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 . .k' y‘ E 1h. ‘H‘l

‘ X x u H

, ‘ AN INTRo-‘U DN To 1,,

‘ Functional Programming
 An Introduction to
FUNCTIONAL PROGRAMMING
Through
LAMBDA CALCULUS

Greg Michaelson
Herior-Warr University

DOVER PUBLICATIONS, INC.

Mineolu, New York
 Copyrigh t
Copyright © 1989, 2011 by Greg Michaelson
All rights reserved.

Bibliographical Note
This Dover edition, first published in 2011, is an unabridged republication of
the work originally published in 1989 by Addison-Wesley Publishing Company,
Wokingham, England. The author has provided a new Preface for this edition.

Library of Congress Cataloging-in-Publication Data

Michaelson, Greg, 1953—
A n introduction to functional programming through Lambda calculus l
Greg Michaelson. — Dover ed.
p. cm.
Originally published: Workingham, England : Addison-Wesley, 1989.
Includes bibliographical references and index.
ISBN-13: 978-0-486-47883-8
ISBN-10: 0-486-47883-1
1. Functional programming (Computer science). 2. Lambda calculus. I.
Title.
QA76.6.M4854 2011
005.1'14—dc22
2010031017

Manufactured in the United States by Courier Corporation

47883101
www.doverpublications.com
Preface to the Dover Edition, 2011
Context
When I started to write this book in 1986, functional programming seemed
on a n upward trajectory, out of academia into “real-world” computing.
Spurred by the Japanese 5th Generation programme, many other nations initi-
ated research and development schemes around “stateless” declarative pro-
gramming languages. The Japanese projects laid great stress on hardware and
software to support logic programming. In contrast, the U K Alvey pro-
gramme gave equal emphasis to functional languages. Thus, major British
multi-University and industry projects sought to develop viable functional
computing platforms at all levels, from VLSI and multi-processor hardware
for graph reduction and combinators, like Cobweb, Alice and GRIP, through
novel programming languages, like Hope, Standard M L and Haskell, to fully
integrated systems like the Flagship.
Despite lasting research successes, overall the 5th Generation programmes
utterly failed to make any impact on the von Neumann/imperative language
status quo, and are now largely forgotten. In particular, declarative languages
were oversold as the solution to the “software crisis”. The core claim was that
the absence of state provided a model that greatly simplified high levels of
abstraction, component based software construction, parallel implementa-
tion and proof of correctness. M y original Introduction to this book is one
such example of zeitgeist enthusiasm.
While declarative languages have many advantages for problems which are
highly compositional in their data, the lack of state is a major hindrance for
most substantive applications which do things in rather than beyond time.
Similarly, while proving properties of declarative programs may, for small
exemplars, be somewhat easier than for imperative code, this again depends
on highly compositional program structure. The bottom line is that con-
structing and proving correct programs is hard, be it in a declarative or
imperative language.
Nonetheless, research in functional programming has remained buoyant
and its industrial significance is steadily growing, if somewhat more slowly
than anticipated 25 years ago. Most strikingly, Ericsson’s Erlang, originally
used for telecommunications, is gaining wider currency for general multi-
process systems. Furthermore, Microsoft Research supports the development
of the Haskell language and has integrated its own Standard ML-derivedF#
into the core .NET framework. Constructs from functional languages have
also found their way into mainstream imperative languages. Thus, functional
abstraction is supported in Microsoft’s system language C#, the general pur-
pose Ruby, the scripting language Python and the Java-derived Groovy.
Finally, cheap high performance computing on tens of thousands of com-
modity platforms has enabled international Internet businesses to build ser-
vices on standardised parallel frameworks, based explicitly on higher order
constructs. For example, Google’s search engines are driven by their proprie-
tary Map-Reduce, and Yahoo deploys Apache’s open source Hadoop.

iii
lV PREFACE TO THE DOVER EDITION

And, 75 years o n from Alonzo Church’s pioneering exploration of the

entscheidungsproblem‘, Acalculus remains central to Computing education
and research. Functional programming is a routine component of many
Computer Science undergraduate programmes, as are computability theory,
and, to a lesser extent, formal semantics. Functional techniques are being
used i n novel approaches to constructing scalable heterogeneous multi-pro-
cessor systems and to developing mission and safety critical systems requir-
ing strong assurances that requirements are met. New calculi building on 1
calculus have been systematically developed for modelling multi-process sys-
tems, for example Milner’s Communicating Concurrent Systems, 1] Calculus
and bigraphs.

Content
Looking at this book from a markedly older a n d greyer perspective, by and
large I feel happy with it. In particular, I remain firmly wedded to the
pedagogy of learning by abstraction from concrete examples, of under-
standing A calculus through actually “doing” it in an explicitly operational
manner, and of gaining oversight of the layers between a simple, founda-
tional system and a rich language of variegated constructs and structures.
The book’s major eccentricity remains my reformulation of classic Acal-
culus syntax. In Church’s notation, applications in function bodies are
unbracketed, but functions are bracketed except where there is no ambigu-
ity. I chose instead to bracket applications in function bodies but to not
bracket functions except where there is ambiguity, as I felt these were more
in keeping with programming language conventions. In retrospect, I suspect
that this may prove unduly confusing to novices trying to use this book to
complement other sources.
I now think that the account of lazy evaluation could be simplified. There
is also merit in one reviewer’s suggestion2 that a pure lazy polymorphic lan-
guage might have been described given that both Lisp and SML are strict and
impure. However, when the book was written, MirandaTM was a commercial
product and Haskell had not been standardised.
Finally, my favourite chapter remains that on recursion.

Conclusion
When I was wee, my parents had lots of Dover books: Charles Babbage,
Lewis Carroll, Gustave Dore I a m tickled pink to be in the company of
such authors.
So, I would very much like to thank:
° John Crossley for suggesting that I approach Dover;
° John Grafton at Dover for reprinting this book, and for all his support.

Greg Michaelson, Edinburgh, May 2011.

1 Church, Alonzo, A n unsolvable problem of elementary number theory, American Journal of

Mathematics, 58 (1936), pp. 345—363.
2 R . Jones, Times Higher Education Supplement, p29, 29/9/89.
Preface

Overview
This book aims to provide a gentle introduction to functional pro-
gramming. It is based on the premise that functional programming
provides pedagogic insights into many aspects of computing and offers
practical techniques for general problem solving.
The approach taken is to start with pure A calculus, Alonzo Church’s
elegant but simple formalism for computation, and to add syntactic layers
for function definitions, booleans, integers, recursion, types, characters,
lists and strings to build a fairly high level functional notation. Along the
way, a variety of topics are discussed including arithmetic, linear list and
binary tree processing, and alternative evaluation strategies. Finally,
functional programming in Standard ML and Common LISP, using
techniques developed throughout the book, are explored.

Readership
This book is intended for people who have taken a first course in an
imperative programming language like Pascal, FORTRAN or C and have
written programs using arrays and subprograms. There are no mathe-
matical prerequisites and no prior experience with functional programming
is required.
The material from this book has been taught to third year undergra-
duate Computer Science students and to postgraduate Knowledge-Based
Systems MSc students.

Using the book

The material is presented sequentially. Each chapter depends on previous
chapters. Within chapters, substantial use is made of worked examples.
Each chapter ends with exercises which are based directly on ideas and
techniques from that chapter. Specimen answers are included at the end of
the book.
vi PREFACE

Approach
Within this book, A calculus is the primary vehicle for developing
functional programming. I was trained in a tradition which saw A calculus
as a solid base for understanding computing and my own teaching
experience confirms this. Many books on functional programming cover A
calculus but the presentation tends to be relatively brief and theoretically
oriented. In my experience, students whose first language is imperative
find functions, substitution and recursion conceptually difficult. Conse-
quently, I have given a fair amount of space to a relatively informal
treatment of these topics and include many worked examples. Functional
programming aficionados may find this somewhat tedious. However, this is
an introductory text.
This book does not try to present functional programming as a
complete paradigm for computing. Thus, there is no material on the formal
semantics of functional languages or on transformation and implemen-
tation techniques. These topics are ably covered in other books. By
analogy, one does not buy a book on COBOL programming in anticipation
of chapters on COBOL’s denotational semantics or on how to write
COBOL compilers. However, a number of topics which might deserve
more thorough treatment are omitted or skimmed. In particular, there
might be more discussion of types and typing schemes, especially abstract
data types and polymorphic typing, which are barely mentioned here. I feel
that these really deserve a book to themselves but hope that their coverage
is adequate for what is primarily an introductory text. There is no mention
of mutual recursion which is conceptually simple but technically rather
awkward to present. Finally, there is no discussion of assignment in a
functional context.
The functional notation developed in the book does not correspond
to any one implemented language. One of the book’s objectives is to
explore different approaches within functional programming and no single
language encompasses these. In particular, no language offers different
reduction strategies.
The final chapters consider functional programming in Standard
ML and Common LISP. Standard ML is a modern functional language
with succinct syntax and semantics based on sound theoretical principles.
It is a pleasing language in which to program and its use is increasing
within education and research. SML’s main pedagogic disadvantage is
that it lacks normal order reduction and so the low-level A calculus
representations discussed in earlier chapters cannot be fully investigated
in this language.
LISP was one of the earliest languages with an approximation to a
functional subset. It has a significant, loyal following, particularly in the
artificial intelligence community, and is programmed using many functio-
nal techniques. Here, Common LISP was chosen as a widely used modern
LISP. Like SML, it lacks normal order reduction. Unlike SML, it
 PREFACE vii

combines minimal syntax with baroque semantics, having grown

piecemeal since the late 19505.

About the chapters

In Chapter 1, we will look at the differences between imperative and
functional programming, consider the origins of functional pro-
gramming in the theory of computing, survey its role in contemporary
computing and discuss A calculus as a basis for functional pro-
gramming.
In Chapter 2, we will look at pure )\ calculus, examine its syntax and
evaluation rules, and develop functions for representing pairs of objects.
These will be used as building blocks in subsequent chapters. We will also
introduce simplified notations for A expressions and for function defi-
nitions.
In Chapter 3, we will develop representations for boolean values
and operations, numbers and conditional expressions.
In Chapter 4, we will develop representations for recursive functions
and use them to construct arithmetic operations.
In Chapter 5, we will discuss types and introduce typed represen-
tations for boolean values, numbers and characters. Notations for case
definitions of functions will also be introduced.
In Chapter 6, we will develop representations for lists and look at
linear list processing.
In Chapter 7, linear list processing techniques will be extended to
composite values and we will consider nested structures such as trees.
In Chapter 8, we will discuss different evaluation orders and
termination.
In Chapter 9, we will look at functional programming in Standard
ML, making use of the techniques developed in earlier chapters.
In Chapter 10, we will look at functional programming in LISP using
the techniques developed in earlier chapters.

Notations
In this book, different typefaces are used for different purposes. Text is in
Times Roman. New terms and important concepts are in Times Bold.
Programs and definitions are in Helvetica. Greek characters are used in
naming A calculus concepts:

or — alpha
3 — beta
x — lambda
n —eta
viii PREFACE

Syntactic constructs are defined using Backus-Naur-Form (BNF) rules.

Each rule has a rule name consisting of one or more words within angle
brackets < and > . A rule associates its name with a rule body consisting of
a sequence of symbols and rule names. If there are different possible rule
bodies for the same rule then they are separated by ‘I’. For example, binary
numbers are based on the digits 1 and 0:

<digit> ::= 1 I 0

and a binary number may be either a single digit or a digit followed by a

number:

<binary> ::= <digit> | <digit> <binary>

Acknowledgements
I had the good fortune to be taught Computer Science at the University of
Essex from 1970 to 1973. There I attended courses on the theory of
computing with Mike Brady and John Laski, which covered )t calculus,
recursive function theory and LISP, and on programming languages with
Tony Brooker, which also covered LISP. Subsequently, I was a post-
graduate student at St Andrews University from 1974 to 1977 where I
learnt about functional language design and implementation from Tony
Davie and Dave Turner. I would like to thank all these people for an
excellent education.
I would also like to thank my colleagues at Napier College, Glasgow
University and Heriot-Watt University with whom I have argued about
many of the ideas in this book, in particular Ken Barclay, Bill Findlay,
John Patterson, David Watt and Stuart Anderson.
I would, of course, like to thank everyone who has helped directly
with this book:
0 Paul Chisholm for patiently and thoroughly checking much of the
material: his help has been invaluable.
0 David Marwick for checking an early draft of Chapter 1 and Graeme
Ritchie for checking an early draft of Chapter 10.
0 Peter King, Chris Miller, Donald Pattie, Ian Crorie and Patrick
McAndrew, in the Department of Computer Science, Heriot-Watt
University, who provided and maintained the UNIX facilities used
to prepare this book.
0 Bob Colomb at CSIRO Division of Information Technology, Syd-
ney for providing a most pleasant environment within which to
complete this book.
 PREFACE ix

0 Mike Parkinson and Stephen Troth at Addison-Wesley for their

help in the development of this book, and Andrew McGettrick and
Jan van Leeuwen for their editorial guidance.
I would particularly like to thank Allison King at Addison-
Wesley.
Finally, I would like to thank my students.
I alone am responsible for errors lurking within these pages. If you
spot any then please let me know.

Greg Michaelson
Edinburgh and Sydney
1988
Contents

Preface to the Dover Edition iii

Preface

Chapter 1 Introduction
1.1 Names and values in programming
1.2 Names and values in imperative and functional
languages
1.3 Execution order in imperative and functional
languages
1.4 Repetition in imperative and functional languages
1.5 Data structures in functional languages
1.6 Functions as values
1.7 The origins of functional languages
1.8 Computing and the theory of computing
1.9 A calculus
Summary

Chapter 2 Acalculus 15
2.1 Abstraction 16
2.2 Abstraction in programming languages 19
2.3 Introducing )\ calculus 20
2.4 A expressions 21
2.5 Simple A functions 23
2.6 Introducing new syntax 30
2.7 Notations for naming functions and B reduction 31
2.8 Functions from functions 31
2.9 Argument selection and argument pairing
functions 33
2.10 Free and bound variables 38
2.11 Name clashes and a conversion 43
2.12 Simplification through 1] reduction
Summary 45
Exercises 47
xii CONTENTS

Chapter 3 Conditions, booleans and numbers 49

3.1 Truth values and conditional expression 50
3.2 NOT 51
3.3 AND 52
3.4 OR 54
3.5 Natural numbers 55
3.6 Simplified notations 59
Summary 61
Exercises 62

Chapter 4 Recursion and arithmetic 65

4.1 Repetitions, iteration and recursion 66
4.2 Recursion through definitions?
4.3 Passing a function to itself 69
4.4 Applicative order reduction 72
4.5 Recursion function 73
4.6 Recursion notation 77
4.7 Arithmetic operations 78
Summary 82
Exercises 84

Chapter 5 Types 87
5.1 Types and programming 88
5.2 Types as objects and operations 89
5.3 Representing typed objects 91
5.4 Errors 92
5.5 Booleans 94
5.6 Typed conditional expression 97
5.7 Numbers and arithmetic 98
5.8 Characters 101
5.9 Repetitive type checking 104
5.10 Static and dynamic type checking 107
5.11 Infix operators 107
5.12 Case definitions and structure matching 108
Summary 111
Exercises 113

Chapter 6 Lists and strings 115

6.1 Lists 116
6.2 List representation 119
6.3 Operations on lists 122
6.4 List notation 124
 CONTENTS

6.5 Lists and evaluation 127

6.6 Deletion from a list 127
6.7 List comparison 129
6.8 Strings 131
6.9 String comparison 132
6.10 Numeric string to number conversion 134
6.11 Structure matching with lists 139
6.12 Ordered linear lists, insertion and sorting 140
6.13 Indexed linear list access 142
6.14 Mapping functions 146
Summary 150
Exercises 151

Chapter 7 Composite values and trees 153

7.1 Composite values 154
7.2 Processing composite value sequences 155
7.3 Selector functions 157
7.4 Generalized structure matching 160
7.5 Local definitions 164
7.6 Matching composite value results 164
7.7 List inefficiency 167
7.8 Trees 168
7.9 Adding values to ordered binary trees 169
7.10 Binary tree traversal 173
7.11 Binary tree search 174
7.12 Binary trees of composite values 176
7.13 Binary tree efficiency 178
7.14 Curried and uncurried functions 179
7.15 Partial application 181
7.16 Structures, values and functions 183
Summary 183
Exercises 184

Chapter 8 Evaluation 187

8.1 Termination and normal form 188
8.2 Normal order 189
8.3 Applicative order 190
8.4 Consistent applicative order use 191
8.5 Delaying evaluation 193
8.6 Evaluation termination, the halting problem,
evaluation equivalence and the Church-Rosser
theorems 196
8.7 Infinite objects 197
xiv CONTENTS

8.8 Lazy evaluation 199

Summary 204
Exercises 205

Chapter 9 Functional programming in Standard ML 207

9.1 Types 208
9.2 Lists 209
9.3 Tuples 210
9.4 Function types and expressions 211
9.5 Standard functions 212
9.6 Comparison operators 218
9.7 Functions 218
9.8 Making bound variables’ types explicit 219
9.9 Definitions 220
9.10 Conditional expressions 221
9.11 Recursion and function definitions 221
9.12 Tuple selection 222
9.13 Pattern matching 223
9.14 Local definitions 225
9.15 Type expressions and abbreviated types 226
9.16 Type variables and polymorphism 227
9.17 New types 230
9.18 Trees 234
9.19 )\ calculus in SML 237
9.20 Other features 238
Summary 238
Exercises 238

Chapter 10 Functional programming and LISP 243

10.1 Atoms, numbers and symbols 244
10.2 Forms, expressions and function applications 245
10.3 Logic 245
10.4 Arithmetic and numeric comparison 246
10.5 Lambda functions 248
10.6 Global definitions 250
10.7 Conditional expressions 251
10.8 Quoting 252
10.9 Lists 253
10.10 List selection 255
10.11 Recursion 256
10.12 Local definitions 257
10.13 Binary trees in LISP 257
10.14 Dynamic and lexical scope 259
Other documents randomly have
different content
certain lower animals (the dog, wolf, horse, ox, etc.), but rarely
those of man.

Malarial Hæmaturia and Hæmoglobinuria.

SYNONYMS.—Intermittent hæmaturia; Paroxysmal hæmaturia; Malarial

yellow fever; Swamp yellow fever; Paroxysmal congestive hepatic
hæmaturia (Harley).

Perhaps the most important form of hæmaturia and hæmoglobinuria

resulting from general causes is that due to malarial poisoning. I
prefer the term malarial to intermittent or paroxysmal, not only
because it more precisely indicates the cause of the condition, but
also because the condition itself is by no means always intermittent,
sometimes continuing without interruption until checked by
appropriate treatment; and I have known it to continue
uninterruptedly for a year, in spite of all treatment.

The first complete report of an undoubted instance of this affection

appears to have been published by Dressler in 1854,2 although
incomplete and uncertain cases were reported prior to this date—
one as early as 1832 by Elliotson.3 G. Troup Maxwell of Ocala,
Florida, writes me, in 1883, that he first observed cases in Florida
thirty years ago, and published an article on the disease in the
Oglethorpe Medical Journal, Savannah, Ga., July, 1860. George
Harley4 early contributed to our accurate knowledge of the subject in
1865, and since then numerous papers and reports of cases have
appeared in English and American journals, the southern part of the
United States being a fertile scene of the affection, while it is by no
means rare in the Middle States.
2 "Ein Fall von intermittirender Albuminurie und Chromaturie," Virchow's Archiv, Bd.
vi. S. 264, 1854.

3 "Clinical Lecture on Diseases of the Heart, with Ague (and Hæmaturia)," London
Lancet, 1832, p. 500.
 4 "Intermittent Hæmaturia," Medico-Chirurg. Trans. London, 1865.

Two degrees of the disease are met with—a milder form, in which
other symptoms as well as the hæmaturia are less pronounced, and
of which instances occur in the Middle States as well as the South
and West of the United States. Of this kind seem to be the cases
studied by Harley and other English physicians. In addition to this,
there is a second, more malignant, form, attended by great
prostration, vomiting, and yellowness of the skin, along with copious
discharges of bloody urine. Instances of the latter are numerous in
the Southern States of this country, where they have recently been
studied with much care; also in the East and West Indies and in
tropical countries generally. In neither degree of the disease is it
necessary that the red corpuscles of the blood should be present.
They may be represented by their coloring matters alone, when the
condition is called a hæmoglobinuria or a hæmaturia.

The Milder Form.—The subjects, in my experience of eight cases,

have been, with one exception, men, and I believe the experience of
others included more men than women. They are generally able to
recall a history of exposure to malaria, and often of distinct attacks
of malarial fever, intermittent or remittent. The hæmaturia appears
suddenly, and when paroxysmal may occur daily or on alternate days
or a couple of times a week, or even at longer intervals. When the
attacks occur at longer intervals, say of ten days or two weeks, if the
disease is left alone the interval is apt to gradually diminish until the
passage of bloody urine becomes daily. The urine in the morning
may be perfectly clear, and at two o'clock is evidently bloody. It
continues so through one or two acts of micturition, and then
becomes clear again; or it may be bloody on rising and clear up by
noon. Sometimes the bloody urine is preceded or accompanied by a
sense of weariness and chilly feeling, or sometimes simply by cold
hands and feet or by cold knees, or by pallor and blueness of the
face, or by accelerated pulse, or by no other symptoms whatever.
There is sometimes a sense of fulness in the region of the kidney
and sacrum. The attacks are often induced by exposure to cold.
Harley states that in one of the two cases which he reported there
was a slight jaundice, and in the second a "sallowness which
appeared to be due to a disturbance of the hepatic functions," but in
none of the cases which I have met was this symptom present. In
the more malignant form occurring in the tropics and the Southern
States of America, jaundice is a constant symptom.

While a majority of cases of malarial hæmaturia are intermittent,

many are continuous, and of my eight cases only three were
distinctly intermittent. One of these cases I published in a clinical
lecture in the Philadelphia Medical Times as far back as September
1, 1871.

Negroes are not exempt from this milder form of the disease, as
they seem to be from the more malignant form of the South. While
writing this paper I was consulted by a negro thirty-one years old
who had a true malarial hæmoglobinuria, which yielded promptly to
the treatment by quinine. But this was the only negro out of seven
cases.

The duration of the disease is very various, and if neglected may be

indefinite. Stephen Mackenzie5 reports a case which lasted twenty-
three years.
5 "On Paroxysmal Hæmoglobinuria," London Lancet, vol. i., 1884, p. 156.

PHYSICAL AND CHEMICAL CHARACTERS OF THE URINE.—The urine is usually

acid in reaction when passed, sometimes neutral, rarely alkaline, and
ranges in specific gravity from 1010 to 1028. It is always
albuminous, and always tinged by blood coloring matters, the depth
of color varying from the trifling degree known as smoke-hued to a
dark-red or claret color. Sometimes it is even darker, and is often
compared to porter, though this degree of coloration is more
characteristic of the malignant form. The urine deposits a dark,
reddish-brown sediment, generally copious, but varies in quantity
with the degree of coloration of the urine. This sediment is made up
chiefly of red blood-discs or the granular débris resulting from their
disintegration.

Casts of the uriniferous tubules are also often present. They are
usually made up of aggregated red blood-discs or the granular
matter referred to; but they may also be hyaline or hyaline with a
moderate amount of granular matter attached. Granular urates also
at times contribute to the sediment and also adhere to the casts.
Renal and vesical epithelium may occur. Crystals of oxalate of lime
and of uric acid are sometimes present, while blood-crystals have
been found by Gull6 and Grainger Stewart, and a hæmatin crystal
once by Strong.7
6 Guy's Hosp. Reports, 1866, p. 381.

7 British Med. Journ., 1878, vol. ii. p. 103.

That red blood-discs are at times exceedingly scarce, and even

totally absent at the very moment when urine is passed, is a well-
recognized fact; while that the coloring matter present is still that of
the blood, even though no corpuscles are present, is easy of
demonstration by the production of Teichmann's hæmin crystals,8 by
spectrum analysis, or by the guaiacum test.
8 Place a drop of the sediment upon a glass slide and allow it to dry. Mix thoroughly
with a few particles of common salt and cover with a thin glass cover, under which
allow two or three drops of glacial acetic acid to pass. Carefully warm the slide for a
few seconds over a spirit-lamp, and when most of the acetic acid is evaporated,
examine by the microscope. Hæmin crystals will be seen to crystallize out as the
mixture cools.

In the matter of the presence or absence of blood-discs, it is to be

remembered that these may be present at the moment the urine is
passed, but disappear by subsequent solution if the urine happens to
be alkaline or becomes so secondarily. It is an interesting fact, too,
that colorless blood-corpuscles are often present intact, even when
red discs are absent. While I have frequently examined urine sent
me from the South in which the coloring matter of the blood and no
corpuscles were present, only one of the cases coming under my
own observations furnished urine of this character. The proportion of
urea varies, and bears no evident relation to the condition itself.

PATHOLOGY AND MORBID ANATOMY.—The pathology of malarial hæmaturia

consists, as yet, chiefly of theoretical deductions. We can only
conclude that the malarial poison acts upon the blood and blood-
vessels, impairing the integrity of both. This goes so far occasionally
as to produce an actual destruction of blood-discs, and always so
alters the capillaries that they permit the transudation of blood-
elements ordinarily retained.

The morbid anatomy is scarcely more precisely defined. Ponfick9

goes so far as to say that the exudation of hæmoglobulin is not
possible without the concurrence of marked diffuse nephritis.
Recently Lebedeff10 has sought to investigate the more minute
alterations of the kidney in hæmoglobin exudation, but without very
definite results. These, however, on the whole, seem to confirm
Ponfick's view as to the presence of an inflammatory process, as also
do those of Litten11 and Lassar.12
9 "Ueber die Gemeingefährlichkeit der essbaren Morchel," Virchow's Archiv, Bd.
lxxxviii. S. 476, 1882.

10 "Zur Kenntniss der feineren Veränderungen der Nieren bei der

Hämoglobinausscheidung," Virchow's Archiv, Bd. xci. S. 267, Feb., 1883.

11 "Verhandl. des Vereins für innere Medicin," Deut. Med. Wochenschr., No. 52, Dec.
29, 1883.

12 Ibid., No. 1, Jan. 3, 1884.

DIAGNOSIS.—The diagnosis of this condition is not usually difficult. We

have first to determine whether the hemorrhagic discharge is from
the kidney rather than the bladder or ureters. The former is the case
when tube-casts are found. But tube-casts are not always present
even when the hemorrhage is from the kidneys. The absence of
clots and of vesical irritation, and of pain in the course of the
ureters, is characteristic of blood from the kidneys. Finally, all
hæmoglobinurias are renal.

It being certain that the blood comes from the kidney, we have to
distinguish it from that due to cancer, to calculus-irritation, and to
cachexias, as purpura and scurvy; or to grave forms of infectious
disease, septicæmia, pyæmia, etc.; or, finally, to poisonous
substances introduced into the blood, such as arsenic, iodine,
arseniuretted hydrogen, carbonic acid and carbonic oxide gas, and
even certain species of edible fungi.

The diagnosis is greatly aided if it is found we have to do with a

hæmoglobinuria rather than a hæmaturia. For although the former
condition is produced by toxic and septic agencies of another kind,
the attending symptoms, when it is thus produced, are so
characteristic that it is not likely that error can be made.

To aid in distinguishing it from cancer we have the history of malarial

exposure, and often that of other forms of malarial disease; and,
notwithstanding the seeming drain upon the system, none of the
cases I have ever seen present the profound anæmia of cancer. The
bloody discharge in cancer of the kidney is always a true hæmaturia;
there are always blood-discs in the urine. There is often pain in the
region of the kidney in cancer, but never in malarial hæmaturia.

In calculous disease there is almost always pain before or during the

hæmaturic attack, and characteristic crystalline sediments often
appear in the urine.

The disease, being comparatively rare in this latitude, is sometimes

overlooked on this account. Of the 8 cases which I have noted
during sixteen years, 5 originated in Pennsylvania, 1 in New Jersey, 1
in Delaware, and 1 in North Carolina.
TREATMENT.—The treatment is distinctly that of malarial disease, and I
have seldom seen more brilliant and satisfactory results than have
followed the use of quinine in a case accurately determined,
although such success is not invariable; and I have known the
disease to resist for a long time the most thorough and judicious use
of anti-malarial remedies. Usually, however, I take hold of a case of
this kind with considerable confidence. When there are distinct
remissions my practice has been to administer 16 to 20 grains of
sulphate of quinia in the usual manner of anticipation of the
paroxysm in intermittent fever—from 3 to 5 grains every hour until
the required amount is taken; the whole amount may be taken in
two doses, or even in one dose. Where there is no distinct remission
I more usually direct 3 to 5 grains every three hours, until the
hemorrhage ceases or decided cinchonism is produced.

The advantage well known to accrue in malarial disease from the

combination of mercurials with quinine applies to hemorrhagic
malaria as well, although I usually reserve the mercurial until I have
ascertained whether the simple quinine treatment answers the
purpose. If the usual method fails, I give 8 or 10 grains of calomel in
the evening, followed by a saline in the morning, before reinstituting
the quinine treatment. In the case of the colored man alluded to
who had malarial hæmoglobinuria 36 grains of quinine failed to
break the attack; but the same quantity, given after 10 grains of
calomel had acted, succeeded.

Where these means failed I have not found the other methods of
treatment commonly resorted to in obstinate malarial disease to be
any more efficient. I allude to the treatment by arsenic or by iron
and arsenic. Indeed, in the only two cases in which, after failure with
the quinine treatment, iron and arsenic were used at my suggestion,
they failed absolutely. In the one case, under the care of James L.
Tyson, this treatment was carried out most faithfully. After four
weeks' treatment with quinine without effect, Fowler's solution was
given, at first in 5-drop doses three times daily, subsequently
increased to 10 and 15, along with 20- and 30-drop doses of tincture
of the chloride of iron, until oedema of the eyelids occurred, when
the arsenic was discontinued, but the iron continued. In two or three
days the arsenic was recommenced in 3- and 4-drop doses for three
or four weeks longer without effect. Fluid extract of ergot in 20-drop
doses was then substituted for the iron, alternating with the arsenic
for two weeks longer, when some slight favorable change was
apparent, but it was temporary. Repeatedly throughout the
treatment the patient complained of weariness and backache, cold
feet and knees, headache and acceleration of pulse, and a feeling of
utter wretchedness; and then again he would feel quite comfortable
for a day or two, but with little or no change in the urine, except
occasionally in the morning, when it would sometimes be quite light-
hued, but after breakfast would again assume its bloody character. A
sojourn at the seaside for two weeks was without effect.

It will appear from the above that ergot, which has been found
useful in some forms of hæmaturia, is of little service here, as is
attested by two other cases in which I tried it faithfully. At the same
time, it is a remedy which should be tried in case of failure with
others.

The usual astringents, mineral and vegetable, of known efficacy in

the treatment of hemorrhagic conditions, should be used alone or in
conjunction with the specific anti-malarial treatment after the latter
has been found of itself insufficient. To this class of remedies belong
the mineral acids, persulphate of iron, acetate of lead, alum, gallic
acid, catechu, kino, the astringent natural mineral waters, etc.

Rest is certainly an important adjuvant in the treatment of this form

of malarial disease. I have known a recurrence to take place after a
long drive.

It is claimed for many natural mineral waters that hemorrhage from

the 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 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
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 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.

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
4.66
Earthy phosphates

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 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 matter 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 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.
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.

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.
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. Waters6 says
that "the main pathological feature of the complaint is a relaxed
condition of the capillaries of the kidney," which permits the
transudation.
4 Stomach and Renal Diseases, 4th ed., London, 1843.
 5 Lectures on Pathology and Therapeutics, 1868, p. 256.

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
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.
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.

Gubler8 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.
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.
9 Med.-Chir. Trans., vol. xlv., 1862.

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.
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.

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.

Acknowledging filariæ to be the essential cause of chyluria, the

precise method in which they operate to cause the obstruction,
dilatation, and rupture of the lymphatics is a matter of speculation.
The embryo filariæ are so lithe and small that they move among the
corpuscles apparently without harming them, but the ova in which
the embryos lie coiled up, and which are often discharged
unhatched, are large enough to cause obstruction in the smaller
lymphatics and lymph-passages of the lymphatic glands, and thus
cause the phenomena of chyluria, as well as of the other diseases of
the lymphatic system with which it is often associated, or which may
occur independently of it, such as elephantiasis, cutaneous lymph-
vesicles with their chylous and lymphous discharges, lymph scrotum,
chylous hydrocele, and other diseases of the lymphatics. Indeed, the
total number of affections other than chyluria which are found
associated with filariæ exceed those of chyluria. Among the diseases
with which it is said to be associated is erysipelas.

It is evident, therefore, that notwithstanding the fact that the

discovery of the Filaria sanguinis hominis has shed a flood of light
upon the subject of chyluria, the fact must not be overlooked that
not a few cases of the disease have occurred in which the most
careful search has failed to find this parasite in the blood. Careful
examinations, during waking and sleeping hours, have been made
without result, so that we cannot deny altogether the possibility of
the disease occurring independent of filariæ as the cause. It is
common, therefore, to speak of parasitic and non-parasitic chyluria.

On the other hand, the filaria embryo is often found in the blood of
persons apparently in perfect health. Manson tells us that out of
every ten Chinamen taken at random, at Amoy, the blood of one will
contain filariæ.

MORBID ANATOMY.—There can hardly be said to be any morbid

anatomy of chyluria, unless we regard the lymphatic lesions which
sometimes accompany it as a part of the disease. Again and again
do we read the reports of autopsies at which the kidneys were found
normal, and where lesions have been noted they were such as are
found due to other causes, and the coincidence was accidental.

SYMPTOMATOLOGY.—Apart from the characteristic urine of the condition,

there are no symptoms which can be regarded as in any way
peculiar to the disease. The mode of onset is usually sudden, and
yet many patients experience no symptoms whatever, and would be
quite unaware that they were afflicted in any way, were they not
aware of the fact that they are passing lactescent urine. Since the
discharge is, however, a drain of very valuable nutrient and force-
producing material, most patients sooner or later gradually grow
weaker; and this symptom of weakness becomes sometimes very
marked, so that they fall into a condition of extreme debility, even to
fainting on exertion.

Another symptom sufficiently frequent to deserve mention is pain in

lumbar region, sometimes very severe, sometimes on one side, at
others on both.

Painful micturition, due to obstruction, is also a symptom traceable

directly to the condition of the urine. The disposition of chylous urine
to coagulate has already been alluded to. The coagulation taking
place in the bladder, it is the clot which sometimes obstructs the
urethra and makes urination difficult or impossible. Plugs of
coagulum are ejected, sometimes with considerable force, after
prolonged straining, and with this comes relief to the symptoms,
which may be reproduced through the operation of the same cause.

Other symptoms which are occasionally present may have an

accidental relation to the affection, while they may be due to it. Such
are headache, nausea, and other gastric symptoms.

Mention has been made, too, of the concurrence of superficial

lymphatic leakage, especially on the lower part of the abdomen, the
thighs, and the legs. Such leakage is often from little vesicular
elevations which are evidently dilated lymphatic vessels. The
presence of such leakage should suggest the examination of urine
for lesser degrees of chyluria. In like manner, the urine should be
examined in case of elephantiasis, lymph-scrotum, and chylous
hydrocele, with which also chyluria is sometimes associated.
The effect of intercurrent febrile states, whether symptomatic of
local inflammation, as of the lungs, or whether the result of the
idiopathic fevers, has often a singular effect on chyluria in causing its
disappearance for a time. It would seem that states of high vascular
tension, however induced, tend to make it cease.

While chyluria has made its appearance, for the first time, in a
number of cases during pregnancy, this condition in other instances
has caused it to disappear, especially toward the later months;
whence it would seem that the pressure of the rising womb has a
favorable effect.

The DIAGNOSIS of chyluria consists in the recognition of the chylous

state of the urine. This, ordinarily very easily recognized, might be
taken in its slight degrees for phosphatic or uratic or purulent
conditions of the urine, and vice versâ. The disappearance of the
first on the addition of acids, of the second on the application of
heat or alkalies, will resolve any doubt, while the microscope will
detect the pus-corpuscles in the last. None of the reagents named
will dissolve the fatty molecules of a chyluria, while ether will cause
the fluid to clear up completely.

The PROGNOSIS is usually favorable. Very rarely is an attack fatal, and

when such is the case it is from exhaustion—from the drain to which
the system is subject. Tubercular phthisis is therefore a not
infrequent immediate cause of death.

TREATMENT.—On the supposition that filariæ are the essential cause of

the disease, the rational indication would be first to destroy them by
the introduction into the blood of some parasiticide; and, second, to
repair the lesion of communication between the lymphatic system
and the urinary passages. As yet no agent is known which would not
be as fatal to the host as to the filaria, if used in sufficient quantity
to destroy the latter; nor has it ever been possible to find the point
of communication between the two systems, although treatment has
been directed to producing closure of such communication, and with
some show of success. Thus, in a case under his care Dickinson of
London injected into the empty bladder twelve ounces of a solution
of perchloride of iron, containing at first two drachms of the tincture
to the whole quantity, gradually increased to four drachms. The
solution was retained in the bladder for from eight to twelve minutes
with little or no inconvenience. The operation was repeated almost
daily for twelve days. The effect was always to check the milky flow
and to substitute a clear urine. But after the operation had been
repeated a certain number of times there was a decided rise of
temperature, with headache, nausea, lumbar pain, hæmaturia, and
albuminuria which continued a short time after the hæmaturia
ceased. Singularly, too, with the subsidence of these symptoms, the
chyluria remained absent for some time. The injections were
resumed on its return, and each time were followed by relief. In the
course of their use, however, the strength of the solution was
increased to an ounce of the perchloride to twelve ounces of water,
and the strongest solutions were retained in the bladder for as much
as an hour, the weaker longer. Ultimately, however, the use of the
injections became so painful that they had to be discontinued.

Another measure, employed by Bence Jones, was abdominal

pressure by means of a belt. This also, in his experience, relieved
the lumbar pain. In his case, which was about eight years under
observation, Dickinson applied the pressure by a sort of tourniquet
about an inch below the umbilicus. This lessened, though it did not
stop, the pulsation in the femoral arteries. It also was successful at
first, the chylosity lessening, and finally ceasing, but on the removal
of the belt the chylous character gradually returned, and in sixteen
hours was as bad as before. Repeated trials were followed by the
same transient effect, but no cure. Under this treatment, however,
combined with a liberal diet and rest, the patient gained many
pounds in weight, and was able to leave the hospital and resume her
occupation as dressmaker, the pursuit of which, and the absence of
the favorable conditions of hospital-life, as invariably caused a return
of the symptom and its resulting debility, which again caused her to
seek admission.
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