HYDRONEPHROSIS AND RENAL ATROPHY; 
ESPECIALLY AS RESULTING FROM FUNCTIONAL 
DISTURBANCES OF MICTURITION. 
BY 
ROBERT T. EDES, M.D., 
OF WASHINGTON, D. C., 
FORMERLY PROFESSOR OF MATERIA MEDICA AND JACKSON PROFESSOR 
OF CLINICAL MEDICINE IN HARVARD UNIVERSITY. 
FROM 
THE MEDICAL NEWS, 
August io, 1889. [Reprinted from The Medical News, August io, 1889.] 
HYDRONEPHROSIS AND R E N A L AT R 0 P H Y; ESPE- 
CIALLY AS RESULTING FROM FUNCTIONAL 
DISTURBANCES OF MICTURITIO N. 
By ROBERT T. EDES, M.D., 
OF WASHINGTON, D. C., 
FORMERLY PROFESSOR OF MATERIA MEDICA AND JACKSON PROFESSOR 
OF CLINICAL MEDICINE IN HARVARD UNIVERSITY. 
Hydronephrosis is a dilatation of the pelvis and 
calyces of the kidney from retention of the secre- 
tion. It may vary from the slightest stretching of 
the pelvis beyond its normal dimensions, with per- 
haps a slight flattening of the papillae, up through 
all the stages of gradual distention of the cavity and 
atrophy of the renal substance, until the kidney be- 
comes a mere shell of fibrous tissue, to which are 
attached a few remnants of true renal parenchyma 
retaining somewhat of their structure and func- 
tion. This condition may affect both of the kid- 
neys, or one of them, or in some cases only a part 
of one. 
It is so nearly always the result of a demonstrable 
anatomical obstruction in the normal flow of the 
urine that, in the few cases in which the exact seat 
and nature of the obstruction cannot be discovered, 
it is fair to conclude that the exception does not 
indicate an independent pathology, but simply that lEDES) 
hindrances may exist which are riot obvious to the 
sound or on the dissecting table. This remark ap- 
plies quite as fully to congenital as to acquired 
hydronephrosis. 
The object of my paper is to suggest that in some 
of these exceptional cases the search, if prosecuted 
during life physiologically and clinically, will reveal 
causative conditions not evident upon the post- 
mortem table, but, notwithstanding, really sufficient 
for the effect produced. 
The points at which obstructions may occur are 
many; and according to their positions will be the 
amount and character of the changes existing above 
them ; not only the dilatation, which is the subject 
of the present paper, but the inflammatory and de- 
generative alterations in addition. These lesions 
have been carefully studied and described, and I 
will take but a few moments in a brief recapitulation. 
The ureters may be occluded by a calculus at any 
point from their exit from the pelvis to their entry 
into the bladder. 
Wounds or blows on the back may cause com- 
pression of the ureters by means of hemorrhagic or 
inflammatory effusions. 
An obstacle may also exist anywhere in their 
length in the form of a valve or fold, constituted 
either by the mucous membrane or by the whole 
thickness of the tube. Such a valve, although re- 
taining the secretion most of the time, may be per- 
vious under some states of distention or position; 
and in this way are formed the so-called intermit- 
ting hydronephroses. Folds or kinks existing in HYDRONEPHROSIS. 
3 
the ureters have long been recognized as obstruc- 
tions, but it is possible in some cases that these may- 
be, in part at least, secondary, inasmuch as when a 
hydronephrosis occurs from other causes which may 
be temporary, the ureter is not only dilated but also 
lengthened, and is obliged to form a fold in order 
to accommodate itself to the surrounding parts. 
They are frequently, however, of such form and in 
such numbers that no such explanation is admis- 
sible. 
The ureters may be congenitally impervious 
through the whole or in any part of their course. 
(Trans. Path. Soc. London, xv.; Bull. Soc. Anat. 
de Paris, 1867, xxxi. n, 305.) They may have no 
opening into the bladder or even attachment to it. 
(Med. Times and Gaz., 1876, i. 546.) In some 
such cases there is an attachment to the rectum but 
without an opening into it. (Gerster : N. Y. Med. 
Journal, 1878, xxviii. 511.) When arrested or ir- 
regular development of this kind occurs in the ure- 
ters, it is not uncommon, in fact usual, to find asso- 
ciated with it other deformities, frequently of the 
intestinal canal, but often of entirely separate re- 
gions ; as, for instance, the hands and feet, showing 
a tendency in this direction more than local. There 
have been instances where a woman has borne sev- 
eral hydronephrotic children in succession. 
Whenever the obstruction exists long enough there 
will be a dilatation of the parts above, not neces- 
sarily everywhere equal, since the ureters differ in 
density and in the amount of outside support they 
receive at different parts of their course. It is not 4 
EDES, 
unusual to find in the course of a ureter which is 
elsewhere considerably dilated, points at which it 
retains its normal calibre. One of these points is 
likely to be found just where the pelvis of the kidney 
joins or becomes the ureter. 
Compression of the ureters may be caused by 
bands of adhesions and in a few cases by a branch 
of the renal artery passing across them. 
Among the more common external obstacles are 
to be found pelvic tumors and in particular cancer 
of the uterus. Displacement of the uterus, and in 
particular prolapse, can have this effect by twisting 
and dragging on the ureters. 
The brim of the true pelvis, where the ureter 
makes a somewhat abrupt turn, and is especially 
liable to compression in passing from the abdominal 
cavity down behind the bladder, may cause an ob- 
struction to the flow of urine, as will be shown by 
the difference of calibre, the tubes being dilated 
above and normal below. (Medical Record, 1887, 
xxxii. 734.) 
As we come lower, omitting the bladder itself, 
which will be more fully discussed later, we may 
find the obstacles where the urethra leaves the blad- 
der. This may be absolutely impervious, there being 
no orifice whatever, its proper position being indi- 
cated by a papilla (Billard : Maladies des Nouveau 
nes; Lehmann: Nederland. Weekblad., 1853, No. 
12); or there may be an adhesion of the sides of the 
urethra in this region too strong to be overcome by 
the pressure of urine, but yet easily broken up by 
an instrument passed in the usual way, which re- HYDRONEPHROSIS. 
5 
lieves the distended bladder and removes its cause, 
or cutting may be necessary. (Lamotte : Traite des 
Accouchements; Smellie’s Midwifery.) In other 
cases nearly the whole urethra may be obliterated 
or wanting (Lehmann, loc. cit.). It may, like the 
ureters, be obstructed by a valve of mucous mem- 
brane. {Bull. Soc. Anat. de Paris, 1869, p. 130.) 
In the adult the hypertrophied prostate is a not 
infrequent obstacle, and gives rise to an incipient 
or moderate bilateral hydronephrosis, as in the speci- 
men just shown by me,1 and in one by Dr. Prentiss 
{Maryland Medical Journal, April, 1883), and in 
many others too numerous to quote. 
The function of the kidneys may not be seriously 
disturbed for a long while. 
If a cystitis is added, as it is likely to be, we may 
then have, not a simple dilatation of the passages, 
but, from the fact that it is an inflammatory urine 
which is backed up into the kidneys, a pyo- instead 
of a hydro-nephrosis. 
This list is to be extended by the mention of stric- 
tures of the urethra, of which there are several speci- 
mens in the Army Medical Museum, and of papillo- 
mata in the neck of the bladder. 
Finally, the prepuce may present an efficient 
obstacle in the form of a phimosis, although the 
irritation of an adherent foreskin may lead to 
hydronephrosis by another chain of causation, as 
will be seen later on. 
Many of the conditions mentioned can, of course, 
1 To the Medical Society of the District of Columbia. 6 
EDES, 
exist only in the foetus or the newborn. Where a suffi- 
cient amount of depuration of the blood can be carried 
on by the circulation of the mother without refer- 
ence to the activity of the foetal organs, one or both 
kidneys may, even if entirely obstructed, continue 
to grow into the enormous tumors of this kind some- 
times met with. A certain amount of time is requi- 
site for the development of an extreme degree of 
hydronephrosis. It is a process of growth and not 
simply one of distention, and since after separation 
from the mother an absolutely complete occlusion 
of both ureters in the child must lead to death by 
uraemia before the dilatation can reach its extremest 
limits, we meet with the most striking examples ot 
double hydronephrosis in connection with impervi- 
ous urinary passages only in the foetus or the newly 
born. The abdominal swelling in some of these 
cases of congenital hydronephrosis may be so great 
as to constitute a serious hindrance to delivery or, 
on the other hand, the pressure during delivery may 
be so great as to force a passage of the urine in 
spite of the resistance and empty the sac. 
In adults an absolutely impermeable obstruction 
may exist upon one side and a slight or moderate 
hydronephrosis be formed in consequence, but, 
when the dilatation is bilateral or when it is extreme 
on one side, it must have been the result of an ob- 
stacle sufficient to increase the pressure under which 
the urine was secreted during a long time, but not 
sufficient entirely to stop it at once. The stoppage 
may finally become an absolute one, but cannot have 
been so from the beginning. It is a curious fact that the amount of urine passed 
against a certain degree of back-pressure instead of 
being diminished, as we should naturally expect from 
a knowledge of the physical laws governing this 
secretion, is increased. The back-pressure, when 
not too great, seems to act as a stimulant to the 
secreting structure. If, however, it gets beyond this 
point, the secretion obeys the ordinary law of physics 
and takes place more slowly. 
After the consideration of these and all similar 
causes for hydronephrosis, we are likely to meet with 
cases which are not to be explained thereby. My 
former instructor, Prof. J. B. S. Jackson, went so far 
as to say that in a large proportion of cases, so far as 
he had seen, no cause whatever could be assigned. 
We may accept, as expressing the general conclusion 
in the matter, the words of Roberts, who says, “There 
are cases which must at present be regarded as 
mechanically inexplicable.” I propose now to ex- 
amine a case or two of my own with reference to 
the causation and compare them with a few obser- 
vations I have been able to find in medical litera- 
ture. 
Case I.—A boy, aged five, was seen by me in 
December, 1882, with my friend Dr. Gilbert, of 
Dorchester. He looked rather less robust than his 
younger brother and sister. He had always been 
in the habit of wetting his bed and clothes. Re- 
cently his habits had improved, although he still 
passed a small amount of urine in his clothes. He 
did not, however, entirely empty his bladder in this 
way, as his mother said he could always pass water 
HYDRONEPHROSIS 
7 8 
EDES, 
whenever they tried him. There was no difficulty 
in micturition. He passed a full stream. The daily 
quantity was considerably increased and was of low 
specific gravity with a small amount of albumin and 
a slight sediment of small cells, but no casts. Two 
years later the urine was still lighter and it contained 
albumin, but no casts. A short time before his 
death he had several attacks of retention of urine. 
He had headache for a month or two, and his death 
was immediately preceded by convulsions. 
At the autopsy the body was found emaciated. 
The heart was hypertrophied, especially the left ven- 
tricle. The right kidney was represented by the 
dilated pelvis and a small nodule of secreting struc- 
ture at one end and a few thin pieces elsewhere; 
right ureter dilated. The left kidney somewhat 
atrophied, mottled with yellow, lobulated, capsule 
adherent, pelvis and ureter slightly dilated, but 
much less than right. Bladder large, the walls more 
trabeculated than would be expected in a child of 
his age. No obstruction anywhere in ureters found. 
Free passage of water into bladder and free passage 
of sound in either direction. Urethra free to sound 
in either direction. 
The next case lacks the confirmatory evidence of 
a post-mortem but presents what is better, the result 
of treatment directed to the relief of the causative 
condition. 
Case II.—A rather delicate girl, aged three, was 
seen by me in consultation with Dr. Rice, of Graf- 
ton, Mass., in January, 1886. She had had a convul- 
sion in the previous July and some feverish attacks 
since. She had passed urine in large quantity and 
with some effort for some months, and these were HYDRONEPHROSIS. 
9 
all the obvious symptoms. The urine was of low 
specific gravity and contained a large trace of albu- 
min with pus, blood, epithelium from the neck of 
the bladder, renal epithelium, and some casts. A 
previous examination had discovered some epithe- 
lium from the pelvis of the kidneys. She was placed 
on the benzoate of lithium, with which her general 
condition improved, and she went through the night 
without passing water, but the albumin, pus, and 
casts remained, and were noted on several examina- 
tions up to March 7th. On the 8th the bladder and 
urethra were examined under ether. She passed a 
full stream of urine and a large bougie entered the 
bladder without difficulty. A probe detected a little 
roughness (trabeculation ?) at times, but nothing 
morp. On the 26th of March her mother wrote to 
me that she had seemed much better, appetite very 
much improved, and since the examination decided 
decrease in the effort to pass water. 
The next examination of urine, of which I have a 
record, shows there was a deposit of pus and some 
albumin present, but no casts were found after a 
somewhat prolonged search and only a few large 
cells. 
The urine of June the 14th was opalescent and 
deposited only a flocculent stratum of pus. One 
hyaline cast of medium size was found after search- 
ing a number of drops. On the 15 th a large taper- 
pointed catheter was introduced into the urethra for 
puposes of dilatation, and the urine drawn contained 
neither pus nor casts, and only a small amount of 
albumin. On the 23d there were a few scattered 
leucocytes and no casts. Some time in the winter 
of 1887-8 the urine contained a trace of albumin, 
but in July, 1888, the attending physician writes EDES, 
that “It is free from albumsn and the patient is the 
picture of health.” 
If we take into consideration cases where hydro- 
nephrosis coexists with thickened bladder and a 
severe chronic cystitis, and where the dilatation is 
fairly referable to the increased frequency of mictu- 
rition and the spasmodic contraction of the bladder, 
we can find a considerable number. 
Case III.—In a case under my own observation 
(seen with my friend, the late Dr. Arnold, of Rox- 
bury, in its last stages), a boy had attacks of dysuria 
from irritability of the neck of the bladder, and 
probably cystitis, from the age of six to nine. For 
some time before his death the urine was pale, 
scanty, purulent, and ammoniacal. He died with 
uraemic symptoms. The bladder was thickened and 
the ureters dilated. The right kidney was repre- 
sented by a nodule the size of a pea on the outside 
of the membranous bag. There remained of the 
left kidney one round mass at the lower end three- 
quarters of an inch in diameter, and two or three 
other smaller ones. 
I think we have in the first two of these cases a 
complete and a fortunately incomplete instance of 
the class recognized by all writers on this subject as 
“mechanically inexplicable”; inexplicable — that 
is, if we regard only the conditions found after death 
or by surgical examination, since we find a hydro- 
nephrosis with indications of increased work on the 
part of the bladder, but the passages everywhere 
freely permeable to instruments in either direction ; HYDRONEPHROSIS. 
11 
not altogether inexplicable, if we regard the action 
of the bladder and the function of micturition. 
The amount of back-pressure in the kidneys re- 
quired to produce a complete compression of the 
secretion is estimated at about one and six-tenths 
inches of mercury, while less than half an inch will 
greatly impair it.1 Since, then, in most cases of 
hydronephrosis the secretion is not checked, but 
the contrary, we may safely say that a very small 
amount of back-pressure in the bladder, if constant 
or frequently repeated, is sufficient, after a time, 
to produce slighter grades of hydronephrosis with 
consequent destruction of kidney substance. 
Normally, of course, there is little pressure in the 
bladder most of the time. Once emptied, it fills 
again with urine coming down the ureters, partly 
perhaps by hydraulic pressure, but largely by the 
peristaltic movements analogous to those by which 
the intestinal contents are propelled. 
To this there is little or no resistance on the part 
of the bladder until a certain degree of distention is 
reached, varying, not only according to its total 
capacity, but according to its irritability, when it is 
emptied by a contraction of one set of muscles and 
relaxation of their opponents. 
It is stated that the detrusor urinae is able to over- 
come the resistance of the sphincter vesicae, but it 
comes within the personal experience of everyone 
who has been obliged by circumstances to delay the 
1 Wundt: Physiologie des Menschen, p. 434. Quoted by 
James: Physiological and Clinical Studies, Edinburgh, 1888. 12 
EDES, 
evacuation of the bladder after it has become over- 
full, that something more than overcoming a passive 
resistance is necessary in the act of micturition. 
There must be a simultaneous and harmonious re- 
laxation of the sphincter as well as stimulation of 
the detrusor. In this respect micturition may be 
said to resemble vomiting, where efforts of the ab- 
dominal muscles are unable to evacuate the stomach 
until the cardiac orifice relaxes. 
The function of the urinary bladder in receiving 
and discharging the urine at more or less regular 
intervals is not a purely passive one. It should be 
a pump as well as a reservoir. Its proper action in 
this way depends on a proper relationship between 
the forces that propel and those that restrain its con- 
tents, and when these forces are so disordered that 
it fails to perform its function, or performs it insuf- 
ficiently, then more work is thrown upon the other 
propelling forces. These are: first, the pressure 
under which the urine is secreted, which, as we have 
seen, is but slight, since half an inch of mercury 
pressure will materially impair it; and, secondly, 
the peristaltic movements of the ureters. 
During the normal act of micturition no urine can, 
of course, enter the bladder from the ureters, but 
since the emptying of the bladder occupies so short 
a time no harm is done. The amount of urine 
which accumulates in the ureters during this interval 
is too small to distend them beyond the proper 
limits. If, however, the contractions be very fre- 
quent and long continued there will be enough 
accumulation of urine in the ureters to cause their HYDRONEPHROSIS. 
13 
dilatation, and, subsequently, that of the kidneys. 
This dilatation, by weakening the walls of the ure- 
ters, will naturally tend to increase rather than de- 
crease. Such frequent contractions result, as we 
well know, from various sources of irritation in the 
urinary tract, but especially from inflammation of 
the bladder itself, or of the urethra. 
Suppose, now, on the other hand, the detrusor 
to be weakened relatively to the sphincter, or, what 
amounts to the same thing, the resistance of the 
sphincter to be increased, we may have a consider- 
able accumulation of urine taking place against the 
constant elastic pressure of the bladder which is not, 
however, sufficient to empty it, and allow the flow 
from the ureters to go on again without resistance. 
We then have the condition of incontinence from 
retention—i. e., a bladder full to overflowing, so 
often seen in the old, usually in connection with 
enlarged prostate, but not common in the young. 
The kidneys and ureters are thus working against a 
pressure, never very great perhaps, but always above 
the normal, exactly the condition to produce a 
gradual distention. If the voluntary muscles of the 
abdomen are called upon to assist the contractions 
of the bladder, the matter is made worse rather than 
better, for they cannot exercise so equal a pressure 
in every direction as the constrictors of the bladder 
itself, and the entrance to the ureters is not guarded, 
under the circumstances, as in the normal condition' 
by the contraction of the fibres immediately sur- 
rounding them. Urine may thus be forced upward 
as well as downward. The absence of the valvular 14 
EDES, 
condition of the entrance of the ureters into the 
bladder is expressly noted in two of the subsequent 
cases of paralysis of the bladder. 
It will, of course, be understood that the amount 
of pressure required to produce dilatation in the 
course of weeks or months is an entirely different 
amount from that which would be necessary sud- 
denly to dilate the organs to the size they may attain 
even in the more moderate cases of hydronephrosis. 
In fact, it would probably be impossible to arrive at 
this state of things by any rapid process. 
Hydronephrosis, then, may take its rise in two 
distinct forms of faulty innervation, paralysis and 
spasm. This origin is not fully recognized in medi- 
cal literature, but a few cases may be quoted in sup- 
port of my view. 
Auge (These de Montpellier, 1878) reports a case 
of hydronephrosis from paralysis of the bladder, of 
which, however, the clinical details are too scanty 
to make it of much value for our purpose. The 
bladder was greatly dilated, it was thin, and the 
mucous membrane injected and punctated. The 
ureters were much dilated and the inferior orifices 
opened. The pelves of the kidneys were dilated 
and the tissues progressing toward atrophy. 
The following somewhat resembles the first of 
mine. Bernard (Jonrn. Sc. Med., Lille, 1881, p. 
546) describes the case of a child, aged thirteen, 
who had incontinence of urine, wetting the bed, 
and passing water into his clothes during the day; 
he could pass water whenever he pleased, with some 
difficulty, the jet being short, and he being obliged HYDRONEPHROSIS. 
15 
to contract energetically the abdominal muscles. 
When sounded, the bladder was found to contain a 
considerable quantity of urine, but there was no 
obstacle to catheterism, and no calculus. The mus- 
culi recti abdominis were hypertrophied. There 
was a large quantity (three litres) of urine passed, 
which deposited muco-pus. After death the bladder 
was found to contain urine, pus, and blood, and was 
as large as the fist. Ureters dilated. Of the left 
kidney the structure was entirely gone; in the right 
the changes were less advanced, but there were 
abscesses. The ureters were without the usual 
valvular opening into the bladder, being without 
any intra-parietal portion. There was thickening 
of the walls of the bladder, and slight cystitis, but 
the urethra was normal. 
James (op. 42) reports the following: A 
child had, at three, phimosis as the result of an 
injury. After this had been “ pricked by a doctor,” 
the swelling got better, and he seemed nothing the 
worse. He had then no incontinence. The incon- 
tinence began at the age of four. After this a 
feverish attack which weakened him, and, on admis- 
sion to the infirmary at the age of eight, he looked 
thin and weakly. The prepuce was contracted and 
almost completely adherent to the glans. No pain, 
but great incontinence. There was increased fre- 
quency of micturition, often three or four times in 
an hour. Only a few drops of urine were passed at 
a time, and the bladder was never distended. The 
quantity of urine was probably increased, and it was 
pale, with a small amount of pus and renal cells. 16 
EDES, 
Circumcision gave temporary relief, but he finally 
died comatose. 
The bladder was somewhat contracted, and its 
walls thickened. 
There was no cystitis, but great roughness, owing 
to the hypertrophied muscular fasciculi and diverti- 
cula. The cavity of the bladder, when distended, 
was smaller than natural, and the walls about a 
quarter of an inch thick. There was no stricture in 
the urethra, and the openings of the ureters through 
the bladder-wall were normally patent. Both ure- 
ters were greatly dilated in their entire length; both 
kidneys were hydronephrotic. 
The author remarks that this is one of three 
similar cases, in the other two of which the cause of 
the urinary irritation was the condition of the pre- 
puce. He also mentioned other cases where incon- 
tinence, associated with an abnormally light urine, 
was relieved by circumcision. 
The following references belong to cases which 
may have had something of this character, but in 
which the clinical details are not sufficient to enable 
us to classify them with certainty. 
A case read by Dr. Acker to the Medical 
Society of the District of Columbia, on February 
13, 1889: A child of five had phimosis, but was 
said always to pass a good stream. The urine 
was said to be normal, but latterly profuse. Death 
from tuberculosis. The bladder was thickened, 
and the ureters and pelves of the kidney slightly 
dilated. HYDRONEPHROSIS. 
Webster {U. S. Med. and Surg. Journal, June, 
1835)- 
Ramsbotham (.Proc. Path. Soc. London, 1848-49, 
P- 75)- 
Little (.Path. Trans., 1861-62). 
Broadbent {Path. Trans., xvi. p. 165). The re- 
porter of this last case thinks there may have been a 
valve in the urethra because one was found in the 
ureter. 
There is a point in the first one of my cases to 
which I should like to call attention, although not 
intimately connected with the subject of the paper 
—that is, the occurrence of hypertrophy of the heart 
in connection with a purely local disease of the kid- 
neys. This has been noted in other cases, some of 
which I have come across in consulting the literature 
of the subject without this special object in view. 
It has occurred in cases of traumatic origin. 
These facts are not in harmony with the theories 
largely held in regard to the connection of cardiac 
and renal disease, nor indeed with that which I have 
myself advocated, to the effect that this connection 
consists in a common dependence on a primary 
condition of the whole arterial system, at first func- 
tional, and afterward structural. They seem to 
show that, sometimes at least, the kidney lesion may 
be directly causative of the cardiac change, and 
without any intervention of arterial degeneration. 
The following report cases of the kind : ' 
Footner {British Med. Journal, 1878, xi. 57). 
Weill {Mem. et Comptes Rendus de Soc. de Med. 
de Lyon, xxiii. Pt. 2). 18 
EDES, HYDRONEPHROSIS. 
Soller (.Lyon Med., vol. xxxv. p. 233). 
Is it not possible that some cases of interstitial 
nephritis in the young, even when they are accom- 
panied by hypertrophy of the heart and by the other 
symptoms usually found in older persons, may origi- 
nate in some local trouble, and not be so closely 
connected with a constitutional affection as those 
with which we are more familiar in persons in 
middle life? Certainly the causes to which we 
attribute, so far as we can, chronic interstitial neph- 
ritis are less operative in the young. 
It seems to me not unreasonable to suppose that 
even that quite slight obstruction to the flow of urine 
may, by the mechanism described above, and with- 
out producing more symptoms than can easily be 
overlooked, set up an amount of renal irritation that 
will in time run into chronic interstitial nephritis; 
and that the back-pressure may be so slight as to 
fail to dilate the ureters and exert itself solely on the 
renal substance. This, I admit, is pushing my doc- 
trine to its extreme limits and beyond the bounds 
of demonstration, but I offer the suggestion for what 
it is worth. THE MEDICAL NEWS. 
A National WeeklyMedical Periodical, containing 28-32 Double- 
Columed Quarto Pages of Reading Matter in Each 
Issue. $5.00 per annum, post-paid. 
Uniting in itself the best characteristics of the magazine and the news- 
paper, The Medical News renders a service of exceptional value to the 
profession. It presents original articles, hospital notes and clinical lectures 
by the ablest writers and teachers of the day, discusses living topics editor- 
ially in a clear and scholarly manner, and employs all the recent and 
approved methods of medical journalism—the telegraph, reporters and a 
corps of special correspondents covering all the medical centres of the 
globe. It thus imparts, without loss of time, all advances of knowledge 
attained in the medical sciences. In short, it is the effort of all concerned 
in the publication of The News that it shall be indispensable to every 
physician in active practice. 
The American Journal of the Medical Sciences. 
Edited by 1. Minis HAYS, A.M , M.D. 
Published monthly, beginning with 1888. Each number 
contains 112 octavo pages, amply illustrated. Price 
reduced to $4.00 per annum, post-paid. 
In his contribution to A Century of American Medicine, published in 
1876, Dr. John S. Billings, U. S. A., Librarian of the National Medical 
Library, Washington, thus graphically outlines the character and services 
of The American Journal—" The ninety-seven volumes of this Journal 
need no eulogy. TJiey contain many original papers of the highest value; 
nearly all the real criticisms and reviews which we possess; and such care- 
fully prepared summaries of the progress of medical science, and abstracts 
and notices of foreign works, that from this file alone, were all other pro- 
ductions of the press for the last fifty years destroyed, it would be possible 
to reproduce the great majority of the real contributions of the world to 
medical science during that period.” 
The Medical News, published every Saturday,' 
The American Journal of the’ Medical 
Sciences, monthly, 
COMMUTATION HATE.—Postage paid. 
in advance, $7 50. 
LEA BROTHERS & CO., 706 & 708 Sansom St., Phi/a.