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. 


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One  kidney  reduced  to  size  of  a  bean  ; 
the  other  greatly  hypertrophied,  and  its 
ureter  exceedingly  dilated  down  to  its 
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several  litres  of  urine,  and  the  secretion  again 
became  normal. 

A  few  days  after  was  attacked  with  fever 
and  died. 

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of 
.a  ^< 

Anglada : 

Rccueil  des  Trav.  de  la 
Soc.  Med.  du  Depart. 
d'Indre  et  Loire,  Tri- 
mestre  I.,  1843. 

1^   £ 

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atheromatous  ;  heart  normal. 
Ze/t  Aiditei/   much   shrunken, 
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as  impacted  in  the  infundibulum. 
mperviiius  in  its  entire  length ; 
■  an  orifice  in  bladder. 
dne?/,  weight  7  ounces,  contained 
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le  malpighian  bodies  contracted 
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ANURIA. 


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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. 

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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. 

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CJJ 

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No.  51. 

5  days,  then 
51  days. 

ANUKIA. 


35 


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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 


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II 

Dr.  Ambrose  L.  Ranney: 

New  York  Med.  Jour., 
vol.  xxxi.,  p.  4S5,  1880. 

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Bromide  potass. ;  ca^ 
thartic. 

Fifteen-drop  doses  fluid 
extract  jaborandi  every 
three  hours ;  milk  diet ; 
hip-baths;  hot  fomenta- 
tions to  back ;  saline  ca- 
thartics ;  bismuth ;  hydro- 
cyanic acid. 

Alcohol-bath,  and  bot- 
tles of  hot  water  to  feet. 

S 

s 
s 
Si 

Patient  greatly  prostrated  ;  pulse,  90  ; 
temperature,  100°;  pain  in  lumbar  re- 
gion, extending  down  both  groins. 

March  24th. — Ceased  to  urinate  ;  head- 
ache ;  nausea  ;  constipated. 

March  20th. — Bowels  had  moved,  but 
no  urine  nor  desire  to  pass  any ;  slept 
but  little;  used  catheter,  no  water  in 
bladder. 

March  27th.— No  change,  except  more 
nausea. 

April  3d. — Had  passed  no  water;  tem- 
perature, 100°  to  101°  ;  pulse,  90  to  100. 
The  only  other  abnormal  conditions  were 
insomnia,  restlessness,  and  occasional 
muscular  starts. 

April  Jth.— Drew  with  catheter  four 
ounces  of  urine,  and  no  more  was  ob- 
tained until 

April  (ith,  on  the  morning  of  which 
day  temperature  rose  to  112°  ;  pulse  to 
100,  feeble  and  regular;  mind  perfectly 
clear.  One  hour  after  using  alcohol-bath 
came  a  profuse  perspiration.  In  two 
hours'  time  the  temperature  fell  to  100°  ; 
inilse,  80.  In  three  hours  drew  off  eight 
ounces  of  urine,  and  the  flow  thereafter 
continued  of  itself. 

In  five  weeks  the  patient  was  conva- 
lescent. 

There  were  eleven  days  of  complete 
anuria,  then  a  floio  of  eight  ounces  of 
ivater,  and  another  complete  anuria  of 
tico  days. 

Note. — The  remarkable  feature  of  this 
case  was  the  excessively  high  temiiera- 
ture  on  the  eleventh  day  (112°  1 ),  in  which 
respect  it  differs  from  all  the  other  ob- 
servations collected. — 1\ 

i 

5 
O 

1 

11 
It 

Dr.  Sue : 

Michigan   Med.   News ; 
also,  Louisville  Med. 
News,  vol.  X.,  No.  7, 
p.  83,  1880. 

<3  02 

(i;  § 

No.  and 
Duration. 

No.  81. 

11  days 
and  2  days. 

ANURIA. 


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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 

0 

3 

3 

2 

3 

7        4 

5 

4    j      6 

5 

1 

3 

Number  Recoveries. . 

0 

2 

2 

1 

1       2 

2 

3    1    0 

1    ^ 

0         2 

2 

1   ° 

0 

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 

\\     0 

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 
0 
5 
0 
0 
1 

0 
6 

14 

4 

0 
0 

0 
0 
0 
0 

1 
2 
1 
0 
2 
1 
0 

1 
1 

11 

3 

4 
1 

0 
1 
0 
0 

1 
2 
0 
2 
0 
0 
1 

0 
0 

6 

6 

12 
0 

2 
0 
1 
1 

5 
4 
1 
1 
2 
1 
0 

1 
2 

16 

6 

Calculus,  with  previous  destruc- 
tion of  one  kidney 

Cystic  degeneration  of  kidneys . , 

Renal  artery  obstructed 

Renal  abscess 

0 

0 
0 

Ureters,  valvular  occlusion 

Ureters,  occlusion  by  renal  artery. 

Scirrhus 

0 

1 

Scarlet  fever 

0 

Measles 

0 

Cholera 

2 

Hysteria 

0 

Spinal  irritation 

0 

Traumatic 

0 

Calomel 

0 

Corrosive  sublimate 

5 

Uncertain  or  not  given 

3 

Total 

93 

21 

67 
0 

24 
0 

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. 


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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 

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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^ 


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