kidneys is one of the affections cured by their use. Chalybeate and
alum springs might be expected to be of advantage by the local action
of these astringents in their transit through the kidneys, and they
frequently are. The following case illustrates their efficiency: The
patient was a lawyer who consulted me in June, 1881, at the suggestion
of W. W. Covington of North Carolina. He had frequently had chills, and
a congestive chill in 1873. Three months before I saw him he began to
pass bloody urine. He had no other symptoms, except a soreness and
weakness in the neighborhood of the sacrum, extending into the outer
part of the left thigh. The urine passed for me at the time of his
visit was dark reddish-brown in color, acid in reaction, had a specific
gravity of 1028, highly albuminous, and deposited a sediment of almost
tarry consistence, which was made up almost entirely of
blood-corpuscles. There were no tube-casts. He had been a dyspeptic
since seventeen years of age, and medicines disagreed with him; but he
was treated faithfully with quinine, iron, arsenic, ergot, benzoate of
lime, all without the slightest effect. At the end of about a year from
the time he consulted me he heard of the Jackson Spring, located in
Moore county, North Carolina, fifteen miles distant from Manly Station
on the Raleigh and Augusta Railroad. He went there, and remained one
week. He stated that for the first two or three days the water acted
decidedly on his kidneys, and he voided a number of clots of blood. On
the third day all traces of blood disappeared, and it recurred but once
since, on a very cold day in November last, but again disappeared after
a day or two in the house. Unfortunately, no precise analysis of this
water seems to have been made, but {112} from what my friend writes it
evidently contains iron and sulphur, and magnesia is also said to be
present. It is promptly diuretic. Since this occurred I have used the
water of alum springs in other instances with advantage.[13]
[Footnote 13: See the report of a case treated successfully by
Rockbridge alum-water by Radcliffe, _Med. News_, Jan. 12, 1884.]
The following are some of the chalybeate and alum springs the waters of
which may be expected to be of service in hæmaturia: Orchard Acid
Springs, New York; Rockbridge Alum Springs, Pulaski Alum Springs, Bath
Alum Springs, Stribling Springs, and Bedford Alum Springs, all in
Virginia. In all of these waters iron and alum are both present,
accompanied, in many instances, by free sulphuric acid, by which their
efficiency is increased. In one of my cases the hemorrhage disappeared
temporarily under the use of the water from the Bedford Springs,
Penna., but again returned. These waters contain a little iron, but no
alum. Subsequently, the same patient was promptly relieved by quinine,
which had not been previously tried.
But the cases most promptly relieved by the alum waters are the
non-malarial cases depending, upon hemorrhagic diathesis without other
local disease. A remarkable instance of this kind was related to me by
letter by J. Macpherson Scott of Hagerstown, Md. After enormous doses
of quinine had been used under the supposition that it was malarial, it
was promptly and totally cured.
Malignant Malarial Hæmaturia.
The second more serious form of this disease, as it occurs in the
tropics and the southern part of the United States, is characterized by
such increased intensity of all the symptoms that it may be well called
malignant. Singularly, however, the disease has seemed to be much more
prevalent during the last fifteen years. My attention was first called
to it in September, 1868, when I received specimens of urine and the
history of some cases from R. D. Webb of Livingston, Ala., who wrote
also that it was not known in that part of his State prior to 1863 or
1864.
In this, as in the milder form, there is a distinct but more invariable
history of malarial exposure, and the attack often begins as an
ordinary case of chills and fever, there being often one or two
paroxysms before the hæmaturia appears. At other times the hemorrhage
ushers in the disease suddenly. The urine is often black and almost
tarry in consistence, and passed in unusually large quantities--it is
said as much as a pint every fifteen or twenty minutes until a couple
of quarts have been passed, or one or two gallons in the course of
twelve hours. But after twenty-four hours the quantity diminishes.
Epistaxis sometimes occurs, but is not often profuse. Distressing
nausea, and vomiting of bilious and even black matter, like that of
black vomit, also occur. Intense jaundice rapidly supervenes--said to
come on sometimes in the course of an hour, often in from two to six
hours. The tongue is brown and dry. The bowels are at times
constipated, and at others loose. Although the patient may be feverish
at first, with a temperature of 104° to 106°, and the skin dry, the
pulse rapidly becomes small and feeble until it is {113} scarcely
perceptible. Drowsiness and coma sometimes intervene, and at others the
mind is clear until the moment of death, which frequently supervenes
within twenty-four or sixty hours; or the symptoms may subside, to be
repeated again the next day if not prevented by treatment. If recovery
takes place, which it sometimes does, and lately more frequently,
convalescence is slow and tedious, the patient remaining for weeks in
an enfeebled and anæmic state.
In this form, especially, of the disease it often happens that the
coloring matter and the débris of blood-discs only are found in the
urine, very few and often no entire ones being discernible: in other
words, we have a true hæmoglobinuria or hæmatinuria. The urine is of
course albuminous. A specimen recently received from North Carolina and
analyzed by Wormley contained no corpuscles, but revealed the
spectroscopic band characteristic of hæmoglobin. It contained 2½ per
cent. of urea. The specific gravity of the urine ranges between 1010
and 1020, being lower when it is copious.
As to the jaundice, it is evidently a hæmatogenetic, and not a
hepatogenetic, form with which we have to deal. It is due, not to the
retention of bile, but to the disintegration of blood-corpuscles and
the solution of their coloring matter, which diffuses through the
tissues and stains them yellow or yellowish-green. This form too,
apparently, is more frequent in males, and negroes appear to be exempt.
This is not the case with the milder form, for it will be remembered
that one of my patients was a negro.
Autopsies reveal the same intense yellow coloration of internal
organs--lungs, liver, spleen, stomach, kidneys--anæmia rather than
congestion, while the blood is dark-hued and is indisposed to
coagulate. The spleen is often enlarged.
The TREATMENT for the breaking of the paroxysm is pre-eminently quinine
or quinine with mercurials, and although this does not always succeed,
there seems to be no other remedy. The quinine may be given
hypodermically. The nausea has been controlled by morphia and
lime-water, by carbolic acid, and by creasote. In addition, restorative
measures are necessary, including the free use of stimulants.
Turpentine has been used in large doses (fluidrachm j), it is said with
advantage, in Alabama.
{114}
CHYLURIA.
BY JAMES TYSON, A.M., M.D.
The term chyluria is applied to a condition of urine in which the
secretion is admixed with fat in a minute state of subdivision, whence
the urine acquires a milky or chylous appearance. The proportion of fat
varies greatly between such as gives a mere opalescence to the
secretion and that which makes it absolutely indistinguishable, in
appearance, from milk, while even the characteristic odor and taste of
urine are often wanting. The further resemblance of such urines to milk
is found in the fact that, on standing, a cream-like substance rises to
the surface. On the other hand, a spontaneous coagulation into a
jelly-like substance containing fibrin proves an unmistakable relation
to blood.
The chemical composition of such a urine, having a specific gravity of
1013 and neutral in reaction, is given by Beale,[1] as follows:
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . 947.4
Solid matter . . . . . . . . . . . . . . . . . . . . . . . 52.6
-----
Urea . . . . . . . . . . . . . . . . . . . . . . . . . . 7.73
Albumen . . . . . . . . . . . . . . . . . . . . . . . . . 13.00
Uric acid . . . . . . . . . . . . . . . . . . . . . . . . 0.00
Extractive matter with uric acid . . . . . . . . . . . . 11.66
Fat insoluble in hot and cold alcohol, but soluble
in ether . . . . . . . . . . . . . . . . . . . 9.20 |
Fat insoluble in cold alcohol . . . . . . . . . . 2.70 | 13.90
Fat soluble in cold alcohol . . . . . . . . . . . 2.00 |
Alkaline sulphates and chlorides . . . . . . . . . . . . 1.65
Alkaline phosphates . . . . . . . . . . . . . . . . . . |
Earthy phosphates . . . . . . . . . . . . . . . . . . . | 4.66
[Footnote 1: _Urinary and Renal Derangements and Calculous Disorders_,
Philada., 1885, p. 73.]
Such urines are of course albuminous, as will have been seen from the
table. They therefore coagulate when boiled or on the addition of an
acid. They also exhibit a tendency to spontaneous coagulation more or
less complete, which is apt to be followed by later disintegration of
the clot. The proportion of solids is larger than in ordinary urines.
Microscopically, the urine is found to contain, in addition to its
usual elements, immense numbers of molecular particles easily soluble
in ether, and therefore fatty in their composition. It may be rendered
perfectly clear by the addition of ether, and again approximately milky
after evaporating the ether and shaking the residue; but now the
microscope shows the oil in the shape of oil-drops and not molecules.
Oil-drops are also sometimes sparsely present in the fresh fluid, but
the fatty particle is commonly molecular. Indeed, the molecules are
commonly so small that an {115} aggregated mass of them appears like a
delicate cloud under the microscope, rather than a collection of
individual particles. Blood-corpuscles may also be present, sometimes
in sufficient quantity to produce a distinct pink coloration, but no
unusual proportion of leucocytes is common. The pink tinge, and even an
almost bloody appearance, is very apt to precede the chyluria. This
bloody character sometimes gradually increases until the chyluria has
become a hæmaturia, so that we have sometimes a chyluria spoken of as a
first stage of hæmaturia. Tube-casts do not occur. Chyluria is seldom
constant, and a specimen of urine passed a couple of hours after one
white as milk may be, again, perfectly clear and in all respects
natural. Thus, a second specimen, passed by the same patient as that of
which the analysis is given above, was almost clear. It had a specific
gravity of 1010 and a slightly acid reaction, and contained a mere
trace of deposit, consisting of a little epithelium, a few cells larger
than lymph-corpuscles, and a few small cells, probably minute fungi.
Not the slightest precipitate was produced by the application of heat
or addition of nitric acid. The following is Beale's analysis:
Water . . . . . . . . . . . . . . . . . . . . . . . . . . . 978.8
Solid matter . . . . . . . . . . . . . . . . . . . . . . . 21.2
-----
Urea . . . . . . . . . . . . . . . . . . . . . . . . . . 6.95
Albumen . . . . . . . . . . . . . . . . . . . . . . . . . 0.00
Uric acid . . . . . . . . . . . . . . . . . . . . . . . . .15
Extractive matters with uric acid . . . . . . . . . . . . 7.31
Fat insoluble in hot and cold alcohol, but soluble in ether|
Fat insoluble in cold alcohol . . . . . . . . . . . . . . | .00
Fat soluble in cold alcohol . . . . . . . . . . . . . . . |
Alkaline sulphates and chlorides . . . . . . . . . . . . 5.34
Alkaline phosphates . . . . . . . . . . . . . . . . . . . 1.45
Earthy phosphates . . . . . . . . . . . . . . . . . . . . .15
DISTRIBUTION OF THE DISEASE.--By far the largest majority of instances
of the disease originate in tropical and subtropical climates. Thus,
India, China, and South America--and in South America, Brazil, and
Guiana--are countries in which it is common. It is said to be rarer on
the coast of South America than in the interior; yet it is especially
partial to insular countries, and most of the cases observed in this
country originate in the West Indies--in Barbadoes and Cuba, in Bermuda
and the island of Trinidad. Many cases occur in Bahia, Guadeloupe,
Madagascar, the Isle of Bourbon, and Mauritius. Indeed, the first
important study of the subject was based on cases observed in the
latter island by Chapotin.[2] In Africa both Egypt and the Cape of Good
Hope are favorite localities, and in Australia, Brisbane has furnished
many cases.
[Footnote 2: Thèse, _Topographie médicale de l'Ile de France_, 1812.]
At the same time, cases do originate in temperate climates, and
although the disease is rare in Europe and North America, Dickinson has
collected five cases from his own practice or that of others, which
undoubtedly originated in England. I know of but one case of certain
North American origin, that of a woman reported by McConnell to the
Medico-Chirurgical Society of Montreal, April 27, 1883. She was
thirty-three years old, a native of the province of Ontario, and had
had the disease eleven years. At the time of her death, which appears
to have been from tubercular phthisis, there were cavities in the
apices of both lungs.
{116} SUBJECT'S ATTACKED.--There seems no election as to nativity,
natives and foreigners being indiscriminately attacked in the countries
in which it occurs. There is some difference of opinion as to whether
the disease is more frequent in males or females; which is a reason for
believing that it occurs with nearly equal frequency in both.
It is more common in middle life, but Prout reports an instance in a
child eighteen months old, and Rayer one in a woman at seventy-eight
years. She had had it, however, since she was twenty-five, or about
fifty-three years. Dickinson was consulted with regard to a boy of
five, and mentions a case fatal at twelve. Roberts says: "Chylous urine
prevails mostly in youth and middle age."[3] Of 30 cases collected by
him, 3 were under twenty; 7 between twenty and thirty; 11 between
thirty and forty; 6 between forty and fifty; and 3 over fifty.
[Footnote 3: _Urinary and Renal Diseases_, 4th ed., Philada., 1885, p.
344.]
The subjects of the disease are apt to be pale and relaxed as to their
tissues, but while this may be a possible result of the disease, it can
hardly be regarded as a predisposing cause.
PATHOLOGY AND ETIOLOGY.--The precise mode in which chyluria is brought
about is unknown. It is to be inferred, in view of our existing
knowledge, that there has been produced, in some way, in each instance
a communication between the urinary and chyliferous systems, although
exactly where such communication is has as yet only been guessed at. It
may be in the kidney itself, or its pelvis, or the ureter, or in the
bladder. Cases originating in the tropics have been found associated
with elephantiasis, but this is not very frequent. Dilatation of
cutaneous lymphatics, producing cutaneous papules and vesicles and a
discharge of lymph from them, has also been noted coincident with
chyluria.
Prout,[4] among the earlier writers on this subject, and more recently
Bence Jones,[5] Waters, Bouchardat, Robin, Bernard, and Egel, did not
consider a positive lesion necessary, but ascribed the condition to a
vice of nutrition and blood-making, accompanied by a slight consequent
textural alteration in the blood-vessels of the kidney, through which
the elements of the chyle transuded. Waters[6] says that "the main
pathological feature of the complaint is a relaxed condition of the
capillaries of the kidney," which permits the transudation.
[Footnote 4: _Stomach and Renal Diseases_, 4th ed., London, 1843.]
[Footnote 5: _Lectures on Pathology and Therapeutics_, 1868, p. 256.]
[Footnote 6: _Med.-Chir. Trans._, vol. xiv. p. 221, 1862.]
The results of examination of the blood, in cases of chylous urine, by
Bence Jones, Rayer, and Crevaux, who found in certain instances an
excess of fat, have been quoted in support of these views, but these
examinations seem to have been microscopical and not chemical, and the
results have not been confirmed by recent observers. Such views were
also upheld on theoretical grounds by Bouchardat,[7] based on the
greater commonness of the disease in warm climates. He reasoned that
when the heat-producing elements, whether absorbed from food or
produced by metamorphoses of other proximate principles, are in excess,
and an elevated external temperature does not favor their consumption,
their elimination is attempted by certain organs, notably the liver and
kidneys. The effort by the kidneys seems, however, to be attended by a
structural change in the blood-vessels, as the result of which blood is
{117} eliminated with fat, especially at the beginning of the disease.
Later the blood disappears, but the albumen remains some time longer,
disappearing finally with the fat.
[Footnote 7: _Ann. de Thérapeutique_, 1862.]
Bernard and Robin also compared the blood of such cases to that of
geese artificially fattened, being that condition of blood which is
normal after digestion but transient. Egel also held similar views,
ascribing the imperfect elaboration to the effect of hot climates.
Gubler[8] first suggested that chylous urine was due to a passage of
chyle directly into the urinary passages, and that this was immediately
preceded by a dilatation of the renal lymphatics similar to that known
to occur on the surface of the body and attended by the local flow
alluded to.
[Footnote 8: _Gazette médicale de Paris_, 1858, p. 646.]
Vandyke Carter,[9] of Bombay, suggested that the communication was
between the lacteals and lymphatics of the lumbar region and those of
the kidney. Those who have seen the semi-diagrammatic drawing of a
dissection of the lymphatics as seen from behind, in the remarkable
case of Stephen Mackenzie,[10] cannot fail to be impressed with the
probability of such communication.
[Footnote 9: _Med.-Chir. Trans._, vol. xlv., 1862.]
[Footnote 10: _Trans. Path. Soc. of London_, vol. xxxiii. p. 394,
1882.]
That a chylous urine is the direct result of a discharge of chyle into
the urinary passages at some point between the kidney and the neck of
the bladder, is further rendered likely by the experience of W. H.
Mastin of Mobile, Alabama, with a case of chylous hydrocele: W. H. W.,
a native of Alabama, aged twenty-two, presented himself with a
hydrocele. Mastin tapped the sac and drew off a white milk-like fluid,
which was sent to me for examination. It was perfectly white and
undistinguishable by the eye from milk. Upon microscopical and chemical
examination, I found it presented all the physical and chemical
characters of chyle. Six months later, the sac having refilled, Mastin
evacuated eight ounces more of the same fluid--some of which was again
sent to me--and then laid open the sac freely. Examining the cavity
carefully, he found it smooth, polished, and pearly white, but at its
upper portion, just where it began to be reflected over the testis, was
a small, round, granular-looking mass about the size of an ordinary
English pea. This he sliced off with a pair of scissors, and at once
recognized the patulous mouths of three or four small vessels which did
not bleed. These he dissected back for a short distance, and found that
they passed into the connective tissue around the upper border of the
testis. He then passed a ligature around the mass and brought the ends
of the ligature to the outside, excised all the front wall of the
tunica, and closed the sac. The patient recovered, and there was no
return of the hydrocele. Although it is to be regretted that the
patulous vessels were not watched for a few minutes, I do not think
there can be any reasonable doubt that there was here a lymphatic
varix, and that the chylous fluid in the tunica was the result of
leakage through its walls. Since the patient had had gonorrhoea,
Busey,[11] in his remarks on this case, suggests that the obstruction
to the onward movement of the lymph, and the cause, therefore, of the
dilatation and rupture, was inflammation attacking a single gland or an
area of lymphatics.
[Footnote 11: _Occlusion and Dilatation of Lymph-Channels_, by Samuel
C. Busey: A series of papers reprinted for private distribution from
the _New Orleans Medical and Surgical Journal_, from Nov., 1876, to
March 1878.]
{118} If it be acknowledged, then, that in chyluria some direct
communication must exist between the lymphatic and urinary systems, how
is this communication brought about? Various causes have been supposed
at different times to be responsible for this condition, among them
traumatism in its various modes of occurrence, such as being thrown
from a horse. Mental shock has also been held responsible. So, also,
syphilis and hereditary tendency. But most cases still remained
unaccounted for when, on August 4, 1866, Wücherer first detected in the
chylous urine of a woman in the Misericordia Hospital at Bahia an
unknown worm. In 1872 it was announced that Timothy R. Lewis had found
in the blood, and also in the urine, of a person suffering with
chyluria in Calcutta, a delicate thread-like worm about 1/70 of an inch
long and 1/3500 of an inch wide. This observation was confirmed by
Palmer and Charles. Lewis named it Filaria sanguinis hominis. Since
then the filaria has been found in the blood and urine of many cases.
Lewis found six in a single drop of blood from the ear, and estimated
700,000 as approximately correct for the whole body. But Mackenzie
calculated that there were in the blood of his patient from 36,000,000
to 40,000,000 embryo filariæ. These minute nematodes, discovered by
Wücherer and Lewis, proved to be, as was indeed early suspected, the
larvæ of a larger filaria which was discovered by Bancroft of Brisbane,
Queensland, Australia, in December, 1876, first in a lymphatic abscess
in the arm, and afterward in the fluid of hydrocele of persons infested
with the smaller worm. The parent worm is about the thickness of a
human hair and three or four inches long. It was named, by Cobbold,
Filaria Bancrofti. Lewis himself found, in August following, a male and
female of the parent worm, in a scrotum infiltrated with chylous fluid,
in a case of elephantiasis. The female contained ova with embryos
precisely like those found in the blood and urine. The worms are
viviparous, but abortions seem frequent, ova being frequently
discharged unhatched.
It has been rendered highly probable, by the researches, first, of
Manson in China, and later of Lewis in India and Sonsino in Egypt, that
the filaria in its fully-developed form is introduced into the stomach
and intestines of man with water. Thence it makes its way into the
blood and lacteal system, where it reproduces the embryo filariæ. These
embryonic or larval filariæ are taken from the human blood by a
mosquito, in the body of which it undergoes further development, after
which the perfect Filaria Bancrofti is deposited in water, through
which it again reaches the stomach of man, and thus the disease is
perpetuated.
One of the most singular features in the history of the filaria is its
nocturnal habit. It is found in the blood only at night, unless, as
Mackenzie has shown, night be converted into day--that is, if the hours
of sleeping and waking be reversed. In Mackenzie's case the worms
appeared about seven o'clock in the evening, increased up to midnight,
and disappeared by eight or nine o'clock in the morning. What becomes
of them at the time when they are undiscoverable in the blood is as yet
unknown.