Olfllumbia MnturrBttg in tl|f (Ettg of 5J^ui fork (Enllf gr nf PhyHiriana anfi ^urgrnna 3Trom lljr library of OlljurrltiU OlarmaU. M. S. ^rrarntrd by lljf icxlfrnr (lllub of Nrni Ifork Digitized by the Jnternet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/suppressionofuriOOfowl Left kidney and supra-renal capsule. Cystic - degeneration. SUPPRESSION OF URINE CLINICAL DESCRIPTIONS ANALYSIS OF SYMPTOMS BY E. P. FOAVLEK, M.D. NINETY-THREE CIJNIUAL CASES, WITH ILLUSTRATIONS, TABLES, AND DIAGRAMS Pa-er prese7ited iu The New YoiK " dl>) -Chikurgical Society, Hlh December, 1880 NEW YORK WILLIAM WOOD & COMPANY 1881 Copyright WILLIAM WOOD & COJIPANY 1881 Tuow's Printing and Bookbinding Company, 201-213 East zith Street, NEW YORK. CONTENTS. SECTION FIRST. Anuria, a case of Dr. Fowler's, ten daj's and two hours, 1 Autopsy of same, ............ 6 Table I. — Temperature, pulse, and respiration of same, . . . .13 SECTION SECOND. Clinical cases (93 in number), 14-51 SECTION THIRD. Anuria, cases merely mentioned, . . . ... . . . . .52 Anuria, alleged marvellous duration of, ........ 52 Alleged entire destruction of kidneys, with a continued flow of water, . . 58 Urea in blood, but absent in urine, ....'.... 54 SECTION FOURTH. Statistics Respecting Anuria and Associated Symptoms. Vomiting, ■ ... 56 Table II., 56 Constipation and diarrhoea, , . . . . . . . . . .57 Muscular twitching, ............ 57 Table III., 57 Convulsions, general, ........... 57 Table IV., 58 Pupils, contraction of, 58 . Table v., - 58 Sight, 58 Diagram No. 1, .... 59 Ptosis, 60 Delirium, .60 Insomnia, .............. 60 Table VI., . . . . • . . 60 Sopor, 60 374787 Vi CONTENTS. PAOE Coma, *''l Table VII., CI Ammoniacal or urinous odor 01 Table VIII., 62 Pulse 63 Table IX. , 63 Temperature, 63 Table X., 64 Respiration, .............. 64 Uroemia, ......•.•••••• 65 Table XL, 65 Sex, 65 Age, 60 Tables XJI. and XIII 66 Diagrams No. 3 and No. :] 07 Duration of anuria, . . . . . . . . . ■ ''^, 73-83 Causes of anuria, 66 Table X^V^, 68 Autopsies, number of ....... . ..... 68 SECTION FIFTH. Resdme. Alimentary tract, 69 Nervous organism, 69 Pulse — Temperature — Respiration, 70 Blood-poisoning, ............. 70 Sex— Age — Causes, 71 SECTION SIXTH. Table XV. — Statement of data and symptoma of the 93 cases, . . . 73-77 Table XVI. — List of cases, duration of anuria, authors and references, . . 78-81 Authors, alphabetical list of, giving the number of the case reported by them, 85-80 ILLUSTRATIONS. PAGE No. 1.— Dr. Fowler's Case : External Representation, Front of book. No. 3o— Dr. Fowler's Case: Sac op Left Kidney, . . " " Diagram No. 1, 59 Diagram No. 2, 67 Diagram No. 3, 67 (Owing to unavoidable accident, the two microscopic illustrations are omitted.) No. 1.— Dr. Fowler's Case : External Reprbsentatiow. ANURIA. SECTION FIRST. Mr. W , aged forty -five, banker ; height, five feet eight inches ; brown hair, gray eyes, and clear complexion. Had been regularly nnder my professional care for fifteen years. During this period he suffered but two illnesses. The first was twelve years ago, when he had a rather severe attack of diphtheria, lasting about three weeks. The second was a week's illness from "kidney-colic," at which time he passed a small calculus. I was at the time in Europe, and unfortunately, the physician who was in attend- ance is not living. With these two exceptions the patient has never com- plained of any serious deviation from health. For the last two or three years he has been somewhat annoyed by an in- crease in size of abdomen, and by occasional " uneasy sensa- tions," which were more apt to occur at night. On November 10th he was accidentally struck by the elbow of some one passing him. The blow was received on the right side, just above the hip. He experienced some pain, but, not regarding it as a serious matter, upon his return home he obtained the advice of a physician in the immediate neighbor- hood. November 12th. — The family thought matters seemed to assume a serious aspect, and in the afternoon I was sent for. I found the patient greatly under the influence of narcotics, the use of which I stopped and waited until I could examine him in his natural condition. 2 ANURIA. Early on November 13th the picture of his case was as fol- lows : There was an aching throughout the entire abdomen, with a centre of more actual pain just above the right ilium. No decided tenderness upon pressure. Two inches and a half above the right ilium, in a direct line to the acromial end of the clavicle, there was distinct to the touch a tumor of about the size and shape of the convex surface of half a duck's egg. The whole abdomen was distended, and percussion gave dulness over the entire region of the stomach and liver. The tempera- ture (sublingual) was 99.5° F. (taken morning, noon, and even- ing); pulse, 51 ; respiration, 28. During the two previous nights there had been almost constant wandering of mind, and a little inclination to it throughout the da}^ — perhaps somewhat due to the opiates. There was slight inclination to nausea, though appetite was fair. The alvine movements were regular, water free, and both of normal character. November 14tli and 15th. — There was little change. The temperature ranged from 98° to 99° ; pulse, 48 to 69 ; respira- tion, 20 to 22. November 16th. — The "duck's-egg" tumor disappeared; otherwise no change. Temperature, 98° ; pulse, 49 ; respiration, 18 ; bowels free ; water natural ; the latter I had, during the preceding days, repeatedly examined, and found in every re- spect normal ; specific gravity, 1020 to 1022. In the evening I left instructions that all the water voided from that time until the following morning should be kept for me. November 17th. — Found that no water had heen passed since between nine and ten o'clock the night before. The day went by with no evacuation of water and no fulness of the bladder. Between nine and ten o' clock in the evening, Dr. J. C. Minor, by my request, visited the patient, and, as no water had yet passed, he introduced the catheter, but did not obtain a drop of water. Temperature, 99° ; pulse, 48 ; respira- tion, 21. November 19th. — No change. Drs. Carnochan and Minor saw the patient with me. Dr. Carnochan used the catheter, and later in the day I did so myself, but without getting a particle of urine. I had taken the precautions that no evacu- ation of any Idnd should be cast away before I had inspected it, and there was not a trace of water commingled with the fsecal pissrges. Temperature, 97°; pulse, 52; respiration, 20. ANURIA. S Mind entirely clear and placid, appetite good, and no special pain ; was up and down about the room. November 20tli.- — Same as yesterday ; catheter used once or twice, but no water. Temperature, 99° ; pulse, 48 ; respiration, 22. Bowels free. November 21st.— Catlieterized ; no water. Temperature, 97.5° ; pulse, 61 ; respiration, 19 ; mind very clear, collected, and calm. November 22d. — Dr. Carnochan introduced the catheter ; no water. Temperature, 98° ; pulse, 48 ; respiration, 18. Wind often rejected from the stomach, which had a decided amnio- niacal odor. Mind not the least disturbed, and in every re- spect the nervous system seemed in complete repose. November 23d. — A close repetition of yesterday. Tempera- ture, 99° ; pulse, 49 ; respiration, 20. Seven full days of com- plete anuria had now elapsed, and at eleven p.m. Drs. A. L. Looniis and John C. Minor saw the patient with me. The right side of the abdomen, between the hips and ribs, was increased in volume, and there was a tolerably distinct fluctuation. Dr. Loomis found some crepitation at the poste- rior surface of the lungs, especially upon the right side (the side upon which the autopsy proved the hydronephrosis to be most extended). He expressed the opinion that the fluctuation indicated the existence of a hepatic abscess ; he also thought that in all probability there was occlusion of the right ureter (perhaps from gouty deposit). He had no theory whatever by which to account for the suppression of water, and concurred with the project which we entertained of aspirating, though lie thought best to delay for a day or two. Insomnia. November 24th. — Used catheter ; no water. Temperature, 99.1° ; pulse, 58 ; respiration, 18 ; mind entirely clear and active. Bowels open ; more abdominal pain and distention. Cupped over the right loin, taking two ounces of blood, which the family sent to Dr. Dalton for chemical analysis. Dr. Dalton declining to make the analysis, the specimen was given to me, and I placed it in the hands of Dr. G. M. Dillow for examina- tion, who kindly sent me the following report : " The hlood gines no emdence of the 'presence of iLrea.^'' This blood was obtained on the eighth day of the anuria. November 25th. — Catheterization ; no result. Temperature, 98.7° ; pulse, 57 ; respiration, 18. Yomiting and diarrhoea of 4 ANURIA. dark green matter (first trouble from vomiting) ; mind still clear as ever ; continued insomnia. November 26tli. — Temi)erature, 99° ; pulse, 60 ; respiration, 22; still no Avater. At 8.30 a.m. Drs. Carnoclian, Minor, and I met, and Dr. Minor performed asi)iration, selecting for the site of operation a point two and one-half inches on a vertical line above the crest of the right ilium. When the aspirator had penetrated about two inches there was a free fiow of pure blood ; at the depth of four inches there came a light-colored, bloodless fluid, and the instrument was kept in situ until ten and one-half ounces of the fluid had escaped, when it was withdrawn. At the same depth where the blood escaped upon the entrance of the needle, it also escaped upon its with- drawal. A few minutes after the aspirator had been taken away, the patient complained of the most agonizing pain, extending throughout the entire abdomen. The pain did not abate, and it became so unendurable that during the day it was necessary to give three hypodermic injections of morphine. Tempera- ture, 99° ; pulse, 60 ; respiration, 22. At eleven dcloclc in the evening tliree ounces of loater were taken hy the catheter^ there liavinr/ been ten days and nearly two hours of total anuria— from Tuesday evening^ November IQth, to Friday evening, November 2Q>th. The mind had not suffered in the least, nor had> there been any subsultus. The strength had remained very fair, so that the patient was able to walk about the room. November 27th.— Temperature, 99.1° to 100°; pulse, 85; respiration, 20. To this date the tongue had never been dry, and only slightly coated. It now, however, became divy and coated, and there commenced considerable vomiting and diar- rh(]ea of dark green material. The abdomen was greatly dis- tended and tender ; there was aversion to food, and considerable wandering of the mind. Within the twenty-four hours after the urinary secretion commenced there joassed sixty-two ounces of water : specific gravity, 1020 ; reaction acid ; no trace oL' albumen, and no blood or pus. Total amount of urea was not in excess, even taking into account the almost double normal quantity of water. Physical examination of the urine by Br. G. M. Dillow. — " Total amount of urine passed in twenty-four hours, fifty-seven ANUKIA. 5 fluid ounces; very pale yellow ; slight turbidity ; reaction acid ; specific gravity, 1012 ; sediment very slight. '■^Chemical examination. — Normal substances; coloring matters diminished; urea diminished; total quantity, 21.1 grammes (337 grains). Uric acid diminished ; chlorine mark- edly lessened (about one-tenth of one per cent.) ; phosphates diminished. Entire amount of solid constituents, 47.88 grammes (normal, 60 to 70 grammes). ^^t^j^ '•^Abnormal matters. — Albumen about one-thi^a^vper cent." November 28th. — Symptoms of the previous day intensified, with the addition of extreme prostration. Temperature, 101.1° ; pulse, 128 ; respiration, 24. Incessant vomiting and diarrhoea of dark brown matters. Voided ninety-four ounces of urine, specific gravity, 1016 ; no albumen or blood. From 12 m. the patient seemed moribund. The heart-action was very labored ; no pulse to be detected in the extremities ; the whole surface cyanotic and bathed with a cold perspiration ; pinched, hippo- cratic expression of face. Restoration seemed to result from use of hydrocyanic acid. November 29th. — Condition in many respects seemed much better ; for example, the abdomen had become much reduced and softened, and tenderness almost gone. Some sores, which had been accidentally produced by too hot applications, commenced to heal (at the end of two days the healing was complete). Tem- perature, 100.9° ; pulse, 106, and of fair strength at the wrist ; respiration, 21 ; tongue moister ; diarrhoea and vomiting less ; skin moist and warm. The twenty-four hoars gave fifty-four ounces of urine in every respect similar to that of the day before. November 30th. — Buring the last night there was an un- favorable change, and it was very evident that the blood was becoming poisoned or perverted, and that the nervous struc- tures were beginning to give way. There was constant rejection of gas from the stomach ; skin blue and cold ; right eye very bloodshot ; suggillations upon face and neck ; delirium was allnost constant. Temperature, 101.8° to 102° ; pulse, 108 ; res- piration, 20. Thirty-seven ounces of urine, quality unchanged from day before ; specific gravity, 1018. December 1st. — Condition progressively worse than yester- day. Temperature, 100.5° ; pulse, 123 and feeble ; respiration, 22. Toward night exceedingly feeble. Passed twenty ounces of natural urine. 6 ANURIA. December 2cl. — In all respects worse ; constant mental wan- dering ; eyes more suffused and suffering i'rom active inflam- matory process. Discharges from the bowels and bladder in- voluntary and almost; constant. Temperature, 101° to 101.5° ; pulse, 124 to 130 ; respiration, 20. December 3d. — Less of invoiuntar}^ escapements from bow- els and bladder, and clearer again in mind, and the right eye was not so red. There was, however, a paralysis of the left arm and ptosis of the left eyelid, with some defect in ahility to swallow. Sighing was very constant, and the patient com- plained of pain in the occiput. Temperature, 101° ; pulse, 112 ; respiration, 20. December 4tli. — Clearer in mind, but prostration much in- tensified ; no more involuntary escapes ; the paralysis a little more marked ; skin very dark blue, and no pulse to be found at the wrist ; the interval between the systole and diastole of the heart not distinct ; a lohite crust of crystals deposited over the face and necJc, in appearance like dried scdt, and greasy i)i feeling, which was somewhat difficult to remove, and when removed would speedily redeposit. From ten o'clock in the morning the patient was actually dying. Temperature, 101.9° to 102° ; pulse 128 to 130 ; respiration, 20. December 5th. — Temperature, 101° ; heart's action, 130 ; respiration, 19 ; was moribund all the morning, and finally died at 12.30 P.M., quite conscious to the last. Autopsy at 7 p.m. of same day : Abdomen. — Remarkably free from fluid. At the lower part of the pelvic cavity there was about a half-ounce of odorless ma- terial, having the. consistency and appearance of currant-jelly. Liver in every respect normal. Omentum. — Deeply congested and adherent to the parietal peritoneum and to the intestines. Intestines. — Intensely congested, especially the ascending colon and the lower third of the ilium — almost black. Spleen and Pancreas normal. Right Kidney. — AVeighed fifteen and one-half ounces (Troy), nearl}^ three times the natural size, and contained on the pelvic border, above the hilum, a cyst about three centi- metres in diameter, containing a thin, amber-colored fiuid. No calculi. ANURIA. 7 Left Kidney. — Had wliolly disappeared in giving ]')]ace to a cyst- There was not a trace of true renal structure. The cyst was of a multifid character ; the chief one, which remained unopened, was punctured and gave about eight ounces of fluid which had not the characteristics of urine (nor had the fluid obtained by means of the aspirator). The suprarenal capsule was entirely converted into another cyst, the contents of which were quite unlike those of the cysts originating from the kidney proper. The material was of a thick, pasty consistency, and chiefly composed of cholesterine and fatty substance. Left Ueeter. — There remained a shrivelled, impervious bit of it about an inch and a half in length. Right Ureter normal. I* Renal Artery of left side, unfortunately, was not carefully traced. Renal Artery of right side (to the practically only kid- ney) was conserved, and distinctly bore evidence of having been subjected to a long-continued pressure. A tract of the artery, nearly three-fourths of an inch in length, was flattened, distorted, much inflamed, and adherent to the surrounding tis- sues. The channel, though flattened, on section was free. Illustrations Nos. 1 and 2 represent respectively upon the surface of the body the area of dulness, the site of aspira- tion, and the appearance of the contracted cyst-walls of the left kidney two days after its removal from the subject. Illustrations Nos. 3 and 4 (microscopic) are from sections of the kidney prepared by Prof. Charles Heitzmann, showing infarctus in the kidney — produced, without doubt, by minute bits of clot coming from the point of pressure upon the renal artery (after the artery was freed from compression). The therapeutic history, of course, has no practical import, as the sequel demonstrated that no treatment, other than the evacuation of the cyst, would have offered any chance for recovery, and the tj-eatment subsequent to the anuria has no direct bearing upon the subject under consideration. The ideas which suggested themselves during the course of the malady may not, however, be altogether devoid of interest or practical value to others placed under similar circumstances. During the first four days that the patient was under my care there were some grounds for supposing that he was suf- 8 ANURIA. fering from circumscribed hepatic inflammation, with the dan- ger of an abscess. Indeed, the "duck-egg" tumor mentioned seemed strongly to indicate that such a process was somewhat beyond mere initiation. On the other liand, a non-unduhiting, low temperature (at no time exceeding 99.5°), a pulse persist- ently 2D beats below the normal, that is 48 to 51 (pulse in liealth about 70), the sudden disappearance of the " duck-egg " tumor, with no evidence of internal rupture of abscess — all combined were very telling evidence against the abscess theory. The cause of mental wandering at that stage of the illness I could not then, nor do I now understand ; and a still greater mj^stery is the fact that with the commencement of the anuria this symptom almost entirely ceased. From the begiiijjing there had been a steady increase in the volume of the abdomen, but the rapidity of the increase was no greater after the onset of the anuria than it was before. Fluctuation finally became tolerably distinct, and it was placed bej^ond doubt that there existed a collection of some kind of fiiiid within the abdomen ; but what the fluid was, its precise location^ or its source^ were all as much as ever a matter of question. Until further developments we could but content ourselves with the fact of the existence of a fluid collection, and from the most careful examinations it seemed probable that its loca- tion was in the liver ; indeed, upon the thirteenth day of ill- ness — the commencement of the eighth day of anuria — it was Dr. Loomis' opinion that we had to deal with an abscess of the liver, and Dr. Carnochan feared that possibly there might be a soft or malignant hepatic cancer. The dulness and the apparent location of the tumor were so remote from the ana- tomical site of the kidneys, and there was such an absence of symptoms generally accepted as belonging to kidney disease, that the idea of such connection, although often discussed, was not to any extent adopted. AVith the advent of anuria, of course, came the question of its cause. As there had been no renal colic, or any indications of renal calculi, or of kidney disease of any kind (unless low tempera- ture and lowered cardiac action be so considered), my first thought was that of tonic spasm of the renal arteries. General arterial tension did not seem sufficiently reduced to cause the abolition of secretion, and neither digitalis, nitre, or any of the ANUEIA. 9 generally used diuretics exercised tlieir ordinary effects. The theory of spasm could be entertained, however, for only a brief space of time, as it was wholly improbable, and at vai-iance with the facts of general observation in physiological path- ology, that an absolutely uninterrupted spasm of the vaso- motor nerves of any organ should endure for a series of days. About the only reasonable conjecture left was tliat of com- plete mechanical obstruction at some point above the entrance of the ureters into the bladder. It seemed hardly within the limits of chance that both ureters should become thus completely and simultaneously blocked ; besides, there were no symptoms (renal colic, vomit- ing, etc.) such as usually attend the occlusion of the ureter. The absence of these symptoms suggested the question if the blockade could be above the kidneys ; but here again it was quite as difficult to comprehend hovv^ hoth renal arteries could be simultaneously and entirely obstructed, as the position of the tumor did not favor the idea that pressure from it might cause obstructions of the renal arteries. At that time T knew of no recorded instance of occlusion of the renal arteries (indeed, I still know of but one, that reported by Dr. Robert Bentley Todd — " Medico-Chirurgical Transac- tions," vol. xvii., pp. 302 et seq., London, 1844— where there was but one kidney and the renal artery was compressed by an aortic aneurism), and theoretically I should have expected in such case much more positive symptoms. Tlie tapping of the cyst at 8.30 o'clock in the morning, and the obtaining of three ounces of water by catheter at 11 o'clock in the evening, seemed fairly strong proof that between the tumor and the anuria there was in some way a relation of cause and effect, and the autopsy elucidated and completed the demonstration. The problem was entirely simplified by discovering the existence of only one Mdney, and therefore the 'channel of but one renal artery required blocking, and this blocking was effected by pressure from the cyst, as upon autopsy it at once became demonstrated to the eye. After the prolonged pressure of ten da3^s it probably required the space of fifteen hours before the vessel became sufficiently distended to allow any considerable quantity of blood to pass. Theoretically, one would have reasoned that the supply of blood to any organ could not be denied for snch a length of 10 ANUEIA. time without resulting in tissue necrosis ; and certainly it seems impossible that it could have eventuated otherwise had not sufficient blood for tlie nourishment of the kidney found its way either through the arierla ])ropria renalls, or by some collateral channel. In reviewing cases of anuria I am esj^ecially impressed with the fact that sudden and total urinary suppression, in absence of other acute illness or of poisoning, is nearly always co-exist- ent with the presence — physiologically at least — of but one kidney ; it is so much the rule that nine times out of ten I think it would be safe to express such an opinion. (It must be understood that, anatomically, both kidneys may exist, whilst previous occlusion of one ureter, for example — some- times other considerations also — may, as concerns its physi- ology, reduce the organ to nil.) After I had arrived at this conclusion, and while occupied in the investigation of such cases of anuria as I could find on record, I was more gratified than surprised to find an expres- sion of the same opinion in a clinical lecture given by Jonathan Hutchinson, F.R.C.S., at the London Hospital, of which he was at the time senior surgeon. He says : "It is probable that a majority of the rare cases of death from sudden and complete retention " (suppression is evidently meant) " of urine in previously healthy persons, occur in those who have but one usable kidney." . . . . "It is indeed very difficult to conceive of any other condition under which sudden, complete, and permanent suppression of urine can take place." — London Lancet, p. i., July 4, 1847. Perhaps no man has had greater opportunities for observa- tion in this field than those ofi:'ered to Professor Hutchinson, and it was not a matter of dissatisfaction to me to find that I had independentl}^ arrived at a conclusion identical with the enunciation from an authority so eminent. The peritonitis which immediately succeeded the aspiration was undoubtedly due to the escape of cystic fluid into the abdominal cavity. From the peritonitis the patient actually recovered, and the manner of his death was not such as neces- sarily follows or was in any degree characteristic of either anuria or peritonitis. It seemed to result from blood-poison- ing or perversion such as interfered with and profoundly de- pressed the functions of the nervous centres at the base of the ANUEIA. 11 enceplialon (medulla oblongata perliaps). The only remedies wliicli seemed to exercise any unequivocal counteracting influ- ence were hydrocyanic acid and arsenic. In regard to the direction usually talcen hy renal cysts in their expansion, an analysis of the cases which I have found on record (somewhat near a hundred) indicates that, as a rule, they travel over to the side of the abdominal cavity opposite the kidney from which they originate, and tliis naturally re- sults from the fact that the cysts in merging from the kidney generally make their exit from its hilum or concave border. It will be readily comprehended that a cystic growth from the left kidney Avould naturally present greater difficulties in the way of diagnosis than would be offered in connection with one coming from the right, by reason of the intimate position-rela- tions it must enter into with the liver. In the subject of this report, the liver was by all of the medical council at first sup- posed to be the organ containing the fluid, whereas autopsy found the liver in every respect natural and sound. The cyst from the left kidney had travelled to the right side of the abdo- men, back of the intestines, down below the lower border of the liver, carrying before it a portion of the mesentery, and approached the surface only two inches above the right ilium. This crossed direction seems to be, within a certain limit, very characteristic of cystic growths from the kidnej^'s, other renal growths being more liable to confine their extension to the neighborhood of the kidney ; or, if they go far away, they are quite as prone to descend upon the same side. As relates to low temperature, slow pulse, and respiration, it will be observed that an analysis of the series of cases which I have added to this report indicates that, at least in uncom- plicated anuria (perhaps, also, with renal cysts generally), lack of rise in temperature, an abnormally slow pulse and infre- quency of respiration, would appear as somewhat characteriz- ing features. It is very much to be regretted that many of the clinical de- scriptions recorded of anuria (and the same may be said of every department of descriptive pathology), are deprived of nearl}' all value by the employment of ambiguous terms, and by an almost incomprehensible lack of exactitude. If authors would be careful to use the terms supPEESSioisr, iscHUEiA EENALis, suppRESSio TJKiNiE, or ATTURiA, as applying 12 ANURIA. to a condition wliere the kidneys failed to separate the water from tlie blood ; and, on the other hand, to employ ketention, KETENTio UKiNyE, or ANUKESis, to a retention of urine which had actuall}^ been secreted by the kidneys, but impeded in its outflow at some point between the kidnej'' and the external urethral orifice, it would surely be an advantage ; it would furnish much clearer ideas to readers, and inspire writers with much more definite modes of thought and expression. TABLE I. — Statement of Temperature, Respiration, and Prominent Features op the Case. Date. Nov. 12, Nov. 13. Nov. 14 Nov. lo. Nov. 16. Nov. 17. Nov. 18. Nov. 19. Nov. 20. Nov. 21. Nov. 22. Nov.2;3 Nov. 24. Nov. 25. Nov. 20. Nov. 37. Nov. 28. Nov. 29 . Nov. 30. Dec. 1.. Dec. 2 . Dec. 3.. Dec. 4.. Dec. 5.. Temperature, Respira- Fahrenheit. tion. 99 58 20 i 99.5 51 23 98 48 20 1 99 59 22 99.5 49 18 99 48 21 99 54 18 i 97 52 20 99 48 22 97.5 51 19 98 48 18 1 99 49 20 1 99.1 58 18 98.8 57 18 ; 99 60 22 99.1 85 20 101.1 128 24 100.9 106 21 101.8 108 20 1 100.5 123 22 1 101.5 124 20 101 112 1 20 101.9 138 20 i 101-103 130 li. Discomfort ; wandering. Duck's-egg tumor ; wandering. Good appetite ; sleeps ; not quite clear. Good appetite ; sleeps ; not quite clear. Duck's-egg' tumor disappeared. No water since last night ; catheter used. No water ; catheter used ; clear in mind. No water ; catheter used ; clear in mind. No water ; catheter used ; clear in mind. No water ; catheter used ; clear in mind. No water ; catheter used ; clear in mind. No water ; catheter used ; clear in mind. No water ; catheter used ; clear in mind. No water ; vomiting and diarrhoea ; clear ia mind. No water ; tapped 8.30 a.m. ; clear in mind. 62 ounces water ; vomiting and diarrhcea ; mind wandering. 94 ounces water ; vomiting and diarrhoea ; mind wandering. 54 ounces water ; vomiting less ; sores heal- ing. 37 ounces water ; delirium ; suggillations on face and neck ; left eye bloodshot. 20 ounces water ; in other respects same. Involuntary evacuations ; paralysis of left arm ; ptosis left eyelid ; defect in swal- lowing ; pain in occiput. No involuntary evacuations ; clearer in mind ; heart-action imporrect. No involuntary evacuations ; clearer in mind ; white crystals of urea on face and neck. Died at 12.30 P.M. ; fully conscious to last. To the desc'rii)tion of this case I have added n resume o^ ninetj^-three cases, wliich I have gleaned from the medical periodicals of the joast hundred years. The source and author- ANURIA. 13 ity for eacli case are given, and I hope it may be of use in supplying- others with Just tljat comj)act collection oi: ol)serva- tions which I would have been very glad to have found ready gathered by some one else, and which has cost vastly more time and labor of reading than the meagre-appearing result would indicate. I have arranged the cases nnder different heads : First. — Includes all those cases where the urinary appa- ratns was the primary seat of trouble. Second. — Embraces those instances Avhere anuria was an accompaniment or result of some more general constitutional disturbance (scarlet fever, scirrhus, etc.), including one trau- matic case. Third. — Cases wdiere anuria resulted from the action of extraneous poisons on the organism. Fourth. — Comprises all cases where the causes were not precisely ascertained. 14 m P Q O m Q ft;:= ANURIA t^t^i -o >. 5 ^' = 5 "S i? •= S II^IP O ^V - fc.S O M -i:ii§ " C9 0) O _ ■g S :t S = O It. IS th or a one X E-i c .a 3^Z-^%t rx^a a o t;.a p s S "S - ■=•0^ ITi .C ^ 1^1 „•- g. o o p ^ '"' p "■5 "" c cj aj ra -= o .Q f-^ —' j: ^ . X y, S c3 S " s ~ ■■55 Sb = 52S fL^t s o a O O y.~ i- ^ 5°o-' X -a -a 1 GJ c tc -• § - S » ° 2 H &^ 2 ^ d g "O P C5 a "C C5 c o •-< & o ■3 5 s 'A !^fl r1 •as 1^:: ^ 5a pS p. bo >. t»."f-' a ,; a ?> c comin nter b ia. xth da ntity c «, agai ; hour ss. I ed offic c ore w sem of s qua our igh pa um 1 'tea" x; o " 55 3 Entire anuria four.d under medical treatm catheter ; no sym]5ton After hot bath on ev passed calculus and pale urine. After t\ complete anuria for No second stone obse two or three days pat o S ■.^M 3 P. o h3 '^ §§= ANURIA. 15 !« P n ' ri ° a C3 f^ '^ . Qj ■ g i:f " I 2 o c >^ K S S"3 OS r; c6 cd" M 5 g lO ^ -s ^_l K W ^, Ql : " 5 !»■.-• ■^S §" -c « -p e; 01 pq 1 o g s o 1 1 "3 H « «) S H 'C ^ o -« ^ t- ^ !^ j= ?^ S >^ ^5 S^ ^ O J£ CQ « ^ S ■* c a ^ -►s c3 ® M a m 2-S rn o o .c X: 13 .9^ c ... is a, t. os-r; -1^ .-re ~ a; : Israel 1 j"T ^ r- sj J g, I. g^'s rt X S u^ « •" ' o " S o S « I +i a il u P o I ""a «i ^ s o ■5 .P= o g m S S i: s .a p X S_? .a I O) c 'd J= c3 Sot s S c be S S 03 S C O OJ o - c o< o S5S O 60 - 0) 3 o fi bo g K ^-' eo j , o 2; boS a ~ o , 'Oat CO 16 ANURIA. ui S — 5 1 tan „ - o 2 c2 .s ■ t- la's ^ oT o C/ ^ o io >.g S O' c sis EC <3 .- £'3 be S- S ■ c . d 3 o cii c o & ., n a a .^ 4-* es iOs S r-' 52 = P o £ H S S -'-' j: w c; ^ > -^^ P O ./; O £6= .2 S £ S f S 8 .■§ ""t^ ^ W cc c« ANURIA. 17 of tTHS'. •d +J :_ rr-l i%g 5 2"- <■ S M 53 g 0) S s ?• = '" •' I 2 tsit; 3; 11- . =1 ti I I- t. o o ' ° ^ d S S o j: s s 5 ^ ;a3 ca ■r- s -3 -*J r< i» °3 ■^ 3 § ~ "" Jh^ 0) .-o e^ a ?" S C >= '= '-' s g ? s* ^ " fe"" ,6, tiM:^ S ^ § i 3 O fl a s :^ ^ !» a «? ^, ■«; o '3 ?! O il \Zi 1e . TS !3 2 a ® ^> O ■g &^. a "O o" ■p =1 a J3 -p .5 =s ,1 ^ u § g g M w OD F! ■tfS at- O! ^ -! th wa- which r. r also cuius. iso-g-g 3 .2 a 3 P t» "^.^'^ S^-d 2s o '^ '3 ^ Left kid r and ca mly clos Right A mly occl ■Sifl « ja 13 o a "Ss t>.a« is* a o ■d-S -dS is ..=1 t»o .2 o ■a 12 fl ■? 3 ■(u-3 o a oi o ■'^ •• o •s. ^.o- ^§- 02 . a fe 5 oi >t . OS ^ 00 ^^ >o ■a £;fl b " s ca O _^. P^ •S .2^ m .o OQ •a - O ca O -a ;z; lO C9 It .O -d P o s? s^ •? d a 1^ ■3 fi M ^ "O S a . b CU §3 fl J3 Si Tl S d ^ m p. 13 "3 ^S 1 2 >,* fil a rt n J3 SI OJ q- D'-a >. 3 » 2 1 P.^ M tj i:5i 3 •d .S <,0' a si a ^=. ^ a 13 ' a b a P SS : s K ? >■ p. c ; 2^1 > 0) CQ -t-3 .S "2 s ; ■p i 3 c« o j ^ M c a CS u ■d d 03 3 ' ' ^ ^ H a o H •- •»? ■o X) a 1 1 a T-t OS !z; CO 18 ANURIA. •I xn P xn m m < S B- Si ^ S * o o » -. ^ . a "t^ o q3,-"S gr; Sixte Left nodula ing sur white. High. Ureti point o occlude Blad ing a d A "§ « .i^ >^ 6'§ ctf e3 1- ■_r c3 6s . .gsa a"^ u o 13 •' ti !.£| -C o Vio- mor- ulse, lenly othe J.^ii "C tico " .2 a at---r; " a '.g ov u -^ 0) S jD ^ C3 :§sssg P-C =3 .J! .2 S 5 «■? a 1 g S ." • K -^^ TJ< >, S a .,5- O -, D.'^-S^.a . A lent rhoi 84: on t last. . TH ■■>; ^? O -tJCO J3 »T-1 .i^ o .. a c >> O 03 fj w tJ g h* <= c: O 55 a o 1^ d •« iz; ;H t-i i' rr- m ii a m BOSS'S .2 li b a =* >> .Sua ja" d fl =^2 "|«- a Pi-^-J "S§ K a m •2|g isg '^'^t a " tt 0) ^>l ca g § 0) Q F-* „''•§ © -r -K. 5^§ S *• C "« a g 13 ^•3 '^ 3 'aT § a 1 -5 2 .«-2 2.1 g «Sa .&.;s « s s 3 =- s S as s g.J§ _ C3 -. ■3 0) .2 c3 to ,• ~ rH .. ft . g 8^ a a Hutch don Li July 4 a 1-1 ^ ^ on p . a ■a ^ =0 20 ANURIA. © 'd ,^ ;u 5i!;"'3 ■- ° " M — OJ .c ih-o bA -i S c t & a •S5. ^ = O 3 3 " 3 g ■ = 5 o -J S S -^-a 5; § £^"5 . tc 5 a g .i: jy 3 c 'c qj ■5.5: o K 5 J ^ •'- •= -^ b w ■5S-g^g'SE.2.;!>° tr. o — o S c > c ^ t: 1 5 "O ■c a " i: cj '' - c ^ t: ti =/: C „ ~ (3 Ml s t; o ,. 5; = !a>w 5; .- ,5 ij = O = -^ ;g q- c 2 ID s c .S t ^ o g o £ o. of — 5 C g C T^-^" cc B '^ »; £" 7) '£>§ s s d ^-c I'- 4> 3c5 C c 'S Co £ 0° - ^3 o tS 3 c = a : S I c tA 'I- . g S O -c S 2-0 to x: £ S £0 c S s 2j S fl a i - H — H ?* «» O - 3 S ca ANURIA, 21 p « o a f ^ o c 'i If I" 3" -S ° S'? s p-'a-i • o o •^^P g_'G ■= -2 •p ;^ "° ga 1. •<=: •c o & sa « ^ *■' rt •- ft o" ■a o o p.i5 ^ I ^ S ft * ft d "S g t cT "^ " ^ ^ c •a ° ^J' "^ "S hi) S"^c^ & .s 53 >. ; ^-a £ ft Sags ■.S Kfl-g ... : a - o -^ - CJ ^ fr -o - 0) 5; One t3 - ; 5- ft ft-e 2 s ™ O o) -P "O S *^ Jh . uri -^ -S « ^cj= ■ •ftg o o a o o ^ Ird ^ o n . 3 >:;;3 _ .— be _g :4 ft ^ hr-^ ^ ^ o ."^; « ■«"' ft M g "^ ^ o __ c p, o .M Co ft ¥ 3s g.,S Wt 0) M § S o S O fa =3 «■?. o c S d g 01 £s"Sa '3 S S o " 11 . ? ■* S J; c i5 .2 atheromatous ; heart normal. Ze/t Aiditei/ much shrunken, ed to an aggregation of cysts. No y-tissue of any kind. The smaller lined clear fluid ; the larger ones te, like chalk-mixture, containing le and phosphate cf lime. Fluid Cidney weighed 2 ounces. SmaU as impacted in the infundibulum. mperviiius in its entire length ; ■ an orifice in bladder. dne?/, weight 7 ounces, contained e cysts, the largest size of a bean, tructuro normal and healthy : le malpighian bodies contracted les thickened, and with granular a ^ 1: . o- ° H .Hx!.2 (M C !- si a Q and reduc true kidne cysts cont thick, whi cholesterii neutral, calculus w Ureter no trace Bight It four or fi\ General s some of t and capsu epithelinir It « „!a2. Sj^.-c^i" .S o & ca ts t.,*^ V Sr 2 »< Pri c ■a c ai •a oi in t) m 1 J3 -/". ft i^ " H =3 >i p j2 S ^ .. S t-H ^4 (S & Q CD " ."S .S iJ m ft 2 o S o .« - 2,2 •S^"'"S-^..-s.2g.2i ^ ^gQ'S-g-acS£r=^^2^ ^ '-' m I-- m « a? =3 T3 --- S s< rlS (^ -S f^ i: G -S & B'-s 'S -S p=i -fe" fa d ■« ft a-^ m > AH CS m m ^ O 'A 'So 22 ANURIA. death, ixcept- tained taincd much corti- iiisha- f nor- ighian ;kened ," a c tr. r: ':'. c c^ .a Is 1 HHh t o 1 S-cu-^s-^s .oJ=rt 2 |i<->( iafi5 «K >S «r-5'gfel'g *J* .a 1 1 1 — « >, - 5 c 2 C9 0) •^ !i = .. S « 3 H S s « . o •' '^ J3 »-• o ?; ^ ^ S c c £ .— ^.G CJ Ci O •- QJ £ 6 " t .2 H ■- 2 & 4 S ia £S-s i !^ IP P TO rt .^^ -, ^ -c g.e 1 ? c -ssa "t; « c £ .|lligll|2| |I|J s a illlPi.s" ■S i! ■£ -c £1 J3 & o e3 ►> S H-'a o o S (M . 0) o g. s. u .c ej r & .. i XI .0 Z -s £'Sg ■V g e e'2- le'd-^ g 1^1 •as -3 .. "-•^ ? S 'c.S^S a a^ ij e « " c3 £■5 >. , m OS ~; S S ^ 5 0) S a •' « PM SS there pting this, ito a used, •a « "-I .„• a X ii "o >> •3'= " o.a ■a t: r^ k " w P- ^ :g 1 .2 S -2 -a « « cs ^ WS-P = !3.S5 2£^« ■3=-£'^ ..i:^ >;2 r j.tciJ §--0 S .^ 5 'S -g t .2 ce^taooaa « c ^ S ? S-" p S J3 p. c8 S'^ !z; 30 ANUIIIA. 23 bt o atuval Filled aining to the Ureter adder. 03 = ,iS -e -^ ■d II 1 Ifa^- 1 .2 i 5 gg^l s> ill 3 13 43 s« (U > ■^ l-S o a) S' ^ u tJ Sa p. ■c J3 C^ •" ■g go o S .Q Ul ^" a o -. V ^m -a 5 CO ce^ o c3 rcJ «- tc ■a«' c o . fdj "S >>.2 C! C br. ^ c3 -S ■3 "^1 o S s 1 5| 1 S br.T:) 1 |o o cfl - I 1 ftK 1 'O ce (J M " "^ 9 1 a =.2 >>S ' ^ 0) , T^ -^ i5 1 •7 5-S^ 2 jo 43 ■ '-^ C o 1 o — gs o" ' sw d bfi_ M ^ O)^ 3 o ■« >. ■ i ^^1^ - 5 •? " ^^ ^ O QJ M 5^ c ._S Six limbs. Nov Nov o-;3 p,.a •^ S o fH t-^ o . 1 6 ■a 125 s« ^ i 2 ^- J) J) S b "^ ~ 5 e g^« a-ci ''— ■§ s,'^^ ^t-s fui C L~ -^ X - ontai bont ce a , and o o oj Si g «■ i:' [» s » c . S GJ oj • '^ '3 r-^ ■Cffl;; N-J-M j:-g ^ S a •& ° 5 |S§ l-i-S" .iS" 1e R .£"3 §i> S 0) ^ yi i^ "■ ^ U o n t- <« > O ■' -. i" "" .S S d Q. .. W:d •? C X'^ ^ -r-* ,. •^ S-- a r-j ce -S ^- S^M :£ 5^- tfi ^ t- 3.^^ Ph S § • a? d ■= |Zi ^ "2^° >^ 6 ■« oJ S ii = &^ a |5.5§:| . L- — ! 1 afol 1 TJ/O-Ar! l-iiney, struct ur 3 tliin shell, studded \ ontaining about one-ha aid. - .■2 o W' i 1 § ^.2^S|^S?3 ■M in p- a a .d 1 R m t, .^ r i S| i^ 8 |2 § '^5 .8 5 ^ - ="" "^ 60 .2 iS J3 S C C be S ' l"5 •d S •° -c B -§ "^ •'-= ■= ,; 6'--3 "> ^ log rt g g J3 abc III ^■5 s .§^-° ftp .5 j3 t; c P •IS 1 s s .d ^ 2J ^^-d fe.S 1 2J B ° i 00 g Bi salsa c3 ;.,;:: =f- '^ C S3 ° ■P -1 " ..^ i. 115 = =3 „- M . S >.« S !3 fe'O P.2 Ste-S-d- -c^ .2p3P-«e;.-;3 = ^ 1 •0 s g:g ad good health 8f)9, passed no Had no pain or .anse until " d 'd^d'S 0^ ■dd J'^dlo'^ |«|g|^oSa| >-g°v§^-s£iM.: S " » ^=1 il-=iS*iiil '-■ p s 3-= a '^■"goS -cociSB ;;;gS g'g 3 _ ■"S ^■"•^ >. >> ^ >>>>>-." >.!10S' [ii p,.r< d ce' CO .2 ce ce ce' gj ce -S X "^ ^ p p is p ■So > a* " • • "oc-^ -ti C3 1 gs f^ "Id - r^ t- co C ,-1 £ a Sop. ^^ cp r 7 c ■a - 5 g <« ^3 ^ 5^ T3 • P . in c3 tc . >.c4 S^-O |Zi ^t- '"' 24 O (O c - ANURIA • i2 tej= a J3l3 ^•^ a: t^ .■S.E t ^ a C c t O 13 d ^ tiu-, ed ■^ a o 2 c s 2 5 x: -■C ■C -u T) C u 4-t c §1 _2 S c be a Si «> *^ ^-^ s Is C3 1 rt bo ? Is E a cJ O C : ^5 C? !j g = ^ = £<. .1 ,0 'H ^ ^ ■« 5 g g s ^ o o .g C "=^5 .. S o I = g rt " : g M," « ■ . Pi " O -" J _^ O *H .S r— ci K^.^- ■ 3 -e oi IS fc^ « — -cc S •c) -o g B o o £ J 3 u :; >: o ' § 5 'c 5: S ■ ^ c u: rt CJ C o c3 i:\c ■3 i= '^ - 'VJ cS •*; ^-. -u B ^ tu ^ ? ^ ® o S S - o ^,3 c :z; O ^ ^ r^ >>'S £! ^ 3 o c , o '^ c '-3 o ^ c c '5 .2" S -r; 3 bt M o c 5 Si c,2 .a S "u S :i. be-* ^=^ P 'i p^ j= C3l^ w 6 > n ^^ S 1^ '^^ > J= S ■^1 in ? p ^ bcS S 5, :-'§"■• S „•= S;^ Hiss's „- 8 "g s; S •§ s -^ 'i: .a ■cop-Cgs-sE- t^.S'/:pa>SSoS c3 ^ o bo p •r S ^ c a « " « o ^■=.2 5 S ° 5! "_, CO O h . 0>^ His S "O E>a AisruniA, 25 ! g (DXJ 1 ^> « ° I 33 .c-a B-S o- o o ■ cf ?n ci -i^ o s ^ -J -c 03 g. hu.B i" o ft-a is J3 . o" p OJ O . c3CjQ)C35;oaj^u> SI g >>"«'° 1.2 o a -u C^ >. ca "^ in ^ > bftS 3 f= -i^t^ > p "3 "o o =3 CXI a r-i > H c a ^" S S? a vJ j^ O ca -rt ■3 ci rr; M rf ,a n r"r ff os_ twen tioy, beca and latur •3 m'o '>'".d "SSt^gS rr -G 0) m " ><»-pieOo 2-"'SoH §§c~5| ^S2B=: ; of age. In hi: of the right ki der. The urini lecame very paL ; it came to its Sf^icSS'^ .-<£?--E3 ;ty-four yeai I the region ard the bla he subject ira the urin( c3-g-g-g_§i -g ..o^.- liii:ili^ii| death was six severe pain ir he U7'eter tow , black, and t ^appeared fro J^ilifKitll S . 5 7^ is o cc s .s -5 --t; 3 ^-'.i 3x; a ^ I! J QJ '^ %' "a S ^ s CD ? 63 o -a !zi 3 26 ANURIA. 5=S U, 0) i . jj o r y: '- — S "2 g V 3 . o 3 ^3 ^ o g . c !C p, .as iff ■S-S w »2' " "^ att - 5 ■ J3 es ; ») = OS C o >>^ ^ C OS 3 iii^-Hs^i^ _0 B j^ ■5 = 2 = S _ c ^ C *- ^ > Tr C .1 " ■2.S s_a a '3 . O SC ! J2 o a a; o ■COX! °i^ == j: 3 ., i ^ 2 3. ^0*3 'aS'^ P O '' 4J c -s u'S © ni j- 1 " 1 tr^: j: =; ^ -~ -^ 6 a^S-c^l'-M ^ SI3 "-a^.SS a u ■" I o '. . ;. a. 5. £ a. o a o-< 3 :a .■5— • O .ag|.Sl 3 ao -^ a* Q c -= S 15 « § '35 c n L"^ « « © e?/ wholly co mass, studd ed '2}4 or.nce er, throngn n^el into a e in any pai there had be weighed ten gested. r thick as a tended with Ki:£.= ^Sa^SiC_S.2 night Aid into a fibroi cysts ; weig night uj pervious, c\ cord ; no str was though Ufl lidiie intensely co Left xiret qnill and d ,a ,'3'^ J^-- :^ S c Is S ■3 ?2 '^^ S S":; oca ,s .S a f=a;. G bi.2 .S S a'S " '' " •-§ ^^M ■>< s £ t, iS sgbis:-! s c rt g.§ ' S 1 'aTs g I e c3 Cs - s t>j m CJ ^ 'g.'5 -'S £5 a> *- o :s R caco is5 i-h: ''^^ ==^3 typica •ation. ces, ai ey not to be v-pyra oyed. '•'• s s « i 5; -S -5 Jf 23 . „ •■n •« >. .c .';3 aS tf bj -" s . ^ i; •^ 5 ~ rrt Esa? 1 > -^ .:! ~ .V. SsS § i^l^ 1 11 to t inc vate , SOI recii S; So 5;°= 2 P p c -g .2 -g t:"^ ci S g. 3i S« S " »■ • £* ■^-atg = = g a 1= s ■« & ^- ? ^ So S ? S " a) -as 5 S S s5 ffl .£? « > r' 5 4J 3 " »; 5: bD dren. sndd urine ounce 5Ut V ilept: ng ni ■p g .15 „-• S" g -a 2^.0.0x0 o.ajo Otl cto cto cto len CSC cto cto 500 iM '^ J-° S pp3 1 is |8S^„ eg ciffljoo |w &S1 oi c dt^ t "C aS P ft- § ej m . iS c « ^ T. 28 ANURIA. = S q^^r- o x-^l -oo-ag iS.S V •§11 3 " O^ ^ § ti i — " C ^^n 1 OJ -?* < P to = th. (Tro out t Ills h- .-^ "C ti>ifoc5G -ToSS?;^' o Si t-^2 !* S ■ ox: ,2 a)(u>. >,sca jC^-a S.5?-D7= cesof upon e pro- )lood, e car- 6Ub- S 4) J >- >> = s 71 o is c .55 3 o s 2 * •= .i -^ c — b tcx i°^« .^=-50-2 .^ai^ c s 5 -^ — Th utti byt roin . c a I- -3 >^0 s) j' £ ^ i ^J3 = 0.2 w—m A « d 03 13 ■M 3 ' ^ C r- : •-3 '^ 5 1 c -a o w ^ ~ 3 _^ 3 o I !■? ■-•3 "i 3^t o.a o cj S o S ° -s ? s s s .s -^ „ O O a_ -- S '"^' ■" _^ Sag '^ 2- s g 2 = ° is >> 3^2 Is ■^ ■S = J: h — 00 jr' S 2 c 5 C 10 3 "HB be c -i^ .5 'E ^ s °t c ■ 5 "^v ^ ^ C I i2 '• Q) -1 r-t hcg ° = I cj 3 S ?."•?. - .g 3 3 j; "c 'g c .,P "S'C „ ; ^ ^ c o c .c ' o > c 2; W c3 c J^ '- O 5 g ^ <" '. 5 * ^ s : .2 » S !" S T3 ==•« _ I 5 •= -g I I j= .p '3 •§ j: o.a a -^ -^ s^ Jf'JJ 0^ £ o S O O M ^ ili^T'l. 2 K-^ -2 ■" i;^ " §: fe £ —.2 §;_t/) -p -2 >, o to ■'5 IS fj c '1 i c § 2 o ^ a I S >>§ ' ^- o •" £ 1 -^ S s °* ■ S a ""« ' ^ CO M-.S s 3 O O ."t^ 5 OJ c ■^ •■ S o ^f s s a c ~-= g 9 — .■So ■" ils.2| £. = Sfe3 I. £P §■'2 I. .3-3 • 3 J3 S -5 C .-2 ro ^ 2 3 2 '- cu > '^ 3 0) ■° ^•<-' ^-B S 3 °'g S P =3 a-, " S j; ■'• o c3 > . O /• o i/ o s:-^ 5^ = =-^ 5 3 3 p< O 3 j_ fe .bo O 0) .2 a H ft as TO ca 3 . -o 5 ANURIA. 29 A-5 tCK3 txg OS C3 — .^2 g o '^ ..-■^ -2 a) to r^ c fl P. . B< Co ?3 .. .S C4^ ■S lil- "o '^ 0( ^ • r O 03 :r.-.9 c fetgsll-'Ss .^ Sl-O a, I. I >w g !h ffl IS IH t< g = Sgg5SS E S > .^ ^ o o o o o o o o -c c ^ .5 S ft fi ■5 9 A< S I s s c s s ■ s " - 3 ® S if: eg "S s -r; 43 I j; '. .-S '. O CO .S -^ 5 lo 3 J-J B ^< C »H .9 S "^ Si5 S S S bc^ & 1^ 5 q _ o _c .3 o -j:; o o h 3 (1> cu w .=; t- o h 6 >< - tf 4i h tt, .Si 01 O C3 3 ._ -a ■e i5 o.S oi a) 3 cs^f-^2 •S -a 1^ 1"^ . - -a JJ -c jj S 9 o ?J i S « o '.«■"'. ■S 5 -g -c' 5 ■S . 2 O r-; CO 4 ti 2 .S >>>>>. >^ >-,-2 rv t^ ^ ;^ ^ ;- w " . t3 CS CS CO C3 -g ^1— 1)fi| pq pt( fii ftH ^ I j « =0 1 •» 2 ^g|ofe5|H|~S|«2 ■5 o2-|^feS"|t'?Si=Sf-.o Hofeg-c^ a; a; ofc;^5 o 4J to c3 rt P g . S5 (S ID O ^ ^.S £ S? •J ? So "S g^ » o S y 0) p- O 4J . -tj r2 t3 C3 tt-I cc ^ d "■ " -S B i1 ^1s§ O -P f-ii P gc'CaboS-Si o -^ -S •" ^ o '5 « o 5" .S Mo^ g gg " =5 a 2 p. s !>. EC I^.4srgii°|gi5 ■a .5 >-. g If of >> c •.= = >, >> oSJ:oT3-sSi;""=7,2v2 uj .otioo -^co o (3.cac3 .::fc;T-n 9 ! c • o O ^f- J3 O 33 jj ta, Or-1 -c -r 5 •• fs_r •2 5 .o C (D <3t: S 5 .5 '" s| o| S a o 2 .a & t- t^ W « 11 cp bt S . !zi -ceo ■>3' 1 ->>j2 M I ess. ractec ntirel whic undiu S ■« • w 2 g o S a E ^ -O t, VJ „ m « .3 S fJ 2 ^.5 Bothki Both t d near eluded vaded rts. §8.sa .a P m 4J 1 CO t Slt .Q a -c p• o s = ^ .^ o .a 0, -s .:< O -1- ^^ i^v. y. z: u - ^o ~ a; £-^.a^5 ^ ■e S '^ ■« •- . ■§a,-^s2 Eq -S 1 II 1 a o o s ^ ti (2. s § a ^' a (U P •'tS ^ c3 <1> QJ 's.a ce n S o .3 0) > rt ^•■ fc .5 °a o -a s a cJ •" e:S t g S .,; c o t; " .S a p. o a-a o -*^ "fl . '^ ^' a -*j .3 O) ^ B% £::A -t-i -u -. f! ■" 3 . o.il O a S o >> O w a .a • tH ^H m .. .- r- "3 .S a a c3 t; O 0; 3 • •" s^ o 2 ^- 1> t-3 ^ 3-3 2™ P3 d S^ . 4d triT-l •-^ i3 ^ • .^ .a a ^. i-l tc p ffl :•« 1 p . C3 o -a ;z; 00 ■c a o !a h .la! 3 ^ S ii 8 l^tt § pS« P3 o 5 1 a .c 2 ■c "3 O .CO 1 «§ a) c: •' a -as 3 i.s 533 .S? of a "si of o •i;.-gs-»r 1 itSll 1 ai|s« ^. « ftMO 'jtj.E ^2 volved b eie amir weeks, iria ther no twit ssfifS •3 "S >. a .2 tt!E:aP >< iii a •r- a 3 .a o 02 , -a tt'c-: i p| ! ^2 if i ^i s? ! pH S "S a a° Si=- ^ P c3 t. u aE P i =2 p4 o > O "3 ^ t- 32 ANUKTA. m o m O m S P m S o I— I I I >. g. ■a s O •5 *3 ^' S cS v « o 5 i'.cg;:;; ^ O » -g J3 D 3 c, t .a c. c •J./g g "S li "Si'-Sfc u> fc'^ 'S'^SS^ ■3 •go 5 O g V, -M o£ SS-H = S) ii ■^ a o « .s , « 0. s ^ tA '^^ % -SI Si bia "-^iics >, 5 -a . ■= j;_ > M II fe g ■a fl „• tc C o 2 >. cJB ^ a . a . ■a =21 o IZi 3 w H O Xfl O t a 0) c "A s. B 1 1 a 03 i a •S = ! § 1 a a c . 1 B * •°? ^8 2 ;^ s ■a c 16 l» ANURIA, 33 J S c o S5 o 5 -""go i3 C -S O „ w ^S" Mgca c « s p: ^ -2 S ■ p4 c] t< S .9 "^ 11 °-^' o Is o '"'+3 c3 a ts cl Q) !> S J; ° o s s -^s i* S O rt P ra •" e s s S'g-'S'g -I ,- SJI g O .; ■" §g-2g|| a§: CO .,a Socc £ ; _ , aT'a • f5 «■ =1 f ' o S p ?;■; I'S -a 5 *3 a f^ g I III I _ ^' ^' J3 J= ' '. ,13 ^j -M -«3 i? Tji -M a; b- CO C. >!-— - >>£;'£;"?? C ct ^ c3 ce c3 ^ ..^ ^\ go S3 ^ ^ rt ^ 2 £°fi ^«; « § S I -e tS SJ iS >^ (v " g o rt c^ o tHCO a) J5;t; gj 'go 15 35 ago. S '^ ® 2 ^Ti 3 +J «£ 'd "^ g Big's c3 O S +-■ ,13 .^ ^ .».SSi-2 g ,a 3 d . -^ g ■H-g afe 0) =* « S "H . , o S 'J ^ _ ?>£ n F o a '^ f g o! 3 « 2 •§ " " ■" o o u .^^ 2 5 £ 5 — §■ co"° •- ,ss tl bB i dt' 5^ 3 J- a.o < •S-go S *.p ^ o p > i; a a 34 ANURIA. t a 1 8 g 1 If gg.s o ,a a B c S >-. m September 28, 18C9.— Scarlet fever of medium inten- sity. October 11th. — No appetite ; great thirst ; repeated vomiting. October 13th. — Slight oedema about joints. October 17th. — Breath and perspiration had urinous odor ; pulse, 128 ; respiration slow ; and tliere came a white, flaky substance, like soap-foam, along the border of the hair, feeling like sand when rubbed between the fingers — afterward it appeared on other parts of the body ; comatose. October 18th. — Vomiting became less; pulse better; convulsive movements less frequent, and patient became conscious. At midnight of October 18th {eight days of complete anuria) passed water judged to contain blood. October 19tli. — Convulsions confined to muscles of the eyes ; albumen and blood in urine. From this date recovery. 2 1 t'i a "^^ 1 ■^'^^ ^ Hi : rd a o -a ^ 00 a o i^ J3 H ■73 a a J3 -►^ .a t ^ .p; .Q p O .a 4J >.| rt CS S a S o C3 "tS «H "3 M ;-< & M ,a -.^ o ■c m ^.c-S C3 -r.c S P. « "cS'« a>g .a .a 1< .Q d .d O 2 .Mm 8izi.g a a . m ooo 1-5 1-H %1 S Sc^ fi w ^ S S Q >> -a !z; in "3 1^ 1 a a) a •1 s 1 a Short time before had recovered from slight attack of measles ; weak and pale. One morning, drank, as was his custom, several cup- fuls of coffee ; felt nausea, which continued for five days, at the end of which time he vomited and felt relieved! During the entire five days there was complete anuria, though he took daily large quantities of coffee, tea, beer, 2 Si Dr. Huebenthal, of Wietepsk. Hufeland's Journal der Prak. - Arzneikunde, vol. ii.. p. 124, Berlin, 1837. ■<\m. a s -a a fl 2 as CJJ o n No. 51. 5 days, then 51 days. ANUKIA. 35 "2 3^ • 55 • o rrt .a <" c " » - .. & ^ p. £ I a i § A ^ . 5L:,b-s^ Hi > , ,• a afS. ^• A g la rt fl ^1 i .■" S (-> m Pl^ ■BiaS j=i ^ ce "^ CO . |l§1a g « ^ s > S ^ f=- " g ^ -tj ,C H S~ » n 8 -o s~ 3 S a CS ^0 c3 '^ ,C fc, .,=^3 4^ ts ^ ^ Iglgo ^g^^s ^ gf s i s •«Tli a; COS §3 .. taoo -d-d h^ "-3 3 OS »l-5 ^-g 1^ >> ^ a'' m C3 rt Mm ^ ^ rtf a ■ ra c -^ -fl-a P^'d 1 1.2 ..a' ^^ ■3 a t-5 .Jd 8 "^ a r _2 "3 1 & _> fl . Jh"o • ci > in )3 »^ ^"» 1.4 \- i*''^ M •S-c - ■a »'-' fa l=< CO 10 « -a !zi ■* ^ A a p Is ■a.^ z^ ■^ «S 32 .9 " ,a „ -^ cS as 2| ■3 la a axi 38 §1 • •-rtJ gifl ■s5 M bjj <1-.3 fl'3 o'd B fl a aw a.s 60 g^a 11 § ft-'X! ii >>" S d -tS o-o '-' ■=1 »'S > J3 CS a Q m 3 s? -a |Z5 « 36 AISIURIA. >> a S ■< V a o "A w £ 3 S g . « Q t i o o •^ .u a « a ^ 8 •s. >, \ 1 CS 3 8 £ o O u 8 P. ? % % a a 3 •« ■= c 5 a u ■ !rt to fil £? s o ^■§ ^ p. E a'S S It' S Ig o g C 'O "» m W M P 1 '^ 1 1 '..c 1 1 1 5 1-S55 4J <5 +J ^ 4J 3 3 3 3 &r._ bj) bf bf •^ |-<-3-^ ■^ S fi 2^ 8 1. 1 S.'o . 'O'C c ^ a ti 1 ^ S?o -S S -o r ^ •42 a o « --p.^ n (V u S S u ■d a . » c o in > as a ^1 10 la |z; 10 "3 P5 > g a Hot-air bath : dry cups ; actual cautery ; diuretics of all descriptions ; then hydragogucs ; nitrate of amyl : rectal injections of hot water ; asafoetida ; hypodermic injection of Magendie's solution of biineconate of mor- phia (20 gtts.), with marked relief — another of 3Cgtts., and shortly after flow of urine commenced. In few hours after, same injection, same quantity, repeated. S p. S Patient mother of four children. Marked anuria ; frequent occipital and vertex headaches ; dyspnoea upon slight exertion. November, 1875. — Severe attack of occipital headache, and anuria ensiied for one hundred and eight hours. For thirty-six hours had only the severe headache ; then nausea and uncontrollable vomiting ; pallor about mouth; face dusky; tongue moist, but dark; pulse barely discernible ; temperature, 96° ; great restlessness, but no impairment of consciousness; sleepless. Anuria ceased after two subcut.ineous injections of morphine. There was at no time any urinous or ammoniacal odor about the patient. After this attack, others of shorter duration ensued (generally at about the period of menstruation) which would last from sixty to ninety hours, and were relieved by the morphine injections. Drs. McBride and Mann considered the case one of "hysterical anuria." On February 19, 1878. operation for laceration of cer- vix uteri was made, which seemed to restore natural urination. £ .a -cd at; i| Drs. T. A. McBride and M. D. Mann : Archives of Medicine, vol. i., pp. 293-301, New York, 1879. ,• 00 pL, CO ij No. 57. 4 days 13 hours, and several times over 2 days. ANURIA. 37 a > 1-i O . o fl ^ ^ S p 2 o^-e ^ ■« o 3 w ea 2 las - ca ■" o S 'i " £? 11 5'-t3 o G o ^ > +J 1 .,i a " 1 .2 ° "S -*^ ^ o s.S «■§ S|.S J* < iJ S 3 ^ . bp„ •S -^ w -^ "C s : 44 ^ S ^ -^ .S = Tj 'S c o sa " a c3 O -f a 'C ^ 5> H S ^ 2 c: q ^' -p rr-S 2^ 'd *H O 5 ^ cS ^ a S ca W •H w u o I— I I Ph 02 ft o o 02 5 iz; 15 o g •2 .5 C3 111" I 0) ^ __ ^ ex 3 2-2 =■« •r^ =^ . ^ D, g 'o bo M 3 >> oft! II la aj. a ^ (V, .-- ?* •• i^ 2 ID i^ t< S '^ ii; o s c3 '^ 4= .S .g a C bXI« d t, r- JH 1> .■s " o -^ a- § _, g o ??■§ 2 »| CJ S o rt S "' /q CD r:i rt «l rsa ' fc OJ & !^ ■£ „rg-^S' •■a '73 =8 >ij3 n3 ^ s d3 a^ , o ^ O Oi ;* ill g §•« » & » <1 ^ g' >>? 3 B 3 J3 c- a 'd a oci n o Sfl o o •3° >> ■a 2 i s .3 O d <^ •Sg 1 ^ o '. 3 I. !?>; §^ to 13 ■s .S ■§45 5 >> a. y. s-3 1-^ n ID ^ .= o a .' t>>>> s J= In ,^*^.'- 3 . Si is to criH O ^ C O -fJ o ^<«s s -s c3 a !i „ o f^ ■a . ^ Sa cs r < a .•* boooo t> izi S 38 ANURIA. i o 3 < False passages ; no severe inflammation in urinary passages ; intense hyperipmia in kidneys ; microscope gave no evidence of interstitial nephritis or previous renal disease. 1 Death. E o c, S Si c3 3 .a 1 C to a pi ■^ r- a tiS § .it O 0) =" o = 2 Hi t- « -^ ,2 S § m cSq o 2 -co CD U II Dr. Ambrose L. Ranney: New York Med. Jour., vol. xxxi., p. 4S5, 1880. o ° S i 5 '^ ® -c'C :> &£ o o'« a f^-d — « ig ^ •^-s o "^ M'^ u S = <3 2 bo — "^ d .— S^o fq a riS o s a f-.^ f^ o S 1:3 oj D. SmS ° c § « fo >. CQ S.B-^ -g W)5 " - -w B g aga, tl 1? ° ? ja t-i ii -^ 'C c ^ - rS !§§§•§ ■S.BS ^■:: - SS.s'S ■g ° «r = § 0) .^ Si O ,n ■.D 2 « c -2 = O « g 1-1 h i> . .a i^ III th -c g-2 . p.S ^ o ^ .§i is- D R^'^n 1 «• "5 -2 P. w s ^ -d =■ c o » lO p o p^ I o i o M O O I— I o p^ W • m o "■ ' " • -c -r; .„ --c 5 -s -5 c "• o 'S _. ^ -S :.igigii ^ c S I. -g 2 Mja fi. 5 ^ •" c o S -1-1 h a r- £ & =! S * g 1 r o fl " r 2 S g 8 3 £•.£ ^ d 3 tS o rt « •t. (!) W °5^ "S:!! a, S' a S a— o iwi " -a o "p a _• S5a^ c~.H^ ^■^ '&s> ^-gs.! & 0.= ^ ^ " o > 5 'J2 .00-S& m ^■'■i.s'o a «- ^S'd o ■35 g c c. s'S S ■;=; > x: ■^W'*^ m ^|2^ Sgtpg ■ii c -2 «, C 2. s ■J-. c ^ .5 oS => 5 tr. w S S3 H's. ■^ -^ 2 : |o§-.2 > = &■» ._- a ca ^ 1°^l Hg?!- 3 S ^ 2 d .3 .§ a '> ^ ^ = 3^ -c-a « >a SiJ »-> .'O * S S<-} s| "o" 2;o .§2 ^.!i >) M ^ a -S C C O CJ m :i " S" ■» 2^H IZi > o PI ... C3 e o o o a r3 ^■2 't^? •3 o * £ M e c -r «i • ■» ^ •ia ^ S .5'S> ■gg. h » ^«= IB 3 t3 CD =3 > ■- gl sg (». "1 •° >> C '43 g a PM ^ ^ (u m « a -d . ^ i^'jg m ^°° § ^ -^ a ^„'t-- c3 H t3 1 •^ -9 S . 02 g o a •,gi-o p. w S CO d 13 !zi lo ^ 'd <1> QJ ■cs > K m E^ '6>'^ c3 O %k Sg a c o-o p ° S-s » W !2i CO '^ 5^ -« K . C .-rt pq^ i2 ^"^ Cop, fi •rS'-S ft Pq a s O ot» ">> ft'-' ^ ft^ CD O O, g s ^ lO' 40 ANURIA. ■ o 3 _e8 _^ — ■- ■ -'■S ^ " § ; a ja o fc. B 3 'S u .a g ,tp a E o fl a ^ n "C to .S >'S ^ S § §■? « s' O CO 0) C CT c o > C c; . i "S '-3 ? 3 liga ' ; pc, o pi4 « 7-1 f ; !>, tjo 1 O 'C T-t I.S: ■ ■ S cJ C 13 a .oca > j: c ID 3 " i^ =! > rt 9 K- ' o !^ . a ; 3 S Jj c o S C d 0) O tS -• ■57.Q o ! .^ ■« 5 _o I -y 9 p rt ■a 03 o •"• S 1=1 o i-i .S « I 3{i cb • S 3 31 ^ to S C « g D. ji 5 § a from ano ;he author there was ruction of unctional f her. y calculut ■S^ S'^-goPK S5.^ St^o g-2 No ase lan idn» age (M true a ^ Q, m .a S fi .r *q_i 1 f.'D o.a m ^ScSPa e: S'5 .a " £i "^ a £•0 i"ll§i^" Ispil &2^IS c =1 .S ^ .ill § ^ S=5 2 '-§^5 t-.-s - a S a fl u-3 ''■5'& •? C ,^' . -r- g S l^il'fal Iney — Sc and ten icalt Som cede -Pa& Jon •^gl-lliili - „''S ~ C 3> ;zi a ANURIA. 41 p< t» CD I c« 2 oj 1^ 13 S ^ c3 >a' ^ <1 '-S S 3 g lilt's -S ^ iS*- o 8 »5 .S 0) X o to S „5 sj '3 S ^ § o a* _^ J- OJ m ^ S g 03 g Q .2 t" 53 ^ S5 ■S ° bo ^ o ; 01 > o ! "^ o S = ■2 -^ § a § Jl -^ 'be S '^ b & 3 '-3 'fe i i^ O 0) ©■^ K O S > t; d a "3 I c i s ^ 5" "S =3 -2 -g c a)> 11 -c rt a be « e3 ta CC CJ ags N ^'C sa" 02 -S bjo 3 g as '"E • O > s a < i 1 p 1 C3 s s 1 si 1 § ll .i5§| s-2 s ii:i :fii iiiMis § 2S§2 sg'^giJ^S .So""! "1- 1 IP lilli . Ill" a J ^ s|ll£l!llll|£lilallli a o a i - •- i " ,r, 3 '3 S -5 M £■£ ? 2 Ola w I files'? i^l-3l^l^si a: s.as-e^as'g^.,:ss.sgo i.S > §H«S'S'o-M.SEH'3a^^ 03 la's P( . 5 S ,.S > d m ^ S F5 r ic 3 T O O m >>-^ ^ — — m , ., n> (B ., T-i *^ i-j •^ C o a 11 so'-S > (0 s o •i p. o 01 o c3 3 O 1^, .» hn 5'r! •^'^ •5 S [^ iJ3 O > f^ ^ -13 te K S g S » P. " i » •oc 2 a> £ S cc .ii "H „ rt W §1 (^ 00 rt ° - ' ; « o H'" c3 r2 P ci 5? =^ ) = o . ■ II _c; "^ ^ ^ >. :i o zi S - o -c o •_, C3 O _, g S CJ '3) g ^ "^ ti 3 o 2..S o 3': -^ ; X O S C .- ^" jj M aS ■g oS,^i »r;2 a t-^ ci ^ ^ £ ^ ^--SSJI .c; ° C-g^ O , > p- s « S t o !^ o !» rt S 2 , ^ s •§ U3 fel 1 \ m'^^P. s 1-5 ^ gg&T; o i- p.^: 02 ClO C5 =3,-. 1-1 o |l ^ CD SO C3 (21 s 44 ANURIA. 1 1 £: E-i to : - S R S P .S O s-S 3 S'^ s o & 1 H g 'i: -u t^ a) 2 •- . - -S s'^.C § o S s as ei ii ^ J= '■« 1 o <>- o a PS a & s| >> •Ji ■a . «5 J ■> o ^ !3 „■= llili' - '5g^•§|- ts « s; ep4 «a s - " 8^1 ■3 ^ c "" m bD a W o S cl S -^ '~ C5 W c a • 15 g ANURIA. 45 S ■^' ^ w s § S |.sl §" > be o 52fl 1 ■^ :^ c ^ g f^'^ ^ 'isl < o a^'s !< 3 s ii S !ai K M g fig" = -§0 i-s^ o h1 .' - « 3 a rt fi>^-S i^ 6^:a fi %v% rt ?^ 1 d "^ ^ ^ ss- rt > tE CO p (-1 be S . *^'" ills--" •§5 (D O § s I g s .s ^ 0) « - ' o o 73 15 O 'qj S c « o'^ fi 5 "S ^ ■? ■^' s ^ s s „'S g m &•" p. c3 .2 3 'rt g g S a -^-^ t. kg or^ o 2 'd c >>•« S ^ 1^ ^ =5 m cS tr •5 o m S !^ -t^ t^' -a = S!,^ u ° o 'C « K — 5 03 ^ ■;; ffl S o " o — ^ -p a c - .■s S a ^■3 S !« E? « S o i , 5~ a •" s^ j-S o ■f^ B 2 C ■^ ■^ S-S (*>=* a m =^ ^ ^ " -^ «4-l o o o §s d i5 J3 •e is -a ^ ■3 s ^-1 ■5, "& s r- c g ^ ^ CD p _g -je ~iJ o S i ^ ■g M S S 3 S ° Ss ,y o <" ^ 2 S QJ r/1 s g s -« fe C -" •^ r^ .° s ? a O H' C 3 g- g 'O t3 ^ a o^'C a)« 0)53 p.HtSo M 3 >; ^ o o cd S t3 e Pi " " tm -in S 2 '3 >^ I ^2p |.| • Q ofHi-l •gci !^ 05 g' O § g 5 ^ S ^ to' S -3 o 2 ■" o i^- ; .51 ,£P2 9' h — 'c "-si p B tS g a C3 _ o a ft 2J .a 2 o3 a to ,Q ^3 .S CD (j3 ^ 00 iSp f-4 O) " cz> Cd Cfl TO -^ « s • R 03 <» i ft^ J2 'O to" p. ■«•- g dg p aoo R ^-^ J- T3 ■/- sg ^ a- 48 ANURIA. 1 "3 1 1 1 s lll S " o < M)a •~ .S 'E Pu &g ■5 P. ' 6 £ a. a E It tB "5 „ 5 3 a ^ c o O 00 CO t-. o "= 3 '^ ,o a ." t» C3 - .-S p oj o P a S'c-g g '■§ S E g .D '^ .S *^ O ;^-a o o g f? is" In 1837 had pain in Six months after (Octo attack, with fetid, stri urine. Five or six da ceased urinating, and th in the bladder ; had s and two days before dea became comatose. "go's i'i^'S ^ § £ as =^ t>, rt ca ^ - -« S ^ G) :j;3 T-H 4J c a 13 !3_ fi 3 .S § S o iS ^ S o g"! «' i g ^ o g "S'KiS -g s g 03 c^ OS fl rq ; o 5 &S ph Ks" !^ 00 50 ANURIA. IS-s ■as — o pg 5 b -t: ^ .? fee a en i-c oi 3 cs bii « E & S 5 £ t0_a;O o I •" c - b * O -M > o o 't: "^ — ■ .c ?s -4 SooS-S^i^l c3 ti El 1^ la 2 o P3 ^o (Z; CO ATSrURIA. 61 <^' o g ^ ''^ '^ p rS !.« 01 ^ § a fl s cj B o & o O > c o o s Q. P. 1 1 'O , H 4J si o S R S r; Ti >i ^ £1 m 5 o 3 V^ fi a oo t" ' !« tt|T3 u aB p. o a, ■a .3 c p. 13 « IS 2„ig3. Eh ta aJtS S ■£ — ■5' P c3 ^ , S >>! 1 55 '5 " ^.S ,C JD <5 ,^ ^■S' l>» 2 S ^ S 'S ° a; ^ o .S 3 H "C ° IS , P.C ^ •'S.S I S 3 a§2 flM'O ''r-i^.Sr-l'S !h* tH O o o 5 O p. .S m S ^ o CD m O oj-S g S MO-- « S M "^ s o la ^s,^ I -■ o - » 8'=' IP ill 3 .5 J2 f» n3 S ci o OJOO .Si c . 01 u CU35 <3 l5 JO SECTION TIIII^E). • There are many other instances reported in medical litera- ture of reputed anuria, but unaccompanied with such data as are requisite to render them of any real value ; for example, Dr. Boehr, Huf eland's Med. Joiir., vol. iv., 1836, mentions three cases of anuria, each lasting about fifteen days ; no particu- lars or account of autopsy. First case. — Had only weakness and pallor. Second case. — Became comatose. Third case. — Perfectly clear intellect to the very last. Dr. N. W. T. Heath, Med. Record (N. Y.), p. 350, Septem- ber 15, 1876, reports a case of nine or ten days'' anuria in one Mary Stines, an emigrant. The case is not properly substan- tiated, and the autopsj^ was by no means conclusive. There are also recorded some marvellous cases as respects duration of anuria. Among others, the following three or four are mentioned, as they are derived from respectable sources,- though the statements can scarcely be received as sufficiently strict and trustworthy observations. 1. In the "Philosophical Transactions^" vol. li., p. 215, the case is related of a young woman who is said to have had anuria for two years and one month. Catheterization found no urine in the bladder. She constantl}^ vomited urinous mat- ter, and seemed to have urinous secretions all over the surface of the body. At length a tough, slimy substance came away from the ureters, and secretion of urine was re-established. 2. Dr. J. Senter, "Trans. College Phys. and Surg.," vol. i., p. 96, 1793, gives a case of three years'' anuria after twenty months of much passing of gravel. The urine seemed to be eliminated by vomiting. 3. Vieussens., Journal de Med., gives case of a girl, eleven years old, who had anuria for eighteen montlis and recovered. 4. Another case is mentioned in the same journal, of a woman, ANUEIA. 53 fifty years old, who liad seven years of complete anuria, ac- companied witli constipation. The mine seemed to escape by the skin, which phenomenon was made much more apparent by the administration of diuretics and cathartics. In every other respect she seemed well. At the end of seven years, secretion of urine became normal and remained so for eight years, until the time of her death. 5. Dr. Racum, of Riga, Journal cler praJc. Heillcunde, re- lates the case of a child, twelve years old, with se7:)en weeks'' entire suppression and no change in health. Recovered by use of turpentine and balsam copaiva. Mr. Guthrie, in a lecture at the Westminster Hospital in 1833 (see London Lancet, 1833-4, pp. 159 et seq.), says : "Na- ture can accommodate herself for several days, and sometimes for weeks, to a total suppression of the secretion of urine." There are also some curious cases where the kidneys have seemed to be destroyed, and yet fiiiid passed off by the bladder regularly, though lacking the characteristics of normal urine. 1. In Huf eland) s Jour, der praMisch. ArzneiJcunde, ISTo. 51, pp. 3-20, 1820, Hopfengartner makes observation of a case — a woman, forty-eight years old — where both kidneys were dis- organized. The anuria was not quite complete, but the fluid passed had not the components characteristic of urine. The medullary portion of both kidneys was destroyed by suppura- tion, no trace of the original structure remaining. The right kidney had burst out into the surrounding cellular tissue, and a few small calculi were found in the pus which still remained in the kidney. The right ureter, two inches from kidney, con- tained calculus. Bladder distended by pus, and in several places eaten into. Last sickness was nineteen daj^s, and pa- tient died in full possession of her senses. Was troubled with insomnia. Dr. Strange reports a case in BeaWs Arcliwes (p. 276, 1862), of a boy eighteen years of age, who passed about six quarts of water per day, specific gravity 1006. Autopsy found the kidneys to be mere sacs ; no proper kidney-substance could be detected, and it did not appear as though there ever had been any. An almost like case is described by Faber in the Wurtzemb. Correspondenz-Blatt, Bd. xii., S. 266. 54 ANURIA. 2. In Buf eland: s Journal, No. iv., pp. 68-103, 1812, de- scription is given of kidney-consumption by G. Horst, Jr., of Cologne. He reports a total destruction of both Icidneys, and still a continued flow of water from the bladder. He asks : " Where did the water come from ? " He inclines to the belief that there may have been a vicarious action of the mucous lining of the bladder, and that a fluid similar to urine was secreted. The patient was fifty-seven years old, mother of four children ; fourteen years before she had fallen on her loins. (A false estimation of the condition of the kidneys is rather more probable than that the mucous membrane of the bladder should perform the duties of the uriniferous tubes, glomeruli, etc., etc.) A secretion of urine minus urea seems to have occurred in the following case, related by E. J. Shearman, in Mo7it7ily Journal of Med. Sciences, p. 666, Edinburgh, 1848. It is of a boy who was run over by a heavy truck, and injured in the loins. He passed large quantities of blood and urine, hut no urea ; pulse, 130 ; pain in region, of kidneys. After two days he could not be kept awake ; bled him ; Mood contained urea ; urine at same time had not a trace of it. Applied mercury ; urea appeared in urine, by degrees the coma was relieved, and in five weeks health was restored. SEOTIOISr FOURTI-I. STATISTICS KESPECTING ANUEIA AND ASSOCIATED SYMPTOMS. Dr. John Charles Hall {3fedico-CMrurgical Beview, vol. ii., p. 122, London) says : "The secreting office of the kidneys may be completely sus- pended independent of acute disease, and quite independent of any detectable alteration in the structure of those glands. All sucli cases end in coma — some with and others without convul- sions — but all have evident symptoms of apoplexy." (Itali- cizing is my own.) It will be seen that the last part of Dr. Hall's statement — that in italics — instead of being corroborated, is most emphati- cally disproved by statistics. Dr. Wm. Roberts ("Urinary and Renal Diseases," Amer. edition, p. 29, 1879), one of the most exact and trustworthy observers of recent times, says : " When even the suppression is absolute, seven or eight days elapse before the special symptoms of uremic poisoning make their appearance ; but when these do appear the end approaches rapidly, and death is not delayed beyond two or three days. Up to the rise of the proper ursemic symptoms the condition of the patient is, as a rule, wonderfully calm and free from dis- tress" .... "functions generally proceed tranquilly and the intelligence is undisturbed. The most distinctive and invariable of the special ursemic signs are muscular twi tellings. I believe that these are never wanting. Contraction of the pupils is also a constant sign, but later in development than the muscular twitchings. Diarrhoea (unless produced artifi- cially) is quite exceptional, so likewise excessive vomiting. There is never any ammoniacal or urinous odor from the breath or skin, nor from the body after death." Also in note : "This seems a point of distinction from retention of urine." 56 ANURIA. Tlie analysis of the observations •embodied in tliis little monograph hardly lend unreserved snp]iort to Dr. lloberts' remarks ; and, indeed, in many respects they arrive at results quite at variance with generally received ideas. Vomiting. — This is the most frequent sj^mptom accompany- ing anuria, although probably it is not often the direct result of it. In the 93 cases given, it was present in 35, or a little over one-third of the entire number ; 27 of these 35 instances oc- curred on the first day, and 1 on each day respectively of the second, fifth, sixth, eighth, and tenth days of suppression. Twice it first came only on the first day after cessation of anuria, and once four days after. All those 27 instances where the symptom appeared on the first or second days of suppression may reasonably be regarded as purely reflex phenomena, resulting from general kidney- irritation, irrespective of any inclination to anuria. The 7 re- maining cases, occurring after the fifth day of anuria, may, on the *otlier hand, be reckoned as one of the constitutional dis- turbances from the suspended urinarj^ secretion. All cases (7) in which vomiting commenced on and after the fifth day were fatal. Of the other 28 cases (27 on the first, and 1 on the second), 18 were fatal and 10 recovered. Among the fatal cases were all (3) of those in which vomiting com- menced after cessation of anuria. Vomiting, therefore, would seem to have no special signifi- cance unless it commences after the fourth or fifth day of sup- pression. TABLE II.— VoMiTEsra (35 Cases m 93). Day of Anuria it commenced. Kesult of Cases. Duration of Anuria— Days. First day 27 cases. . . . Second day ... 1 case Fifth day. ... 1 case Sixth day 1 case Eighth day ... 1 case Tenth day 1 case After cessation of anuria. First day 2 cases .... Fourth day. . . 1 case j 18 deaths ( 9 recoveries Recovery Death 5 4, 5, 5, 5, 6, 7, 8, 8, 8, 9, 9, 9, 11, ■ 11, 12, 12, 13, 21. 3, 5, 5, 6, 7, 12, 13, 13, 20. 8. 17. Death 22. • Death 13. Death 15. Death 4, 10. Death 6. ANdRIA. 57 Constipation and Diarrhoea. — ^Of these very little can be said, because, as a rule, the medicaments first employed are gener- ally those calculated to act uiDon the bowels. There were 3 cases, however, where no such means were used, and in which there was obstinate diarrhoea. There were 7 cases of obstinate constipation, even tliough cathartics M^ere employed, and it is in various ways indicated that, except for the use of cathartics, constipation would be, if not the rule, at least a very frequent accompanying condition of anuria. Muscular twitehings {Subsidtus tendinum). — Dr. Roberts (p. 59, op. cit.) says that " the most distinctive and invariable of the special urgemic signs (in anuria) are muscular twitehings." The analysis of our cases scarcely verifies this opinion. Mention was made of muscular twitching (during anuria) in only 10 cases out of the 93. It was observed in 3 cases after the urinary secretion had returned (in all 13). Three of the 13 recovered, more than one-fifth. The annexed table gives details, from which it would be in- dicated that muscular twitehings are not necessarily to be con- sidered as immediately or ultimately associated with a fatal ending, and that they may be expected about once in nine times. TABLE III.- -MUSCTJLAK TWITCHINGS (13 Cases in 93). Day of Anuria it commenceci. Kesult of Cases. Duration of Anuria — Days. First day 1 case Death 7. Fourth day 1 case Death 5. Sixth day 3 cases Death 9, 12. Seventh day 1 case. Death 9. Eighth day 1 case Death 10. Eleventh day 1 case. , Recovery 13. Thirteenth day. ... 1 case . Sixteenth day ... .1 case. Death 14. Death 33. All the time 1 case Recovery 31. First day after. , . .1 case Recovery 8. Third day after. . . 1 case Death 4. Sixth day after ... .1 case Death 10. General Convulsions (6 cases in 93). — From the following tabulated statement, general convulsions cannot be regarded as more frequent or significant in connection with anuria than with other maladies. 58 ANURIA. TABLE IV.— General Convulsions (6 Cases in 93). Bay pf Anuria. Bcsult. Duration of Anuria— Days. Twelfth day 1 case Death 13. Thirteenth day. . . .1 case Death 23. Fifteenth day 1 case Death 15. One day before .... 1 case Death 8. One day after 1 case Death 8. ? ? ? lease Recovery 8. Pupils, contraction of (9 cases in 93). — Contraction of the pupils seems in no degree characteristic of anuria. The records of the 90 cases do not confirm Dr. Roberts' statement that "contractions of the pupils is also a constant sign" (0^9. cit., p. 29). When it occurs it is quite significant of approaching death, probably for the reason that it betokens a serious pro- cess enacting at the base of the encephalon, and its appear- ance (when no opiates have been used) justifies more anxiety than muscular twitchings or general convulsions. TABLE v.— Pupils, Contraction op (8 Cases in 93). Day of Anuria first observed. Result. Duration of Anuria— Days. Fourth day 2 cases Sixth day 1 case Death 4, 5. . Death 8. Seventh day 1 case Death 9. Eighth day 1 case Death 10. Eleventh day 1 case Death 11. Thirteenth day . . .2 cases Recovery 14, 20. One day after 1 case Recovery 8. Sight was affected in two instances, both on the fourth days of anuria, but it seemed to be the result of a general reduction of vital powers rather than a symptom of specific poisoning or paralysis of the optic nerve. The accompanying diagram indicates that there are two days upon which anuria is especially apt to end either in death or recovery : these are the fifth and eighth ; next to these ranks the ninth. After the ninth day the proportion of recoveries rapidly diminishes. 60 ANURIA. Ptosis. — Of tliis tliere were also two instances, one on the lif til da}' of anuria and one seven days after cessation of anuria — both fatal cases. In the latter case the left arm was also paralyzed, and the organs of deglutition. Respwatory organs were once paralyzed. Organs of deglutition three times. Delirium — Roberts saj^-s, is rare, which is emphatically true. In the 93 cases there was but one instance, on the sixth day of a thirteen-day anuria, a case which recovered. Insomnia. — ISTotwithstanding there are only 18 cases out of the 93 in which insomnia was mentioned, this symptom must for certain reasons be regarded as characteristic, that is, when it occurs, as it does in anuria, with the distinctive feature of entire absence of fever. The insomnia of high- temperature maladies is quite different in character, and is generally joined with great irritability of temper and a marked disposition to delirium. In anuria it is a great rarity that sleeplessness eventuates in delirium ; the pulse is not accelerated, nor the temperature increased, and there is a calm, placid mood of temper, a freedom from all complaint or apparent discomfort, which seldom fails to excite the wonder of those who see much of the patient. I think this peculiar type of insomnia will be found almost exclusively associated with urinary sup- pression. TABLE VI.— Insomnia (18 Cases in 93). Day of Anuria first observed. During entire time. .8 cases. Second day 3 cases. Fifth day 2 cases . Seventh day .1 case. . Eighth day 2 cases . Ninth day 1 case . . Four days after ... .1 case. Besult. j 5 deaths . . . / 3 recoveries j 2 deaths , . . ( 1 recovery . Death Death , Death Death Death Duration of Anuria — Days. 8, 12, 7, 9, 8. 25, 8, 11 and 2. 4, 5. 4i. 4 and 3, 10. 10. 3 and 10, 12. 7. 6. Sopor.— An excessive disposition to sleep, without tendency to coma, is not frequent. In the 93 cases it was spoken of AlSrURIA. 61 only 4 times : once on tlie fourth day of an annria wliich con- tinued five days ; once on the thirteenth day of a suppression of twenty-two diiys ; once in an eight-day ; and once in an eleven-day anuria ; 3 of the cases were fatal ; 1 (the twenty- two-day one) recovered. Coma.— Coma is more frequent than sopor, but a glance at the table will render it quite evident that coma in all these cases (10), with two exceptions, was a part of the act of dying rather than a symptom of uraemic poisoning. Dr. Prout considered five days the limit within which coma almost invariably ensued in cases of anuria. TABLE VII.— Coma (10 Cases m 93). Day of Anuria. Third day 2 cases . Third to fifth day . . 2 cases . Fifth day 2 cases . Seventh day 1 case. . Eighth day 1 case . . Thirteenth day 1 case. . One day before 1 case . . Death . . . Death . . . Death , . . Recovery Death . . . Death . . . Death . . . Duration of Anuria — Days. 3, 3. 5, 5. 5, 5. 13. Ammoniacal and urinous odor. — The reports upon this par- ticular symptom in the list of anurial cases do not confirm Dr. Roberts' opinion that " there is never any ammoniacal or urinous odor from the breath or skin, nor from the body after death" (in Suppression, op. cit., p. 29). There are 7 cases among the 93 where very special mention is made of this cir- cumstance, and 5 of the cases were those of anuria strictly de- pending upon derangement of the urinary series of organs, and where anuria was also ver}^ complete. The two other cases were respectively one of scarlet fever and one of hysteria. In these two cases the suppression had also been complete. In all the cases there was no water received into the bladder, so that they could not be considered as in any degree belonging to urinary retention. 62 ANURIA. TABLE VIII. — Ammoniacal and Urinous Odor (7 Cases in. 93). Duration of Odor. Result. Duration of Anuria — Days. Addenda. Entire time. Entire time. Entire time . . .1 case (11 days). . . . .1 case (8 days). . . . . . 1 case (8 days) . . . . .1 case (21 days). . . . . 1 case (7 days) . . . Pter . . . 1 case (2 days) . . . to . . . 1 case (A dav8> . . . Death Death Recovery. . Recovery. . Recovery. . Death Death 11. 8. 8 White, uric acid crys- tals on face, neck, and hair. Hysteria. White, uric acid crys- tals on face and neck. Entire time. 21 Entire time. Eight days ai cessation . Eighth day death .... 7. 10.2 12. The nric acid deposits on the skin and hair, which in ap- pearance resemble powdered salt, seem no more frequently associated with anuria than with other varieties of disease, especiallj' kidney disease. Here and there, in periodical medi- cal literature, mention is made of this phenomenon ; see, as examples : 1. CannsiaWs, vol. i., p. 254, 1869, report of two cases (con- tracted kidne3^s) of uric acid crystals on face. 2. Archio.fur Iclin. 3£ecl., vi., p. 55. — H. von Kaup and Th. Jiirgensen report a case in which the ciystals were so profuse that they could be gathered from the beard. There was anuria on the day of death. Left kidney was one-half, and right one- third normal size. 3. Deutsche medicinische WocTienschrift^ p. 113, Berlin, 1878. — Dr. Seebohm relates a case (sui^posed kidney degenera- tion) of crystals gathered in large quantities so that the face looked as if jDowdered with flour. Analysis proved it uric acid. 4. Hirschsprung published in Hospitals Tidende a case which may be found translated in German in the Wlen med. Wochensdi.^ p. 1786, 1865, and accomjDanied by another case of Drache's. Dr. H. has since published a paper on the sub- ject in Swedish, a resume of which may be found in Dublin Med. Press, November 3 and 10, 1865 ; also in the Gazette Hebdom., ii., N"o. 33, p. 526, 1865. 5. In Arch, fur 2^hysiol. HeWc, 1851, 1853, are some cases. 6. Deutsches Arch, fur Tdin. Med.j p. 55, 1869, has two ANUKIA. 63 cases by H. von Kaup and Th. Jiirgensen (same in Camnstatt, vol. i., p. 254, 1869). 7. See also, on this subject, Arcltw fur physiol. IfeilJc.^ p. 88, Stuttgart, 1852. Many more cases and references could be added. Pulse. — It is noticeable that in all cases where there was no alliance with diseases indejoendent of the urinary apparatus, the pulse never at any time exceeded 99, except in two in- stances, where at the moment of death it mounted to 112. The general range was decidedly below the normal, and this undoubtedly will be found always characteristic of anuria when not overshadowed by some concurrent disease. Of the five cases showing a higher pulse, one rose to 160, but only for a few hours, the average being 90. One case of abscess gives an abscess-pulse (104 to 108), and the 3 cases of scarlet-fever show a scarlet fever pulse (120 to 128.) TABLE IX.— Seventeen Cases in which Observations op Pulse were CAREFULLY MADE. No. General Range. Extreme Range. Result. Dm-ation of Anuria — Days. 1 52 52 to 56 Death .... Death . . . Death Death Death .... Death Death Death Death Death Death Death .... Eecovery. . 10. 10.8. 23. 11. 13. 9. 8. 13. 4. 14. 8. 8. 13. 2 55 48 to 60 3 60 60 to 66 (112 at death) . . 66 to 70 (113 at death).. 70 to 80 4 5 66 70 6 72 73 to 99 7 73 73 to 96. 9 9 8 75 9 80 80 to 80 10 84 84 to 90 11 84 9 9 ^9, 96 90 to 96 18 100... , 90 to 160 Four Cases in •which Pulse Observed the Type of Associated Disease. 14 Abscess, 104 Scarlet fever, 120. . Scarlet fever, 120.. Scarlet fever, 84. , . 108 Death Death Eecovery . Death 5 15 130 5i. 9. 16 138 17 130 Temperature.— In most cases the precise temperature was not given, but was referred to as being either normal or below 64 ANURIA. normal. The 10 cases more exactly reported and tabulated are sufficient to indicate tliat one of the most remarkable features of anuria is. an absence of rise in temperature, and in many cases a lowering of it. This characteristic seems to be main- tained even when the nervous-centres have evinced a condition of poisoning. Cholera is a notable example of disease presenting low tem- perature, but in cholera the subject suffers great losses in fluids and is on the verge of, if not actuall}^ in general collapse ; whereas in anuria, with the exception of supiDression, there may be only slight notable deviation from ordinary health. Three of the ten tabulated cases show a higher range of temperature, but it will be seen that of these one was asso- ciated with abscess, one with scarlet fever, and one was an altogether aftomalous case. The remarkable temperature in this case (112°) continued for only three or four hours on the thirteenth day of anuria (its end), and under the influence of an alcoJiol-batJi, which, it is quite possible may account for the rise in temperature. TABLE X.- -Temperature (10 Observations). No. Gencral Temperature. Extreme Temperature. Kesult. Duration of Anuria— Days. 1 2 98° 98° 97° to 100° ? to ? ? to ? 99° to 99.5° 98° to 100° 97° to 99° ? to ? 100° to 112° 100° to 100.4° . . . 99° to 103.5° .... Death Death Death Death Death Death Death Recovery . . Death Death 9. 8. 3 99° 14. 4 99° 4. 5 99° 9. 6 99° 10. 7 99° 11. 8 100° 13. 9 Abscess, 100° 5. 10 Scarlet fever, 103°. . . . 9. Respiration.— This is also quite characteristic, but its indi- viduality consists not so much in frequency or slowness as in ct/. mo^^lity. In frequency it is apt to be below the normal standard, even when in other respects it resembles a " panting respira- tion." After anuria has existed for some days the inspirations are prone to become quick and fall — a little interval ensues — and then follows a very prolonged and often laborious expira- tion. ANURIA. 60 The frequency of respiration generally varies within the limits of 15 to 24 per minute. Ursemia. — The 19 tabulated cases are all those which pre- sented a complete or a tolerably complete picture of the con- dition known as "uraemia." There are other cases in the collection in which there were present one or more of the indi- vidual symptoms ; but such cases, it is well understood, have no more claim to be ranked as " urgemia " than would simple fever, vomiting, and delirium have to be considered scarlet fever, and therefore they have not been included. Existing statistics are of course not sufficiently numerous to Justify any positive deductions, but so far as they go they would seem to imply that " ursemia " is more liable to appear at a comparatively early stage of anuria ; and in comparing these statistics with those of retention of urine, "ursemia" seems more, or at least quite as apt to occur in retention as in suppression of urine. TABLE XI.— " Uremia " (19 Cases in 93). Day of Anuria first observed. Result. Duration of Anuria^-Days. Second day. .... .1 case Death . . 3 Third dav 2 cases Death . . 3 5 Fourth day 2 cases Death 5, 5 Fifth day 1 case Death 5. Sixth day 1 case .... Recovery 8. Eighth day 2 cases Death 8, 8. Eleventh day 2 cases ^ Death 11 13 Twelfth day. .... .1 case Death 15. Thirteenth day. ... 1 case Recovery 13 Fourteenth day . . .1 case Death 15 Seventeenth day . . 1 case Death 17 Eighteenth day. . . .1 case Death 18. After cessation of Anuria. 1 case Recovery 8. 1 case Death 4 22 and 4 8. 1 case Death 4 Sex.— In the list of 93 cases there were : of males, 57 ; of females, 29 ; not stated, 7 ; that is, nearly twice as many males as females. But of those cases where the anuria was demonstrated to have resulted from uncomplicated derangement of urinary organs, there were : of males, 27 ; of females, 7 ; or more than three-fourths males. 5 66 ANURIA. Age.— The period of life most susceptible to anuria is be- tween the ages of thirty-live and fifty years, as exhibited by the following: figures. TABLE XII.— Ages (93 Cases). Periods of Five Years. Hnmber of Cases. Exact Ages. Birth 5 to 10 to 15 to 20 to 25 to 80 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to Ages to 5 years. 10 years. . . 15 years. . . 20 years. . . 25 years . . . 30 years. . . 35 years. . . 40 years . . . 45 years. . . 50 years. . . 55 years. . . 60 years. . . 65 years . . . 70 years . . . 75 years. . . unknown. . 2. 4. 2. 4. 5. 4. 5. 10. 4. 10. 5. 8. 7. 1. 3. 19. Birth, 4. 5i, 5i, 8, 9. 10, 12. 15, 15, 16, 19. 20, 20, 21, 23, 24. 26, 27, 28, 28. 30, 30, 30, 33, 34. 35, 35, 35, 35, 36, 87, 37, 38, 38, 39. 40, 40, 41, 41. 45, 45, 45, 45. 45, 47, 48, 49, 49, 49. 50, 50, 50, 50, 52. 55, 55, 56, 56, 56, 56, 59. 60, 60, 60, 60, 62, 63, 64. 67. 70, 71, 74. Unknown. If now a table be presented of the given ages of those cases in which it was demonstrated that the disease was primarily and entirely restricted to the urinary organs, it will appear that the acme of vulnerable age is the forties, and that of 27 cases there were only 4 outside the limits of thirty-live to sixty- live years of age. TABLE XIII.— Derangement Exclusively op Urinary Organs (27 Cases). Decades. Number of Cases. Exact Ages. 20 to 80 years 1 28. 30 to 40 years 4 35, 36, 37, 39. 40 to 50 years 8 40, 40, 41, 41, 45, 45, 15, 49. 50 to 00 years 6 50, 52, 55, 56, 56, 59. 60 to 'lO years 6 62, 63, 64, 66, 66, 67. 70 to 80 years 2 71, 74. Causes to -which anuria -was ascribed. — In 33 cases of the 93 it was demonstrated that the anuria had its origin in some condition where the urinary organs alone were affected ; and of these there were but 4 recoveries. ANURIA. 67 DIAGRAM No. 3.— Ages at wincir Anukia Occurrkd, Rebttlting phom Various Causes, and Percentage of Deaths— (50 Deaths in 71 Cases). ^ -\ i ■ ^ m i ^ ==: m == ^ =— Birth to 5 5 to 10 10 to 15 15 to 20 20 25 to to 25 30 30 to 35 35 to 40 40 to 45 45 to 50 BO to 55 55 to 60 60 to 65 65 to 70 70 to 75 Total Number 2 4 2 4 4 4 5 10 1 4 9 4 1 ■ 8 7 1 3 Number Deaths 2 2 3 3 2 3 7 4 5 4 j 6 5 1 3 Number Recoveries. . 2 2 1 1 2 2 3 1 1 ^ 2 2 1 ° DIAGRAM TSTo. 3.— Ages at which Anuria Occurred, Resulting Exclusively FROM Disturbance op the Renal Organs, and Proportion op Deaths — (23 Deaths in 27 Cases). 20 to 30 SO to 40 40 to 50 50 to 60 60 to 70 70 to 75 27 2 3 8 6 6 2 23 1 S 7 5 5 2 / Number Recoveries 4 1 \\ 1 1 1 ° \ 68 ANURIA. Of the 33 cases resulting from various other diseases there were 8 recoveries, a little less than one in four. Of the 24 cases from causes unknown or not given there were 11 recoveries, nearly one-half. (The fact of recovery of course added many cases to this class, as no autopsy served to authenticate the precise condition). TABLE XIV. — Causes to which Anuria was Ascribed. Causes. Nnmber of Cases. Died. Recovered. Uraemia. No Uraemia. Not stated. Calculus 15 16 1 2 1 1 1 7 6 1 5 2 1 1 1 7 25 11 16 1 2 1 1 1 6 4 5 1 6 14 4 1 2 1 2 1 1 1 11 3 4 1 1 1 2 2 1 6 6 12 2 1 1 5 4 1 1 2 1 1 2 16 6 Calculus, with previous destruc- tion of one kidney Cystic degeneration of kidneys . , Renal artery obstructed Renal abscess Ureters, valvular occlusion Ureters, occlusion by renal artery. Scirrhus 1 Scarlet fever Measles Cholera 2 Hysteria Spinal irritation Traumatic Calomel Corrosive sublimate 5 Uncertain or not given 3 Total 93 21 67 24 20 5 54 13 17 Previous destruction of one kid- 3 Autopsies. autopsies. Of the 93 cases there are 50 reports of SECTION FIFTH. EESUME. ALIMENTARY TRACT. Vomiting.— This, upon tlie first or second days, lias no characteristic significance. After the fifth day it is generally the result of a profound constitational disturbance caused by the suspended urinary secretion, and there was, amongst the 93 cases, no instance of recovery where this occurred. Constipation is probably the rule, but the almost universal early administration of cathartics interferes with observation on this point. Diarrhoea is exceedingly rare. NERVOUS ORGANISM. Muscular twitehings {sicbsultus tendinum). — These are mentioned in 13 instances, 8 of which (nearly one-fourth) re- covered. This symptom, taken independently, seems to express nothing decisive in way of prognosis. It is more apt to make its appearance after the fifth day of anuria. General convulsions very seldom occur in uncomplicated anuria, and when they do it is nearly always a part of the process of death. Contraction of pupils appears to be an indication of serious encephalic disturbance or lesion, and is an unfavorable sign. Ptosis, or paralysis of any kind, generally associates with a fatal termination. 70 ANURIA. Delirium. — The rarity of delirium is a characteristic ; in the 93 cases its presence is spoken of but once, and in connection with a Case which recovered. Insomnia. — This, associated with a strange, unnatural tran- quillity^ and sweet, cheerful temper, is a remarkable symptom which I have never encountered in other maladies, nor have I observed it mentioned in the literature of medicine as con- nected with other diseases. I should regard it as one of the pre-eminently characteristic accompaniments of anuria. Those cases in which insomnia appears after the fifth day of anuria are amongst the most fatal. Sopor is rare and without special significance. Coma seldom if ever occurs except as a part of the act of death, or as a symptom properly belonging to some malady, other than anuria, from which the j^atient may be suffering. Ammoniaeal or urinous odor. — There were 7 cases in the 93 ; 4 fatal and 3 recovered. Uric-acid crystals on skin and hair. — There were 2 cases : 1 death and 1 recovery. These signs, therefore, are not aids to prognosis. PULSE — TEMPERATURE — RESPIRATION. Pulse. — A slow pulse — frequently from 15 to 25 below the normal — is a marked characteristic of anuria. Temperature. — A low temperature is equally characteristic with a slow pulse. It is not beyond the normal (except it may be in the act of death), and often falls below. Respiration. — In a certain percentage of cases the respiration is also characteristic. In such cases it is generally slow, the inspiration short, a little .interval ensues, then the expiration is prolonged and sometimes labored. BLOOD-POISONING. So-called uraemia. — When complete " urgemic symptoms" appear, death generally follows within forty-eight hours. Of the 19 cases, however, there were 3 recoveries. ANURIA. 71 "Ursemia" is not frequent between the fourth and eightli days. So far as my investigation and experience will jHivnut me to judge, it is not as frequent in anuria as in retention of urine. (I use the term "ursemia" in a conventional manner, as conveying by one word a 'certain generally recognized |')icture of symptoms, without thereby committing myself to any etio- logical theory.) Sex. — Of 83 known sex there were 56 males and 27 females. Age. — The age of greatest susceptibility to anuria is the forties. It seldom occurs before thirty-five or after sixty -five years of age. Duration of anuria. — There seems to be two days of natural limit for anuria, upon which it is more apt to terminate either in death or recovery ; these are the fifth and eighth. There are several cases which seem properly authenticated, of complete, continuous anuria of twenty days and more, and one case (the case of measles. No. 61) of over fifty days. The other instances of alleged great duration have not the nature of testimony. Eleven, twelve, and thirteen days are not extraordinary periods. The etiology, and modus operandi, in a certain proportion of cases, such as in scarlet fever, measles, hysteria, etc., etc., are most certainly questions open for further inquiry. That there should occur a simultaneous paralysis of both kidneys is something highly improbable, nor would this pre- vent the flow of water ; a spasm of the renal arteries, or their branches, might do so by reducing arterial pressure, and the same result may follow serious interference with the nervous system, as, for example, through irritation of the pneumogas- trics, or interruption of the spinal cord or the sympathetics ; or, again, any change in the composition of the blood, or any mental emotion which would serve to reduce the force of car- diac action. Mental emotion, unless extreme, would have the opposite effect, as it would increase the force of the heart's action. 72 ANURIA. The demonstration is well known by the profession, that when arterial pressure falls much below 44 mm. of mercury, all flow of urine ceases. Upon the physiology of urine-secretion there is a very inter- esting article by Dr. P. Gruetzner in the Arcliw.filr Physiol., vol. xi., p. 370 et seq., Bonn, 1875. See also Smiedeberg : Lud~ wig's Arheiten, vol. v., p. 41, 1871 ; and vol. vi., p. 34, 1872. Indeed, there is no paucity of literature upon this topic. ANURIA. 73 H H m M H s -s I'g ?>3.S .ti •s m 5- S •8 ri r/1 'So d ^ S rf p g -a u o o ^ B ^ 1-1 a o -t-> rl 5» g > -t-j ^ 1 'S :§ 1 1 g M a o ^ o c 5 8 >> 2 .a fl -2 s -P « O o =* 3 -S jI ■^ ■H~ o ■o ;fl p. X .y Fi -S m c ^ >. 43 rt 11 t>, •rl 6 Xi S ■^ ^ •jopo suouun JO iTJOutuotuiuy •smo; •oSuEH •oSnc'JI arao.T^xfi — aan^Biaduiai •aarHBiadcaax •SSS^XBJBd •po^oajB !(q3is •paioaBi3sn(JnITO0ji^ O tH o O li-IO O tH-tHC> tH , O •jCsdo^ny •/MAOoaa "S^'Ba; — T3T.I -nny jo nojctBano; ■aSy pnB sag (•jBioadg) •as«o JO 'Oil (•XBlox) •as«o JO 'ON O^O-rHrHi-lT-ITHT-ti-lTHOT OOOTHl-lT-lT-(T-(THT-tT-tO»HT (iHOOOOOOOOrHOO iO co:oco'dcoco^HGOJOCo2iooo:o T-l 1-1 T-1 S (TJOJl-l T-1 S i-i C* CO -^ lO » i- 00 05 O T-l (N CO Tf lO lNC0'^10»t-000:Oi-'5VC0-*>0 74 ANURIA. ^3 h 6 ^25 Q u 1— 1 :ii M r^ o w H o 1 fe H o m 1^ Q o 1— 1 o ^ H :c < W ft W r/j [^ ^ O O 1— ( H ^ U a (^ f^ M N H H 1—1 < is: H rri r/; 1 P 1 h-l f> P >< <1 w o ^-) m -^, H . o H CO 1 •joi)0 snonun. aoiuotiiuoiuuiv I o O O r-l - oo •SIUO} ooo o o o oo ! TH OOO y-t 1 ■aSuBy omaiixa — 08[n,;[ o ■ sis g : : ^ §g : : •asiiia oS gJ s§ g «0 5C t- •t-QO — aainwadiuox o •aan^Biadiuajt =1 ■Bas^lBaBj o 1=^ ..,• s .2 o -eg O oo : •pa^oagw iHjSig o -^ : O •pa^oase siidna: o in rg th o o \^ •BtnoQ o . o o o o O oo '.r-l ; O •jodog o O O O T-l th th o o : ; ! ■eiuraosni o : T-l ; TH T-lrH TH ; i^TH •suoisinAuoo o H O O O O • tH oo -tH ; O •s3nt -HO^iAix JEinoBiijv o n3 >, .g 5^ J 17th 1 day. ill •aqOBpusH OlH ; th o : o •uoi^Tjdpjsuoo o : ■ o o rH : : : •Sapituo^ OtHT-lTH tH t-(00'. r-tTHTH; o H Q •jCsdajny Or-lrH 1H T-l tH iH r-l tH i-l tH r-l t-( tH tH rH •q^caa Or-lrH rt T-l T-l tHt-ItH y-l tH tH rt tH t-1 tH •jfjaAooa'ar THOO OOO OOO O t-ItHOOO O -nuy JO uoj^jBiuo; O l- '-' 'd C3 TOthoo 13 inoootth ci5<^'.o»Tr»o CO TH •aSy paB xag CTcvI T.T o3 (N ^ inioo -r o tr? -r r-i t-^ o S^TO t-io o ^Trmi3t-oio»-To^ (•[upads) •asBQ JO -OM T-lC<«!-<)< lO «Ot-0035 0i-l'M«-COO •asGQ JO -ox 1 Ot 1 -0 -It 05 O T - TH (N 6 H (NO Vc ? h 3 Ob-COC ■Jto 5 5 ANURIA. 75 tH O 1— ( m i-l O O t2 • 5 iHt-I ■ ^^ rHiH ^^ OO •rH(N gl? iHr-l-rtT-lO O T-l OOOOtH :=» O coooot- :;5 jr; 05 i^O O c>. «D lO CO ^ yS lO -._/ ;il g ^ £p=l p=; c^ tH!NM-*iO to £- COOSOr-IIN CO 3" CO CO "^ ^ "^ ^ ^ iH OO ! is .T-l o i CO o ! o ". : lo .' ■ ;o : ; P5 f-tj OOO :th ;■.<=>:; 1^ P5 : ."o ; 1 ° i^ : : o CO . :o :-iH ; :- ; ; o ;o ; ". .•■t-IOOt-I Otic >^o^ TH r-( O T-l O tH OOTlOr-(0 oq i-lff*C0^lOffl lOto i-oo3;o •^ TS"? ^ -^r lo 7G ANURIA. o 03 •jopo snoOTJfl JO iBOBiuomuiy •SUJOJ •asina — aan;«aadwax •Oin:}T!Jodm8X •bosjCitsjbj ■paioago ^qSiS •ps^oa^T! sxidnj ■coioo ^^ •aoclos •■Bxumosui •snoTSinAUOQ •s3ut ■aqoBpcaH •UOHBdl^SUOQ •SanitaoA 1H -4 H < •^fsdo^tny T-I3000 •q^caa •^3AO0a'!£ OOOOO -nuy JO uojiBanci sJ^-^ii •aSy puB xag CO TT CO lO ^ S» ICCOCO^ a [i; ^ ;^' f-i Cxwpadg) •asBO JO -OK T-KNCO-fiO ClB^ox) •aSBQ JO -oii (?> CO "^ ir 5« it 5 3 I^P^' o I— I H I— I I— I P-( 02 o - — i- o o •I-l s 1-1 c 3 - tH — i- r-l - O 03 tH 1-1 c § ANURIA. 77 o o o - lO 4 - ■H IOtHiHtHt OiH OOOOO >o>o woomTf, 05 1£5 C5 '-^O 00 »0 tH 5^ CC "^ lO CC t- « to •* lo aD t- 00 (O ;d :d ^cscc ^ ;> M H o o o M o o o O T-(1H O o o :o o o o ; : r-iiHo : : : CO ; § n Ik •0 ;0 • ; " ! § \ : : :gg • : : :| : : : : :7 : O '. : : '.a* ' : : o :o : : : :o 1 : ; o io : ; : lo tH : : o ',oo : : : :o : o ! : : o :o ; :r-i»HT-( : '.<=>-<-i => : : o '.o : ; : i i : loi-i ,r-l : OlHOrH IrH ; . ; !=> ; ^ : O ; : ; o :o : th : : : : : :o : : : o^noo :::::: :o o : : : : : otio : : : :t-i ; : :o : : ; otho : ■.■.:;:; :o T-lrH-rfi-lr-liH'i-l Ir-I Oi-IO li-l Ir-dH In ■.iHOrH rHi-IOOOOO JoOOOOOOOOOrHr-l :0=>0>-t T-liH IH O T-l O O :t-IOOOOO T-l T-IO Or-rt rti-lOOrl O O O T-l O T-1 rH ;o r-fT-1 T-i tH T-(^ Ot-It-i OO OOT-*rH O o5 ,H(Nco-*m c^'»=^- = SSS3SS?;S5S«ol55S f£? 3SOTH5J CO 5.t.£-l.-i:-l-OOOOQOOOOOQOQ00000003:~. 3: "0 33 78 ANURIA. &^ ?: >, >> >. >> ^^5j> ^ a, o, o. c p.s,Si p< o o o o ooop s s P B;;^ C^Q fl fl n »2 o "3 o a 03 g.- ; •V '■ >. !>. ^S ^ St-< s "c CO r;'-"0 03 "^W 'O ■a a to (?« at rilOrl t- o iH C40? ^lO ^ I— CO C^CD i-i C* -TC ■»-« ? ° ^ C cG > Q " ^ ^ a a s Pi -c 'O ° ■a .-a -d Td ■a > > > 1 >: 'Z ^ s- > > > n: ■:: -e •a i 5?S >>> I& .•^ 5 P K 0) P ,&l ,i'-B > d) >■ S3 rt d c u IB S =c S 05 'c P >i r/T 3 s t, 1: y S cr ''S 31 --a P '>>»>;» >;»>; 1 r; ^ ^ V; rf !3 .r- p ^ ^ S :: .M p !3 p !3 .« ' <^ .- ^ _^ ._r '^ (B C o'f 0) 3 nz: ^ P 'd CJ c c C s ■3 Os o-a ■^ a = 'C 1 Is 3-5 -J o-j ^1 a; ':3 -« ■^^ c Q ^ a C C c C 6 « 0- cc ^n' > a- p. P, tc >r T X p. P 4 i.- '^ S P "" m f^ i ^ (= S oT "^ P P 0. - 1 - cc 3- fi fi 2 1 > _>< 1 IN c ' % p c - P S' 1 "3 a JE a X > t ^ c V CT CJC rt rt ■^ " =«: C c ^ 1 p c %■ f- "o > •c ,;; > 1 r- " 1-3 c s c £ i> pi C3 Pi C c c c "c >» •So; 1- ■ 1 c w is c !?' (£ > 35 c p" cr s as a > c p c _p P> ^ 1^" C c ;^ « c .J r a cot? % I I c 1 1 g aj 1 ^ 1-^ E^ C" K tE ""(5 f !z ^ s p f^ 1 "C 13 ^a c n PI CS iS C3 £ .J „ s' a ' i 1 c a P <3 m S -a i 'Si 1 c 1 V p P ^ b. _P ' -2 J t ) £ ^ 1 1 1 c 1 >■ 1^ 1 p p: !z p P f' (i (S E- rt rt 7 ■^ in IT M c c= "^ t- p IT "" 2 t- tc IP 5C TT '^ % > S (i (i< ^ ^ ^ p % ^ % 1^ S ■c c K sc > ;>^ c- p- ? > > ?• 1 > ' > ■> K -C ^ p> > ^ c T^ t: >i !>i a -i t: (S (c t: c3 cS fC t: c c -c IT £- 1- CJ cr ■C -C ;c CT ■^ " ■^ 10 p- ^ : g ^ S .■ £ a ]^ ^ - C ■- c ] ^ S- T £~ £" a c (^ ^ w "^ >c tr ir- cc o- (33 ^_, (D Ov (N (Tl Oi c?) (M CT CO er 1 O o 1— ( P cc fi OQ o M H ^ O H ^ ^ O fi < w I— I Pm o o ^ iz; '^ u .^ o a ■-' ■? s _ p" g 0-3 S ^ „-■ PI 3 -u p 4-. ti J2 P.J3 a S S?Pl g s 80 ANURIA. o O I xn Ph ^ H -I CO s ^ I ■< H S f^ o Ph CO gp A. .«2^ ft "■-^ cc M H CO O o ^ & p. •« 2 "5 s o el « - -^ ^ C3 lU O to a '5 S . •c *^ O o ^1 c u t^ ■— o S g •u ^ P tp CO i •a !»' c ►^ ^ 3 rt P.g O ■« ""-5 G) QJ ^ a ^ o 'O I ■e ^ o a p< > ,a M C3 W «5 g «■ a >> g s s s<) •a R lO a-i ^^ O Q) 6 S ^" u 3 9 1 fe> E? ft P. S o 3 a SI I' .•» ,<: A C fi « . u = -o ^ ^-s -' — ' a 5 t- 3 CO -^ iO O l- ^ ft E u fl gs ■ •- X X P ffi c C c !2i tZi S s OJ 02 ^ S ft >< tf ^ 1 pa - (Tf N 4^ H ^ M "* W (V ft t-5 § « 1 i 02 a cs'^. be CO Spg^- C s-5" «. 1^ * f fn t: 4> bfl S S c - to" •3 ^ p- n IC •V p^ IS p t > •z 13 a. OS ^^ • - — s: •^ ANURIA. 81 Ka ft? o !2;|3 CO . P< . -13 r "■■§ is O t- t3 § o r g .i « 2 « = B « s;^ e4 "Cor; o m a a B ^ > ■ p, p. d ci P^ O O O O P. 3 a c 13 _0 d cS OJ (5 a o o o o a a a a a 0) 0) 0) a; RPfifi ^ fe -S 3 o o ^ ^ ^ ^ ^ d cs ca ca a p a D< bo o o o o S 8 8 8 8 m a £ S S _ o o o o 'g wwww e3 et»i q_( SH en O O O O 1^ C S3 B a ^ b ti ij b 3 3 S d Qj o o o o g 1-3 l-S r, h, .5 TO .2 .2 .S .2 jJ 00 4^ 4J +3 4J "d ^ '^ *t^ 's^ *C > > > > 2 2 3 3 flj o o c o c' ^^^^ o rt ei c3 d QJ 13 1^ Tj TS 0) ^ t. JL, I, R fiOPP (T! TO « TO ; 3 fe' 1^ g Em ^ ■ca-f.- f- T-l (W TO -^ IC5 (N TO -rrif: as IZi' !zi CD -J °° o ■" > j: Q) «tH O (3 six'-^; ?C^ s s s 2f5g > -= 5- (N -C - > (J 13 ^ b a t 1-3 < i Is ^ -a c S o -4 JS o >> 4J B o Eh < >< 1 M j 'd . t>> t-> o >> >> ft ft ft a >! * 2 2 a s c 3 « 6 « c a e ., V- ., ... , ., An £ j; ■a .= g^ s s ? g S pej fi n C Q O c c o c !z;^ ^.(A >^ 6^ >. t^ t>. a E E s S s E C © ■c •c T .£=£ J3 .c j:: X .c o papq m P3 M K W » c" . - r 1 t- - _' H O.i '? t- ■i ■al c « y 1— 1 o 'g y ft 'i 1 ft .. 1 1-1 en «£: ^ . 3 ft o L. :s > 'U Is!- p '-' g JJI hn . *" ^ o o O ;, vol. vii and Surg 835. and Sill" 2d edition . Gazette, and Surg. 831. Reports, Poisons, rt t-r. '"' -C • m • Q Pi o o 1 ^ O ^ W 1 O fC ^! •="^.2 .o ^. •<; 5 "2 'n Sh H l-I H o Eh C a a 13 (fl .S "3 o e' i Tl |4 %-t o .a 5 1i 1^ > 5 cS ft C3 D o: lO ,^ oo ^ lO 1 M;^' fe fe ^ S3' M s, >1 >» >) >> t>l >> -c-c •c •a ■a ■c to lOlO CO 00 lO ij' lO ^^ _^ ^.^ ^ ^^ ^^ o '— '^.^ ' — ' '?> CO _^ 1- t- r,. ' •■o ■s to -.0 ;;^ CO ® 1 ^ ft ft ft ft Q, ^ 5 3 53 5 ft 3 3 C 3 3 5 "^ a « « ce 3 o o c o c~ o CS C C ^ C C ji..CH o! OS aSeao cj u C 0) CJ o c Q) !? Izi • c! 2^^c: t- » SSJ S lilS'feS&^fclS (S T3 c;'3c8e?'3ce 1(5 ,-( cej (^t c6 x> xi -^ a C5 o .^'^lX■^»n;o^- CO I- I- 1- 1- 1- 1- 1- 1- ANURIA. 83 e^ ja j= J3 i^ o ci 03 rt ci o ft;ft;(i;ft5ft;Rfifl Oh fi il ^^-a i§ iz; :: izi !z; :^ > 4, i -a S E£g « g; h in ft fL| fL| io tZ. -^ ;s !^ p ■-s s^ ^ fl «? «? -r t-> t-.GO ^ ^ a o > • ^ 1-5 .2 = 1 '^ss" " 73 O r-" ° ft^ S b^ a .OH iS Ph H a a IN , , . > c^ S ft .•n'oioi o^ ft i>,^ 33 fe y QJ O ."^ ^ • . CD D a g g^'o^ hi P3 < "S =5 -y jS ^ o'-ip'-' rt Hi ra g c a ^ 05 r-- t:: 13 f^^ fl 0) !C^ !3 n r> f-i f^ o3 T^ ■g-^gft 6 1 t3 q5 cs o i § ^ , -S »-3 J a ►^ 11" W "o H S o o ia o 5«o o -a c c |fl| S ■ tc MS '^' '^' i ;- "3 X ^ s Ifil S e a a la 03 a 5 a; o g_ C5 p: <1 M P3 (S e « tidMMttiPC « w ^ E ^ c o o . : E : ^§£!g£s 5D O 1£3 in i^ a f^' s ;§g&;gag g 1^; H 1-1 T-l H, iH i-( iHrt(NS^(N^( T-l Oi ALPIIABFJICAL LIST OF AUTHORS. WITH INDEX OF CASES DESCEIBED BY THEM. NO. CASE. ackermann, thomas 36 Alexander 80 Allbutt 92 Anglada 16, 70 Archer 48 Bagshawe 20 Bamberger 48 Bartels, Carl (Prof, at Kiel) 13 Bates, George F 46 Biermer, of Wiirtzburg 48 Blacklock, Archibald. . 66 Blane, Sir Gilbert 69 Blasi, S 10 BoEKB, of Berlin 50 Breslaeur, S 7, 8 Brown, J. D 77 Burton, J. W 41 Buxton, B. T 79 Carrier 91 Caspar 68 Clanbry 14 De Leon, H 53 DiENINGER, G 49 Doering, of Ems 23 Drysdale, of Liverpool. . .53, 54, 55, 56 DuBuc 90 DuiGAN 39, 82 Dumas, Adolph 84, 85 NO. CASK. Edwards 31 Fontaine, A. W. 59 Fowler, Edward P 26, 27, 33 Fuller, St. George's Hospital 6, 11 Gallini, of Bresciano 78 Gardlner 42, 83 Gautier 14 GiNDROD 19 Griscom, J. H 12 Hayward, George, of Boston 93 Hachenberg, of Coblenz 35 Hall, J. C 88, 89 Hamilton, Robert 5 Henry, William, of Manchester. . . 64 Huebenthal, of Wietepsk 51 Hunstone 83 Hdtchinson, Jonathan ..3, 18, 38, 87 Heathcote and Roberts 32 Jeaefreson, J. B 73 Jones, H. Bence 4 Knaggs, Samuel J 86 Mann, M. D 57 M.'VRVEL, of Ambert 71 McBride, T. a 57 Mellor 30 86 ANURIA. Millard, Henry B 58 monpalcone ■ 44 MonRBECK •. 24 nunnelly 21 Paget, Sir James 25 Plain, of Maidenhead 45 Ranney, Ambrose L 60 Rayer 28 Rensiiaw, Herbert 39, 42 Reynolds, H. D 75 Roberts-Lloyd 43 Roberts, William. . .10, 30, 31, 32, 37, 43, 82, 92 Russell, James 72 Salgado 2 Soutuey 17 Sue Symb, Sir James. S.G 81 63 76 Taylor, Alfred S 07 Tekling 29 Tenneson, M 1 Todd, Robert Bently 34 ToTT, C. A 61 TovEY, Henry L 74 TuLPi, S 9 Unkkoavn 15, 28 Venables, Robert 65 Ward, of Bodmin 62 Whitelaw, William 47 PUBLISHED BY WILLIAM WOOD & COMPANY, New York. LECTURES ON LOCALIZATION IN DISEASES OE THE BRAIN. By J. M. CHARCOT. By E. P. FOWLER, M.D. 133 Pages, and 4S Illustrations. Price, $1.B0 PHYSIOLOGY AND HISTOLOGY OB" THE CEREBRAL CONVOLUTIONS. By CHARLES RICHET. By E. P. FOWLER, M.D. 170 Pages, 21 Illustrations and. Plates. Price, $1.B0. ANATOMICAL STUDIES BRAINS OE CRIMINALS By MORITZ BENEDIKT, of Vienna. •m-A-asrsXi^TEX) eu,o3vc the G-Exs-nvcj^isr By E. P. FOWLER, M.D. 185 I*ages. Illustx'ations. JPrice, $1.50. C^y^ ■ d::' .^^^/ ^ '^^4,^-/^,^^^2:^=^^=^^=^=^=^^=^ ^X .t^^