. The colum- nar epithelium of the rabbit does, however, show them. High powers (1,000 to 1,200) of the microscope corrob- orated the views of Klein — namely, that the rods are RODLIKE STRUCTURE OF THE EPITHELIA. 13 connected with a reticulum by means of delicate fila- ments inosculating both with the wall of the nucleus around which the rods are located, and also with the delicate reticulum in the inner portion of the epithelia, next to the caliber, where the rods are usually absent. It is striking how the thickness of the rods differs in the different epithelia of the same animal's kidney. Fig. 4. — Straight Tubule from the Kidney of a Eabbit. (Longitudinal section — magnified 1.20U diameters.)— -iV^, nucleated columnar epithelium, showing the rods; E, endo- thelia ; /, interstitial connective tissue, producing the basement layer. Sometimes they are very thin, beaded poles, with quite distinctly marked interstices between them. In this case the connecting filaments, running almost at right angles from rod to rod, are easily discernible. At other times the rods are rather bulky formations, having but extremely narrow interstices between them. In this in- stance the connecting filaments, as a matter of course, are very short, and not easily seen. In a third instance the outermost portion of the epithelium is a compact or 14 beight's disease. homogeneous mass, in wliich no rods can be observed at all. Another striking feature is the great variety of ap- pearances exhibited by the cement-substance. Some- times this is plainly marked at regular intervals between the epithelia. Then the transverse connecting filaments, the formerly so-called thorns, are plainly visible. At other times hardly any trace of cement-substance is seen, but the reticular structure is present in a nearly uniform distribution throughout the epithelial layer. S. Strieker (Zoc. cit) was the first who observed these same varieties in the appearance of the cement-sub- stance in the epithelial layer of the cornea ; also, that the nucleus varies greatly in the degree of distinctness in which it comes to observation. Where the rods are slender, the nucleus, as a rule, is well defined ; where, on the contrary, they are bulky, the nucleus is, on an average, not very plainly marked. The sharpest defi- nition of the nucleus is furnished by the flat epithelia of the looped tubules in which the rods, as before men- tioned, are absent. In inflamed kidneys of man I have repeatedly found the rods as follows : 1. In chronic interstitial nephritis : a. In the convoluted tubules. h. In the straight tubules. 2. In acute croupous nephritis : a. In ascending tubules. 3. In chronic croupous nephritis, in the straight tu- bules. 4. In chronic croupous nephritis w4th waxy degenera- tion, cross-sections of ascending tubules show the rods rather enlarged. Also in straight tubules in the pyra- mid of the same kidney. 5. In chronic croupous nephritis with acute recur- rence, in cross-sections of the convoluted tubules. KODLIKE STRUCTURE OF THE EPITHELIA. 15 6. In fatty degeneration of the kidney, in cross- sec- tions of the convoluted tubules. The rods here sliowed fat globules. The connective tissue was thickened. In these specimens the rods of the epithelia through- out the tubules are clumsy and bulky, the whole reticu- lum being enlarged, rendering the epithelium, with low powers of the microscope, coarsely granular. In many instances the rods are not discernible, as, in their place, a coarsely granular mass is present, pervading the whole epithelial body ; or else the innermost portion of the epithelium looks coarsely granular, the outermost por- tion, on the contrary, being homogeneous and shining. I have repeatedly seen in acute interstitial nephritis even the looped tubules, which in this situation were consid- erably increased in bulk, provided with a coarsely gran- ular reticulum — nay, even with an indistinct rod-like structure. All these features become still more promi- nent by staining the specimens with the chloride of gold after they have been soaked and washed for several days in distilled water. This reagent, in a half-per- cent, solution, brought in contact with the specimens for forty minutes, renders sections from the normal kidney of a brown violet hue, slightly increasing the distinct- ness of the reticular structure of tlie epithelia. In the inflamed kidneys of man, the ejDithelia of a great many of the ascending, irregular, and convoluted tubules, upon being stained with the chloride of gold, as above de- scribed, became dark violet. AVith higher powers of the microscope we can ascertain that it is the coarse re- ticulum, the bulky rods, and the homogeneous masses sprung from coalescence, as it were, of the rods, which exhibit the deepest gold stain. As it is the tubuli uriniferi which have the rod-like structure, which in Heidenhain's experiments with in- digo sulphate are the only ones which are colored by it, so in the infiamed kidney it is only these tubules that 16 bright' S DISEASE. become colored by tlie gold. It seems reasonable to suppose, from the effect of these reagents, that the epithelia with rods, perhaps by virtue of their having more living matter and a more bulky reticulum, are of most importance in secreting or forming the extractive matter of the urine. Numerous attempts to produce the stain with "the gold in the healthy kidney of the dog, pup, rabbit, and pig Fig. 5. — CoNvoLnTED Tubule from a Human Kidney affected with Acute Catab- KHAL (Interstitial) Nephritis. (Oblique section — magnified 1,200 diameters.) — P, inflam- matory corpuscle, sprung from the division of an epithelium ; D, cluster of inflammatory corpuscles, sprung in the same manner ; B, rods of cuboidal epithelia, still recognizable ; E, endothelia, increased in size and number. were ineffectual in rendering the rods plainer than in the unstained condition. In the inflamed kidneys, in which the violet coloration was produced, no doubt the reticulum of the epithelia, owing to the inflammatory process, was considerably increased in bulk. The most marked violet stain was exhibited by a number of the convoluted tubules and by irregular and ascending tubules. We know that living RODLIKE STRUCTURE OF THE EPITHELIA. 17 matter is considerably increased in amount in the in- flammatory process, and are justified, consequently, in maintaining that the reticulum and rod-like formations within the epithelium, being part of the reticulum, are formations of living matter. As to the significance of the rods, it may be inferred from the statements I have made that they are in close relation with the process of secretion. Obviously, the stream of liquid running from the neighboring blood- vessels through the epithelia toward the liquids con- tained in the caliber, and vice versa, will be facilitated by an elongated arrangement of the reticulum — i.e., the rods. In a state of comparative rest the rods lie close to each other — nay, are coalesced into homogeneous masses. In this condition the cement-substance between the epithelia is best marked. In full activity of the epithelium, on the contrary, the rods will be very dis- tinct, will stand further apart, and the cement-sub- stance between the epithelia will in consequence become indistinct. 2 CHAPTEE III. THE ENDOTHELIA OF THE URINARY TUBULES. While investigating the pecnliarities in the structure of epithelia of tubuli nriniferi in their normal condi- tion, I often observed the presence of flat, spindle-shaped bodies between the basis of the epithelia and the adja- cent so-called structureless membrane of the tubule. These spindle-shaped bodies doubtless correspond to those flat, nucleated formations which cover the inner surface of the structureless layer in nearly all epithelial — i.e., glandular — foraiations. By most observers they are regarded as endothelia belonging to the connective tissue subjacent to the epithelial layers. Y. Czerny was the first one to bring them to view in other tissues, which he did by staining the specimens with the nitrate of silver ; and C. Ludwig,' also by the silver stain, first indicated their presence in the urinary tubules. He does not fully describe them, but alludes to them as follows. Speaking of the basement membrane of the tubuli uriniferi, he says: "In general the basement membrane appears to be homogeneous, and cannot be further divided ; but occasionally a nucleus can be brought into view in the substance by carmine ; and in some instances, and for short distances, the same ap- pearances occur in the tortuous canals, when treated with nitrate of silver, as are presented by the blood and lymph capillaries under the same condition." "The basement membrane is as clear as glass, elastic." " The ' Hand-book of Histology, by S. Strieker. London, 1874. ENDOTHELIA OF THE TUBULES. 19 shape of the nucleus is usually the same in all instances, being spherical, sharply defined, and with numerous granules scattered through its substance." Such an endothelial layer, present in all varieties of the urinary tubules, is best visible in the front view of the structureless membrane, where the epithelium is stripped off. Here the endothelia are comparatively large, irregularly polyhedral bodies, with distinct cen- tral nuclei. The nucleus has a plainly marked shell, containing in its interior a few small nucleoli, the nuclei being mostly of oblong shape. In the body of the en- dothelium a delicate reticulum is seen with very minute nodulations. Each body is separated from all its neigh- bors by a delicate light rim of cement-substance, which is traversed at right angles by extremely minute fila- ments or thorns. In side view, obviously, these bodies will exhibit a spindle-shape, the broadest portion of the spindle corresponding to the central nucleus. If the views of recent observers are correct — namely, that the structureless layer, synonymous with the hya- line or basement layer, is an aggregation of endothelia infiltrated with elastic substance — this view may also be applied to the structureless membrane of the urinary tubules. In normal kidneys I failed to discover nu- clei in the structureless layer proper, which would indicate their construction of former endothelia. In inflamed kidneys, on the contrary, no doubt was left as to the fact that the structureless layer is composed by a number of closely attached, in part nucleated, en- dothelia. I have found the endothelia repeatedly in the inflamed kidney in chronic croupous and in chronic interstitial nephritis, in acute interstitial and in acute croupous nephritis, and in fatty and waxy degeneration of the kidney. I have found them most frequently in the ascending, descending, and convoluted tubules. I am 20 bright' S DISEASE. not aware tliat any observer has heretofore recognized their existence as having a pathological significance. In the inflamed kidney the endothelial layer beneath the epithelial is always more marked than in the nor- mal kidney. In chronic catarrhal (interstitial or des- quamative) nephritis, all the tubules that have lost their epithelial investment invariably show an invest- ment of endothelia. Fig. 6. — Convoluted TnBirLE from a Human Kidney affected with Chronic Ca- TABEHAi (Desquamative) Nephkitis. (Oblique section— magnified 1,200 diameters.) — C, caliber, widened by loss of the epithelia ; E^ endothelia, increased in size and number ; F, in- terstitial fibrous connective tissue, with augmented plastids. This, in the transverse section of the tubule, is char- acterized by the presence of flat, irregularly spindle- shaped bodies, which are always more coarsely granular than in the phj'-siological condition. Their nuclei are also more coarsely granular, sometimes homogeneous. The flat shape, the large size in the frontal diameter, and the construction of the nuclei serve for an accurate contradistinction to epithelia. I have failed in obtain- EISTDOTHELIA OF THE TUBULES. 21 ing specimens indicative of a new formation of epithelia after the loss of tlie original epithelial investment. It may be admissible to assume that the enlarged en- dothelial layer serves (at least to some extent) as a substitute for the lost epithelia. In tubules v^^hose epi- thelia, as in chronic catarrhal nephritis, are transformed into inflammatory or medullary corpuscles, the new formation also starts from the endothelia. The final result in this instance is known to be the destruction of the tubule and its replacement by newly formed con- nective tissue — a condition which is known by patholo- gists as cirrhosis of the kidney. [Since writing the rough outlines of this article, I have recognized for the first time well-marked endo- thelia in the urine in a case of advanced chronic croup- ous nephritis with fatty degeneration. I found a clus- ter of three or four of these surrounded by free fat granules.] Still more plainly marked are the endothelia in croupous (parenchymatous) nephritis. In fact, the ap- pearances seen in urinary tubules where casts have just formed could not be explained unless by the presence of endothelia. The results of my researches may be summed up in the following statements : 1. The rods discovered by Heidenhain in some varie- ties of the tubuli uriniferi are part and parcel of a retic- ulum present within every epithelium. 2. The reticulum, including its elongated rodlike for- mations, is the living matter proper. 3. The relation of the rods to the rest of the reticulum of an epithelial body varies greatly, the variation prob- ably being due to different stages or degrees of secretion. 4. The reticulum, including the rodlike formations, in the infiammatory process, both in catarrhal and croupous nephritis, gives rise to a new formation of 22 BRIGHT S DISEASE. living matter, which results in the new formation of medullary corpuscles or pus corpuscles. 5. The structureless membrane is lined by flat endo- thelia lying between it and the basis of the epithelia of the urinary tubules. 6. In nephritis the endothelia become considerably enlarged, and in catarrhal, as well as in croupous ne- phritis, they line the urinary tubules after the epithelia have been shed or lost ; they surround the cast in croupous nephritis after the epithelia have perished in the formation of the cast. CHAPTER ly. THE CONNECTIVE TISSUE OF THE KIDNEY. The importance of this tissue will be readily understood when we consider that to its lesions is due one of the most common forms of Bright' s disease, namely, inter- stitial nephritis. According to G. Johnson (" Lectures on Bright' s Dis- ease") this connective tissue does not exist in the laby- rinth, but I have repeatedly recognized it in healthy kidneys of man, of the rabbit,' dog, and pig. No fibril- lated connective tissue exists between the tubuli con- torti. It is found, however, in the tissue immediately surrounding the Malpighian corpuscles, and especially those lying close to the medulla. These are often en- closed by fibrous connective tissue. Elsewhere, only isolated small fusiform cells lie be- tween the blood capillaries and the urinary tubules of the labyrinth. They do not, however, in any way bind the convolutions of the tubuli uriniferi either to one another or to the blood-vessels. The spaces between the tubules of the medulla in the immediate neighbor- hood of the papilla are filled with a distinctive fibrillated connective tissue surrounding the urinary tubules in a concentric manner. The nearer we approach the limit- ing layer the more delicate becomes the fibrillation and the more abundant the cellular elements. (Ludwig, in Strieker's ' ' Histology. ' ' ) The capillaries forming the glomerulus are covered by delicate connective tissue. This delicate layer also lines 24 bright' S DISEASE. the capsule, both layers being covered with epithelia ; according to Heitzmann that upon the glomerulus be- ing cuboid in the fcetus and flat in the adult, while that upon the parietal portion is flat. In scarlatina, in the case of patients who succumbed rapidly from anuria, Mr. Klebs states that he found the only lesion in the kidney to be an excessive multiplication of the cells (or epithelia) of the connective tissue of the glomerulus, naturally producing compression of its blood-vessels. There is no doubt, however, that inflammation of the glomerulus could not exist without inflammations of other portions of this organ. The convoluted tissue of the glomerulus is often thickened, but not indepen- dently of other inflammation. CHAPTER V. THE CIRCULATION OF THE KIDNEY, The greater part of the renal arteries run into the cor- tex, forming arterise interlobulares. A small portion of these penetrate to the fibrous capsule, and each arte- ria interlobular is sends to a Malpighian body a small trunklet called a xias afferens ; a few of these ^asa affer- entia give off fine branches which break up into capilla- ries through which the blood passes into the capillary plexuses surrounding the urinary tubules. The 'Gas efferens, which contains arterial blood, after leaving the capsule of Bowman runs immediately to the medullary ray, subdividing, as it extends, into a capil- lary network and running in part to the cortical sub- stance. From the capillaries of the cortical substance thus formed, descend straight branches, supplying the medullary rays. These are the true vasa recta. The labyrinth derives its supply of blood from the capillaries running upward from the efferent vessel. The capillaries, composing a plexus surrounding a medullary ray, are never closely adherent to the urinary tubules, lacuniform spaces, frequently filled with fluid, intervening between the walls of the blood and the uri- nary vessels. Both these varieties run immediately toward the fis- sure-like space in the marginal layer of the medulla, between the fasciculi of the tubuli uriniferi. They break up into capillaries that form looped plexuses about the tubules. The circulation of the medullary 26 bright' S DISEASE. portion is therefore derived from the capillaries di- rectly arising from the vasa efferentia and from the vasa recta descending from the cortical plexus. ' ' The i:)eins arise from the capillaries of the cortical substance, es- FiG. 7. (From Heitzmann.) — Boundaet Line between the Cortical and Pyramidal Substance of the Kidney of a Dog. Blood-vessels Injected. — 4, branch of renal ar- tery; Co, prolongiition of the cortical substance; T, tuft; otasTi as a diuretic in chronic croupous nephritis is clearly shown in the cases reported by Dr. J. Hughes Bennett (p. 176). I have myself employed it with great benefit in subacute and chronic croupous iiephritis. The mild and the corrosive cTilorides of mercury have often proved serviceable, but much less so tlian in acute conditions. For indications and mode of use, see Chapter XXI. Cantharides have often been of use in diminishing albuminous excretion and in promoting the secretion and flow of urine. The efficacy of this remedy is often greatly increased by combining it with iron. Nitric acid is often of value, in albuminous and ana- sarcous conditions, in stimulating the flow of urine and diminishing albumin. (See p. 191.) Euonymus or its alkaloid, euonymine (see p. 194), may be useful in torpid conditions of the liver, as is also the muriate of ammonia, podophyllum, nitro-mu- CHEONIC PARENCHYMATOUS NEPHRITIS. 237 riatic acid, etc. Fitclisin and rosaniUn undoubtedly aid in diminishing albuminous exudation. Iodide of 2yotassium, unless in sypliilitic conditions, has never proved of much use to me in this form of nephritis. I have found other diuretics more reliable, and this rem- edy has nearly always disappointed me. The experi- ence of Bartels is to the same effect. Lead. — If this remedy be of real use in chronic ne- phritis, its sphere should be more in the interstitial form. A case is, however, reported by Prof. Gatchell, then of the University of Michigan, of what was probably chronic or subacute interstitial nephritis cured by lead in conjunction with hot-air baths. The cure may have been due to the latter, although the experience of Le- wald shows that lead can diminish albuminuria. Lithia waters should also be most useful in the gouty kidney, or in nephritis accompanied by the uric acid diathesis, but there are certain conditions of deranged digestion, ansemia, etc., even in croupous nephritis, which would not be likely to be benefited by them. The mineral w^aters enumerated in the chapter on Chronic Interstitial Nephritis are here applicable, on the same principles as there mentioned. CHAPTER XXY. - - TREATMENT OF SUPPURATIVE NEPHRITIS. When acute suppurative nephritis can be diagnosti- cated as an accompaniment of and caused by acute nephritis, if the abscesses are small, recovery may take place with the recovery of the latter, and this often occurs when the nephritis is the result of scar- latina or diphtheria. When it has this causology the treatment must be that of the acute nephritis. - When it arises from blood-poisoning, the former of course must receive due consideration, but, at the same time, it must be remembered that with the suppuration there is more or less diffused nephritis, and such treatment as is likely to help this should be employed; indeed, this latter condition, with its treatment, should always be considered. When caused by calculi or cystitis, of course these must be removed or cured if possible; but it must always be borne in mind, unless evidence of disorganization or extensive suppuration exist, that often the abscesses affect only one kidney, that they are often small and circumscribed, and may heal up, the liquid contents of the small ones being absorbed, the rest being converted into a calcareous mass. Sometimes the abscess may empty into the pelvis of the kidney. When the abscesses open into the peritoneal viscera, or into the groin, the proper methods of evacuation must be employed. Extirpation of the kidney has been fre- quently successfully XDerformed in sup^Durative nephritis jDroduced by nephritic calculus, and from other causes. APPENDIX. {a) More extended trials lead me to consider the brine test a more sensitive one than the nitric acid. {b) When a proper light is not otherwise attainable, I find a kerosene or oil lamp with a large flame per- fectly satisfactory. (c) A case so forcibly illustrating the correctness of the views I present in the above chapter relative to the long existence that nephritis may have without albu- minuria, is at this moment, October 22, 1883, under my care, and I insert it here. It is that of a gentleman fifty-four years of age, of an excellent constitution ; his strength has been somewhat impaired for about three years, and he has suffered from dyspepsia, headaches, and debility. For two years previous to last spring I made examinations of the urine every three or four weeks, with the invariable re- sult of finding epithelia from the kidney, pus, and some- times blood corpuscles. No albumin could ever be dis- covered. From May to October 1st the patient was absent from the country. Since October 1st I have several times examined the urine, and have each time found from one-half to three-fourths of one per cent, of al- bumin. The microscopic appearances remain the same, and various symptoms of nephritis have become mani- fest. INDEX. Albumin, source and secretion of, 46 absence of, in interstitial nephritis and cirrhosis, 146 intermittence of, in interstitial nei^hritis, 133 physiological, 39 testing for, 49 by heat, 49 nitric acid, 50 brine, 52 picric acid, 53 the double iodide of mercury and potassium. (Tanret's test), 55 sodium tungstate, 57 ferrocyanide of potassium, 58 test papers, 58 behavior of, with the various reagents, 60 Albuminuria occurring in health, 39 after food, 39 after rest and fatigue, 41 after severe brain work, 42 from cold bathing, 42 from reflex action, 42 in healthy children, 40 as a result of various derangements of the health, 44 Alcoholic beverages in the treatment of nei^hritis, 209 Alcohol as a factor in the i^roduction of nephritis, 124, 125 Anaesthetics, danger from, in nephritis, 230 Apis melliflca in the treatment of nephritis, 193 Appendix, 239 Arsenic in the treatment of nephritis, 192 Arteries, atheroma and changes of, in interstitial nephritis, 135 16 242 INDEX. Baths, hot aii- and vapor, in the treatment of nephritis, 164, 209 Bleeding, local, in acute nephritis, 180 in ursemic convulsions, 196 Bright's disease, as understood by Bright himself, 76 and nephritis, nomenclature of, 76, 77 CAiiOMEL in the treatment of nephritis, 186, 212 Cantharides in the treatment of nephritis, 190, 223 X)athological effects upon the kidney of, 190 Capsule, Bowman's, 2 changes of, in chronic croupous nephritis, 111 Casts, directions for examining the urine for, 73 importance and significance of, 61 diagnosis of mucous and hyaline, 63 nature and formation of, 65 formed at the expense of the ej)ithelia, 68 forms and varieties of, 71 formation of, in chronic croupous nephritis, 107 Cirrhosis, renal, 159 Cirrhosis "without albumin, 146 Climatic resoris in chronic interstitial nephritis, 206 Chloral in uraemic convulsions, 196 Counter-initants in acute nephritis, 179 Convallaria majaUs, its uses, history, etc., 171 in nephritis, 171, 220, 234 Corrosive sublimate, pathological effects upon the kidneys, 189 in nephritis, 186, 236 Cysts, mode of formation, 112 Diaphoresis in nephritis, 164, 232 Digitalis in nephritis, 170, 221, 234 Diet in nephritis, 164, 209, 232 Diuretics in nephritis, 164, 168, 229, 234 modus operandi of, 176 saline and alkaline in nephritis, 176, 230 Dropsy, absence of, in interstitial nephritis, 138 EpitheiiIA, varieties of, in the kidneys, 6 rod-like structru-e, reticulum, and minute anatomy of, 7 of, in inflammation, 14 animals, 11 INDEX. 243 Epitlielia, cloudy swelling of, 15, 87 in the formation of casts, 68 of the kidney, in diagnosis of nephritis, 150 how to examine the urine for, 73 Endothelia of the tubules, 18 Ergot in the treatment of nephritis, 182 Euonymus atropuriDurens in the treatment of neiahritis, 194, 236 FucHSiN in the treatment of nephritis, 182 Gallic acid in the treatment of nephritis, 182 Glonoine in the treatment of nephi-itis (see nitro-giycerine). Gold, chloride of, in the treatment of nephritis, 220 Gold and soda, chloride of, in the treatment of nephritis, 220 Glomerulus, the, 2 functions of, 29 Helonias in the treatment of nephritis, 193 Ikon, chloride, in the treatment of nephritis, 181, 221, 235 Jabokandi in the treatment of nephritis, 167 Juniper as a diuretic, 230 Kidney, atroxDhy of, 117 general anatomy of, 1 circulation of, 23 connective tissue of, 23 cirrhotic, the, 127 epithelia, varieties of, in, 6 granular degeneration of, 117 gouty and cirrhotic, 127 impermeability of, to uric acid in gout, 126 as affected by lead jpoisoning, 128, 129 tubules of, 2 waxy degeneration of, 108 zones of, 1 244 INDEX. Lead in the treatment of nephritis, 237 poisoning as a cause of interstitial nephritis, 128 pathological effects upon the kidney, 128 producing gout, 131 interrupting the excretion of uric acid, 131 Medullaby rays, 3 Muriate ammonia in the treatment of nephritis, 195 Mineral waters, value of, in nephritis, and authoi-ities, 228, 229 Mineral waters in the treatment of nephritis, 224 Carlsbad, 224 Buffalo Lithia, 224 Bilin, 226 Ballston, 226 Contrexeville, 226 Pougues, 226 Franzenbad, 227 Tarasp, 227 St. Nectaire, 227 Mt. Dore, 227 Kreutznach, 228 Saratoga waters, 228 Wildungen, 228 Marienbad, 228 Nephbitis, 75 varieties of, 77 no exclusive parenchymatous, nor interstitial, 77 croupous, 79 synonyms, 79 acute croupous, definition of, 79 diagnosis of, 85 course and prognosis of, 85 pathology of, 86 etiology of, 80 from irritants, 82 malaria, 82 treatment of, 163 chronic croupous, 92 synonyms, 92 curability of, 231 INDEX. . 245 Nephritis, cliroiiic croupous, etiology, 92 ages wlieri most frequent, 96 course and prognosis, 101 diagnosis, 100 pathology, 103 pregnancy as a cause of, 96 treatment of, 231 interstitial, 117 catarrhal, 117 interstitial, synonyms, 117 nature and nomenclature of, 117 general pathological and histological changes in, 118 acute and chronic, 119 curability of, 210 general etiology of, 119 caused by cold, 121 gout, 126 syphilis, 125 lead poisoning, 129 pregnancy, 130 cystitis, 131 valvular disease of the heart, 132 among painters and workers in lead, 129, 130 ages when most frequent, 120 comparative prevalence in the sexes, 121 duration of, 155 diagnosis of, 100 heredity of, 122 hemorrhagic attacks in, 134, 135 polyuria in, 134 heart, hypertrophy of, in, 135, 137 headaches in, 131, 138 nitro-glycerine in treatment of, 188, 220, 234 nitric acid in treatment of, 191, 222, 236 without albuminuria, 141 prognosis of, 155 pathology, 156 treatment of, 205 suppurative, 114 diagnosis of, 116 course and prognosis of, 116 246 INDEX. Nephritis, suppurative, etiology and pathology of, 114 treatment of, 238 Opium in ursemic convulsions, 196 PiLOCAKPiNE in the treatment of nephritis, 167 Phosphoric acid in ursemic convulsions, 192, 222 Polyuria in interstitial nephritis, 134 Potassse bitart. in nephritis, 176, 236 Pregnancy as a cause of nephritis, 96, 130 Eest in the treatment of nephritis, 163, 222 Eosaniline in the treatment of nephritis, 182 Eetinitis, albuminous, in chronic interstitial nephritis, 135 Eetinal changes in chronic interstitial nephritis, 137 Eod-like epithelia, functions of, in urinary secretion, 34, 35 ScoPABius as a diuretic, 175 Tannate of sodium in nephritis, 183, 220, 234 Tufts, Malpighian, description of, 2 changes in, in chronic croupous nephritis. 111 Turpentine in nephritis, 220 UKiEMic accidents in interstitial nephritis, 134, 138, 140 treatment of, 230 Urea and uric acid, excretion of, in interstitial nephritis, 134, 138 interrupted by lead, 130 Urine, nature and sources of, 29 Ludwig's theory of the secretion of, 30 experiments of Overbeck, Heidenhain and others, illustrating, 30 Urinary extractives and urine, rod-like ej)ithelia and tube system in formation of, 34, 35 Vasa afferantia, 2 Vasa efferantia, 2 Vasa recta, 25 Vision, disturbances of, in interstitial nephritis, 137 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 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