not on congestion of the Malpighian bodies, as formerly supposed. The extravasation takes place into the tubes and also in the intertubular spaces. The epithelium in some of the tubes contains oil in minute quantities. As regards the gross and microscopical appearances, both kidneys are affected. in a similar manner and in about an equal degree.

CLINICAL HISTORY.-Subcutaneous cedema is a pretty constant symptom, and is usually the first symptom pointing to the existence of this affection. The oedema is generally first observed on the face, particularly below the eyes, but it is speedily observed in the lower extremities, and sometimes occurs first in the latter situation. Coincident with the appearance of the dropsy is more or less febrile movement, frequently preceded by chills or shiverings, together with thirst, anorexia, and pain in the loins. The skin is dry, and the countenance becomes pallid. The dropsy increases and becomes general, varying considerably in amount in different cases. In some cases the anasarca is great, the limbs, scrotum, and penis, or external labia, becoming enormously swollen. In other cases it does not exceed a moderate amount. More or less dropsical effusion usually takes place into the peritoneal and the pleural cavity. Hydrothorax sometimes occurs to such an extent as to occasion great suffering from dyspnoea, and endanger life.

The urine furnishes important symptoms. The quantity is usually scanty. It may be quite small, and suppression sometimes occurs. The specific gravity rarely, if ever, exceeds that of health, viz., about 1.020, and, not infrequently, it is more or less diminished. The diminution denotes deficiency of urea. Tested with heat or nitric acid, the urine is found to contain albumen usually in considerable, and frequently in great, abundance. Not infrequently the urine contains blood. A small quantity of hematin gives to it a smoky or sooty appearance, which is somewhat characteristic of this renal affection. Rayer compares this appearance to that of bouillon de bœuf. Microscopical examination of the sediment of the urine shows frequently blood-globules, together with renal epithelium and crystals of uric acid. But the most characteristic objects are cylindrical bodies which are evidently moulds of the convoluted tubes, and are commonly known as casts. These casts are of different kind. Those regarded as especially characteristic of this affection are composed chiefly of desquamated epithelium from the convoluted tubes. Johnson distinguishes them as epithelial casts. Their average diameter is about inch. Other casts appear to consist of coagulated fibrin. These are diaphanous or wax-like, and are known as hyaline or waxy casts. To these casts, epithelial cells, in more or less abundance, are frequently adherent. The waxy casts are of large or small size. If large, the diameter is about 3 inch. If small, the diameter is about 1000 inch. Large waxy casts are comparatively few in number in this affection. Occasionally the casts appear to consist of coagulated blood, that is, of fibrin with adherent blood-globules. These are called blood-casts. The renal epithelial cells in the sediment sometimes contain a few oil globules.

7

Coma and convulsions occur in a certain proportion of cases. These are symptoms of uræmia. Owing to an insufficient elimination of urea by the kidneys, it may accumulate in the blood to an extent sufficient for the manifestations of its toxical effects upon the brain. Vomiting and purging may precede, or occur without the cerebral symptoms of uræmia, being probably due to an effort to eliminate urea through the gastro-intestinal mucous mem brane. Impaired vision and amaurosis are among the effects of uræmia occasionally observed.

Complications considered as occurring sufficiently often to show, not merely coincidence, but a pathological connection with the affection, are,

bronchitis, pneumonitis, and serous inflammations, especially pleuritis and pericarditis. Pulmonary edema is an occasional complication.

In the course of the affection, the symptoms are apt to present, considerable variation on different days. The quantity of urine, the amount of albumen, etc., vary, and so with respect to the oedema, the effusion into the cavities, and the febrile movement. If uræmic effects and important complications do not occur, the affection continues for a period varying between a few days and a couple of months, the average duration being about four weeks. The approach of convalescence is denoted by notable diminution or disappearance of the dropsy, cessation of febrile movement, return of appetite, and an abundant secretion of urine. Albuminuria usually continues, but in a lessened degree, after the dropsy has disappeared. At length the urine becomes normal and the casts disappear from the sediment. The latter sometimes continue to be found for some time after the albumen has disappeared. The affection may end in complete recovery, or it may eventuate in a chronic affection. The latter is rare. As a rule, if the patient be not cut off by uræmic poisoning or the complications which are liable to occur, the recovery is complete and permanent.

PATHOLOGICAL CHARACTER.-The pathological explanation given by Johnson appears to be consistent with our present knowledge. He regards the affection as an acute inflammation of the membrane lining the convoluted tubes; and, as a prominent feature is the desquamation of the renal epithelium, he has suggested, as an appropriate name, acute, desquamative nephritis. In this affection, as in the chronic affections which involve structural changes, he regards the secreting cells of the kidneys as the primary seat of the local morbid manifestations, these depending on "an effort made by the cells to eliminate from the blood some abnormal product." According to this pathological view, morbid blood-changes underlie the local affection. The obstruction of the tubes and the loss of secreting cells lead to the transudation of blood-serum, causing the albuminuria, and to the deficient elimination of urea, causing in some cases uræmic poisoning. Exudation of fibrin takes place into more or less of these tubes; hence, the hyaline or waxy casts. The diminished density of the blood-serum from the loss of albumen, together with the embarrassment of the capillary circulation from the retention of urinary principles, occasions the dropsy. An examination of the blood in cases of acute albuminuria shows a lessened proportion of albumen, a low specific gravity, paucity of red corpuscles, and an augmented amount of urea. According to Picard, assuming the normal proportion of urea in the blood to be 0.0177 in 1000 parts, the morbid increase varies between 0.0846 and 0.0215. The bronchitis and serous inflammations which are apt to occur as complications are supposed to be due to the action of urea accumulating in the blood. Vomiting and purging are attributable to an effort on the part of the gastro-intestinal mucous membrane to eliminate the urea vicariously.

Both kidneys being alike affected, the affection is bilateral, a fact which goes to sustain the doctrine of dependence on a morbid condition of the ours blood. As exemplifying the pathological law of parallelism, and in other respects, the affection is analogous to bronchitis, and, although involving an obvious solecism, the name renal bronchitis has been applied to it. The epithelial and other casts contained in the sediment of the urine may be compared to the matter of expectoration in cases of bronchitis.

Traité des Maladies à Urines Albumineuses, etc., par J. Abeille, Paris, 1863.

CAUSATION. This affection may occur at any period of life; young infants are not exempt from it. It occurs oftener in males than in females. As already stated, in the majority of cases it is a sequel of scarlatina. It may occur during the progress of scarlatina, or follow directly the stage of desquamation, but it is most apt to occur in the second or third week after the date of convalescence. It is an important question whether this sequel proceed exclusively or chiefly from an agency pertaining intrinsically to scarlatina, or whether it depends on extrinsic causes, such as the action of cold. It occurs in cases in which the utmost care is taken to place the patient beyond the agency of extrinsic causes, but it is probable that the latter are frequently involved.

Exclusive of the cases in which it is a sequel of scarlatina, it occurs in various pathological connections; it is an occasional sequel of diphtheria. It sometimes occurs during the development of pulmonary tuberculosis, in the course of articular rheumatism, in cases of typhoid and typhus fever, erysipelas, measles, and epidemic cholera. Albuminuria and general dropsy occurring in pregnancy depend, in a certain proportion of cases, on this affection. As a primary affection, it occurs especially in persons addicted to intemperance. In these cases it is sometimes difficult to say how much causative agency is to be attributed directly to the action of alcohol and how much to the exposure incidental to intemperance. It is observed not infre quently to become developed after lying on the ground in a state of intoxication. It appears in some cases to be caused by exposure to cold in persons who are temperate, and, finally, it sometimes has no obvious causation.

DIAGNOSIS. The existence of albuminuria is not, in itself, adequate evidence of either the affection under consideration or of the chronic affections of the kidneys which remain to be considered. Clinical observation shows that albumen may be present in the urine, in a small or moderate quantity and for a brief period, in the course of a great number of diseases. In general, the diagnosis is easily made, being based on the occurrence of anasarca, developed rapidly and accompanied with febrile symptoms, and an examination of the urine showing albumen in abundance. Dropsy is an early symptom in the great majority of cases, but it is sometimes wanting. The diagnosis is then to be based on symptoms pertaining to the urine, in conjunction with general symptoms. In addition to the presence of albumen in the urine, the quantity is usually notably lessened; it frequently has a smoky or sooty appearance from the presence of hematin, and it is sometimes distinctly bloody. The sediment of the urine, examined microscopically, is found to contain, in greater or less abundance, the casts which have been described. The presence of these, in conjunction with other characters pertaining to the urine, and the general symptoms, render the diagnosis positive.

PROGNOSIS.-The danger, in cases of this affection, is from uræmia and the complications which are liable to occur. Coma and convulsions always denote imminent and great danger to life, but recovery sometimes takes place notwithstanding these effects of uræmia. Pleuritis, pericarditis, peritonitis, meningitis, and pneumonitis, developed in the course of the affection, are apt to prove fatal. Edema of the lungs may prove a cause of death. Dropsical effusion into both pleural cavities may take place to such an extent as to destroy life. I have seen two cases within the last year in which alarming dyspnoea was due to this cause.

Exclusive of uræmia and serious complications, the prognosis is favorable. The affection does not tend to disorganize the kidneys. It is a self-limited

affection, seldom continuing more than two months, and rarely assuming a chronic form. Cases of the chronic affections which remain to be considered, as a rule, do not originate in an acute attack.

Uræmic poisoning is to be apprehended when the urine is very scanty, and its specific gravity low; in other words, when the quantity of urea eliminated by the kidneys is small. Suppression of urine lasting twenty-four or forty-eight hours places the patient in imminent danger, and, if it continue, is a fatal symptom. Danger from uræmia is not passed, although the albumen may have disappeared from the urine, if the sediment still contain casts. I have known fatal uræmic convulsions to occur under these circumstances.

TREATMENT. The treatment embraces the following leading objects: 1. Diminution of the intensity of the renal inflammation, promotion of resolution, and restoration of the secretory function of the kidneys. 2. Diminution or removal of dropsical effusion. 3. Elimination of urea through the skin and gastro-intestinal mucous membrane if uræmia exist or be threatened.

With reference to the first of these objects, rest and warmth of the surface are important. In general, the patient should keep the bed. The diet should be unstimulating. Water and other bland liquids should be allowed as freely as the thirst dictates. Opium should be given very circumspectly, and, as a rule, is inadmissible on account of its tendency to diminish the secretion of urine. Dry cupping over the loins is the best method of revulsion or counter-irritation, and, if the patient be not feeble or anæmic, the scarificator may be employed. General bloodletting is advisable only in cases in which the patients are plethoric and attacked when in good health. As a rule, after scarlatina, in intemperate persons, and whenever the system is enfeebled from any cause, this measure is inadmissible. Fomentations over the region of the kidneys, by means of moistened cloths covered with oiled muslin and several thicknesses of flannel, or the spongio-piline, are useful. Saline laxatives are useful by way of depletion.

With reference to the dropsy, either saline cathartics or more active hydragogues are indicated in proportion to the amount and situation of the dropsical effusion. In cases in which suffering and danger are incident to hydrothorax, the elaterium is the most prompt and reliable hydragogue. I have repeatedly obtained, by means of this remedy, effectual relief in a few hours when the pleuritic effusion was sufficient to occasion alarming dyspnoea. Gamboge is highly recommended by Abeille, given at first in small doses, progressively increased to fifteen or twenty grains. Jalap and the bitartrate of potassa form an efficient hydragogue. Diuretics are not to be relied upon for the relief of the dropsy; the kidneys will not be likely to respond to them. Moreover, they are generally considered as inadmissible, because their action on the kidneys may increase the inflammation. They are, however, recommended as safe and frequently useful by Christison, Bennett, Gairdner, and others. They may, at all events, be tried so soon as the inflammation abates.

Measures for the vicarions elimination of urea are indicated whenever the diminished quantity of urine and its low specific gravity show the elimination by the kidneys to be greatly deficient. By timely meeting this indication, uræmic poisoning may perhaps be forestalled. Of course, measures for this object are urgently indicated when uræmic poisoning has taken place. Hydragogue cathartics are the most efficient, and next to these the hot-air bath. Both are to be employed in alternation if uræmic coma or convulsions have occurred. If the indication be not urgent, salines and sudorific remedies may suffice. An eligible sudorific remedy is the liquor ammoniæ acetatis in half ounce doses thrice daily. The statement with respect to the use o)

diuretics, with reference to dropsy, of course, is equally applicable to their use for the elimination of urea. They may be cautiously given for both objects when the kidneys begin to act spontaneously. The bitartrate of potassa, digitalis, and the decoction of broom are eligible diuretics.

During convalescence, carefulness as regards diet, exercise, and exposure to cold, is important. Tonic remedies, and especially preparations of iron, are generally indicated.

My clinical records furnish illustrations of complete recovery from this affection when the dropsy was excessive, when life was threatened by hydrothorax and edema of the lungs, and also after the occurrence of uræmic coma and convulsions.

СНАРТER II.

Degenerative Changes or Lesions of the Kidneys generally Characterized by persistent Albuminuria, collectively termed Chronic Bright's Disease or Chronic AlbuminuriaAnatomical Characters-Clinical History-Pathological Character-Causation-Diagnosis

-Prognosis-Treatment.

THE researches of Bright form a memorable epoch in the history of pa thology and practical medicine. Prior observers had been led to the discovery of albuminuria and its connection with general dropsy, and it had long been known that the suppression of urine was followed by coma, convulsions, and death. But Bright was the first to point out the existence of certain morbid conditions of the kidneys, generally characterized by the presence of albumen in the urine, and, leading to secondary affections, in addition to general dropsy, and to fatal toxical effects dependent immediately on the accumulation of urinary principles in the blood. The morbid conditions of the kidneys described by Bright have been considered as constituting an affection commonly known as Bright's disease. Subsequent observers have added much to our knowledge of these conditions, especially as regards the information obtained by means of the microscope. Our knowledge of the blood-changes induced by these conditions, and of ulterior morbid phenomena, has also been much increased by continued clinical observation. The vast importance of the researches of Bright is manifest when it is considered how largely, at the present time, the morbid conditions embraced under the name Bright's disease enter into medical practice.

Under the name Bright's disease, are commonly embraced the acute affection considered in the last chapter, and the chronic, renal lesions which are now to be considered. With respect to the morbid conditions in the acute and chronic form of Bright's disease, there are differences of opinion among pathologists, some regarding them as different stages or modifications of one disease, and others considering them as essentially different affections. The grounds for considering the acute disease as distinct from the chronic have already been referred to. It seems to me sufficiently clear that the term chronic Bright's disease embraces different affections; but, with our present knowledge, it is not always practicable to discriminate them at the bedI shall therefore consider them under one head, noticing incidentally ascertained points of difference relating to anatomical characters, clinical history, etc.