§ 8. Ischuria.—This term is employed to express suppuration in opposition to retention of urine: the fluid is not secreted at all. Coming on sometimes after exposure to cold, it occasionally ap pears without any very direct cause ; rarely seen in perfectly healthy conditions of the organ, it is more usually met with in cases of low inflammation supervening on long standing disease. The eye of the experienced practitioner will discover in the as pect of his patient those evidences of renal disease which we shall have to notice under albuminuria ; but to the patient and his friends the existence of such a malady is unknown. Ile con ceives himself to have been in his usual health immediately be fore, he cannot understand why it is that he passes no urine, as he feels little or no pain, and complains of no suffering. There is nothing to mark the disorder in its commencement besides the suppression, but soon the pulse becomes slow, the patient drowsy, and ultimately completely comatose. The very same sequence occurs more slowly without complete suppression when the de puratory action of the kidney is much interfered with ; here they are only more rapidly developed. It may be the immediate result of an attack of nephritis; and the common occurrence of rigor at its commencement suggests the probability that, even when the organ is unsound, some congestive or inflammatory action is ex cited, which deprives the secreting structure that remains of its power of carrying on functions which, impaired though they be, are still necessary to life.
Little need be added in regard to its diagnosis. The chief point is to make sure that the bladder is empty, and this can only be done by a careful introduction of the catheter. No surgeon should leave the hospital to enter upon general practice without feeling confident that he is competent properly to manipulate this delicate instrument ; for even now incalculable mischief is fre quently perpetrated through ignorance or want of skill.
§ 4. A Thuminuria.—Among the various deviations from the normal or healthy condition of the urine, this is unquestionably that most frequently met with, and in diagnosis the most import ant, whether we consider the serious consequences to the patient which directly spring from a permanent condition of albuminuria, or its influence in modifying or giving rise to other disorders which may be indirectly traced to disease of the kidney. The name does not merely imply that the urine contains albumen, but is used to express a condition which we know to be associated with organic change of structure in the kidney. I have preferred employing it, because the nomenclature of diseases of the kidney has undergone some changes of late, which have rendered the meaning of "Bright's disease" somewhat uncertain: because, too, there seems no great practical advantage in discriminating (if they can be distinguished during life) between a small granular kidney and a large, smooth, and mottled one; and, still more, be cause it is the presence of albumen in the urine from day to day, and the partial absence of other constituents, which produce the baneful consequences on the patient's health. Albuminous urine
during life is to us much more important than the changes of struc ture revealed by dissection; the presence of albumen is a fact which can be readily appreciated in diagnosis, and which, coupled with diminished specific gravity, implies the deficiency of other ele ments—a circumstance not less important, but not so easily as certained by analysis ; and the name albuminuria will equally express the effect of destruction of tissue by the development of cysts, of the absorption caused by dilated ureters and tubes from pressure or obstruction, and the more common condition found in degeneration, by whatever name they may be designated.
The commencement of the disease is very rarely traceable. Some have thought they might venture to go back to an attack of scarlatina; occasionally we may have a really truthful history of an attack of nephralgia, which post-mortem appearances enable us to associate with the subsequent changes ; but these are the curiosities of diagnosis, and their practical value is not great.
The patient gradually loses strength, becomes pale, finds him self liable to catch cold, or suffers from headache, or from diar rhoea; in fact the symptoms presented are exceedingly ill-defined, and it may be not until anasarca makes its appearance that he supposes himself seriously ill. When questioned, he will gene rally admit that he has suffered from pain in the loins of a dull, aching kind ; but how many suffer in the same way from weak ness only, who never have albuminous urine. The circumstances in the aspect of the patient which prepare us for the discovery of albumen in the urine are a waxy or an extremely pallid face, with pearly eyes, and puffiness around the eyelids, or oedema of the ankles, which the attendant may notice before the patient becomes conscious of it. Such indications are the more valuable, inasmuch as the albumen may for a time, in the progress of the case, be reduced to a mere trace ; in fact, it occasionally disappears altogether, and repeated analysis may be needed to make out the true nature of the case. But they are only to be regarded as hints of what may probably be discovered ; they result from the cachexia of the disease, and may be seen in other cachectic states, of which antemia is a prominent characteristic.
When dropsy is fairly established, it then becomes of import ance, in regard to treatment, to have clear notions of its c,ause; and as has been already pointed out, the first questioneis whether, if there be coincident ascites, the effusion occurred first in the abdomen or in the areolar tissue ; then, following the order we have adopted, the condition of the heart must be carefully examined ; next we inquire whether there be any circumstances which point to disease of the liver; and lastly we examine the urine. But the existence of one form of disease does not exclude the possibility of another being conjoined with it; on the contrary, we know that there is a constant allian.ce between disease of the heart and disease of the kidney.