the prompt and efficient action of these measures. We have no knowledge of remedies which will neutralize the toxical properties of urea accumulating in the blood. Elimination, so as to reduce the quantity below the amount requisite to produce poisonous effects, is the only resource. It is a therapeutical object to forestall the development of uræmia sufficient to give rise to poisonous effects in the cases in which an examination of the urine shows a notable deficiency of urea, or an examination of the blood-serum shows an excess of this excrementitious principle. A moderate bydragogue action may be maintained for this object, or the hot-air bath may be employed once or twice daily. Under these circumstances diuretics may be adequate, if the kidneys respond to them. It might be supposed that diuretics are objectionable on the score of their increasing the excretion of albumen in the urine. Experience shows that they do not produce this effect; although the quantity of urine is augmented, the amount of albumen is generally not greater than before, and it may even be diminished.

So far the treatment relates not to the disease itself but to its effects. There are no known therapeutical measures to be employed for the removal of the morbid conditions of the kidneys. Certain remedies have been sup posed to have a special curative effect, viz., the tincture of cantharides, nitric acid, and preparations of mercury. Experience has failed to establish the efficacy of these or other remedies addressed directly to the kidneys. Much, however, may often be done by judicious management toward arresting the progress of the disease, prolonging life, and, in some cases, securing comfortable health for an indefinite period. Tonic remedies are indicated. The preparations of quinia and iron are the most efficient. Here, as in other affections in the treatment of which the long-continued use of tonics is important, a change of remedies from time to time is advisable.

Hygienic measures are of the first importance. Alimentation, as abundant and nutritious as the powers of digestion will admit of; clothing, to secure uniform warmth and activity of the functions of the skin; and such an amount of out-door life as the strength of the patient will bear, constitute the hygienic management. Abeille states that hydropathic measures have been found useful in France. Travelling, especially a long sea voyage, has been found highly useful. Some striking illustrations of the efficacy of the latter are cited in Johnson's treatise. It is hardly necessary to add that all causes of debility or disorder are, as far as possible, to be removed. Overtasking of body or mind, exposure to vicissitudes of weather, the use of alcoholic stimulants, save as a means of aiding appetite and digestion, and taken for these objects, if at all, very sparingly, venereal indulgences and dietetic imprudences, are to be interdicted.

Symptoms, other than those already referred to, in certain cases, call for treatment. Cephalalgia and neuralgic pains in different situations call for palliative measures. Opiates, however, are to be given with circumspection. Observation has shown that opium, in moderate doses, is liable to produce marked and even fatal narcotism if the blood be surcharged with urea. fact that an unusual amount of narcotic effect may be produced by opium does not preclude its use, but enforces the importance of using it with

caution.

The

Vomiting and purging, if excessive, claim interference, but it is to be recol lected that generally these symptoms denote the vicarious elimination of urea through the alimentary canal. It would be injudicious to attempt to arrest the eliminatory process in this direction, but, as excessive vomiting and purging preclude adequate alimentation, palliative measures are sometimes to be employed. Relief may be procured indirectly by favoring elimination through the cutaneous surface by means of the hot-air bath. Direct palliation may

be obtained by pieces of ice taken into the stomach, by rubefacients or dry cups applied to the abdomen, and by the internal use of hydrocyanic acid, creasote, the oxalate of cerium, and the preparations of bismuth. The latter are often highly useful.

Astringent remedies have been advised with a view to restrain the excretion of albumen in cases in which the urine is highly albuminous. Tannie or gallic acid, the acetate of lead, and the astringent preparations of iron have been used for this purpose. I have repeatedly made trial of remedies for the end just stated, but with little or no effect.

The treatment of complications, such as serous inflammations, or of affections which may be accidentally associated with chronic Bright's disease, is to be modified by the coexistence of the latter. Active measures, which, under other circumstances might be admissible, are contraindicated. General or local bloodletting, mercury, and other depressing measures, as a rule, are injudicious. If there be exceptions to this rule, they are of rare occur

rence.

In conclusion, the management, as has been seen, does not embrace special medication, but, in addition to remedies for particular symptoms or effects, and the treatment of consecutive affections, it consists, in a great measure, in the removal of all morbific causes and in hygienic regulations. The object is not to effect recovery from the damage that has been done, but to prevent further injury of the diseased organs, recollecting that the existence of a certain amount of disease is not incompatible with the continuance of life and comfortable health for many years. The advantage of an early diag nosis is very great in this disease. The same consideration is applicable here as in cases of pulmonary tuberculosis, viz., inasmuch as everything is to be hoped for from arrest of the progress of the disease, the earlier its existence is ascertained the less will be the amount of damage before the disease is stayed.

CHAPTER III.

Simple Renal Cysts-Hydatids in the Kidney-Renal Tuberculosis-Carcinoma of the Kidneys-Movable Kidney-Diabetes Mellitus-Anatomical Characters-Clinical HistoryPathological Character-Causation-Diagnosis-Prognosis-Treatment.

THE kidneys are sometimes the seat of affections involving structural changes other than those already considered. Carcinoma and the tuberculous deposit occasionally occur in these organs. Hydatids and simple cysts are additional affections in this category. Their interest for the pathological anatomist is greater than their practical importance to the physician, inasmuch as it is often difficult or impossible to determine the fact of their existence clinically. On this account they claim, in this work, only a passing notice. Having noticed these affections, the remainder of this chapter will be devoted to the consideration of diabetes mellitus.

SIMPLE RENAL CYSTS.

Cysts discoverable with the aid of the microscope, or microscopical cysts, are frequently found in chronic Bright's disease, more especially in the contracted kidney. Cysts apparent to the naked eye are not infrequent, varying

in size from that of a pin's head to an almond or even larger. The manner in which they are produced has, of late, excited considerable discussion. Johnson attributes them to dilatation of portions of the renal tubes. Simon and others consider them as "abnormal development of epithelial germs." Either with or without the morbid conditions which belong to Bright's disease, cysts are sometimes produced in sufficient number and size to involve considerable, and even total, destruction of the renal parenchyma. The volume of the kidneys is, in some cases, greatly increased. A cyst may project from the kidney and form a tumor considerably larger than the kidney. My colleague, Prof. Alexander B. Mott, has a specimen of this kind. There may be a single cyst of greater or less size, or numerous cysts. One kidney of both kidneys may be affected, oftener the latter. The cysts contain a liquid which may be limpid and colorless, of a citron color, or sometimes quite dark. Occasionally the contents are thick and sometimes nearly or quite solid. They sometimes contain crystals of cholesterine, and I have seen a tumor of the size of an English walnut projecting from the kidney, which contained a solid mass of pure cholesterine. The liquid contents of renal cysts rarely contain the constituents of the urine.

The symptoms may point to the existence of renal disease if the cysts are sufficiently numerous or large to occasion considerable interference with the circulation in the kidneys, or with their secretory function. The urine may be scanty or abundant; it will be likely to contain albumen, and will be more or less deficient in urea and the other solid constituents. General dropsy may occur and the effects of uræmia. Under these circumstances, the

disease will be considered as Bright's disease prior to the autopsy.

Renal cysts are often discovered in the dead-house, when there had been no symptoms during life pointing to disease of the kidneys. If the cysts be not large nor numerous enough to involve considerable destruction of the renal parenchyma, and Bright's disease be not associated, they may not have occasioned any appreciable inconvenience.

Were their existence discoverable during life, the indications for treatment would relate to the symptoms and effects.

HYDATIDS IN THE KIDNEY.

Hydatids in the kidney are, in all respects, similar to those in other organs, for example the liver, and a description of them need not be here repeated. Their occurrence in the kidney is extremely rare. They occur in only one kidney, as a rule to which there are very few, if any, exceptions. They do not, therefore, interfere with the excretion of urine sufficiently to occasion uræmia. If they interfere with the secretory function of one kidney, the augmented functional activity of its fellow makes up for the deficiency. So long as the hydatids remain intact within the renal parenchyma they give rise to no well-marked symptoms, and they may remain for an indefinite period completely latent. They are found after death when no renal trouble had been manifested during life. They sometimes attain to a sufficient size to form a tumor perceptible by palpation. The symptoms to which they give rise depend on inflammation, ulceration, and the discharge of the hydatids in different directions.

If the hydatid cyst open into the pelvis of the kidney the hydatids pass through the ureter into the bladder, and are discharged with the urine. In their passage along the ureter they may give rise to the same train of symp toms as the passage of a renal calculus, in other words, to nephritic colic. Owing to their elasticity, hydatids of considerable size may pass into the bladder and through the urethra without great difficulty, and without much

pain. Cases have been reported in which they were discharged in great numbers. Their passage may be accompanied with hematuria and pyuria. The latter is due to suppuration of the hydatid cyst.

The hydatid cyst sometimes develops in a direction toward the suface of the kidney, and opens into the post-renal areolar tissue. Suppuration takes place and an abscess forms in the lumbar region, which, when opened or allowed to open spontaneously, gives exit to hydatids together with pus in greater or less quantity. Hydatid cysts in the kidney have been known to open into the peritoneal cavity, the stomach, intestinal canal, and even into the lungs; the bydatids, in the latter case, being expectorated. And, again, hydatids in this as in other situations, sometimes die, the cyst contracts and becomes obliterated, or contains a certain amount of calcareous matter, a spontaneous cure in this way taking place.

The diagnosis of this affection cannot be made prior to the discharge of the hydatids in some one of the directions just stated. The prognosis, in cases in which the hydatids are discharged through the renal passages, or in the lumbar region, is not very unfavorable.. The treatment does not embrace any special therapeutical measures, but is to be governed by the symptoms and circumstances proper to individual cases.

RENAL TUBERCULOSIS.

A tuberculous deposit in the kidneys is always secondary to pulmonary tuberculosis. It is rare for secondary tuberculosis to occur in this situation, but specimens of an abundant deposit are occasionally met with. I have seen both kidneys crammed with yellow tubercle, the deposit contained in abundance within the pelvic cavity as well as within the renal parenchyma. In this case the vesiculæ seminales were also filled with tuberculous matter.

The diagnosis can hardly be made with any degree of positiveness, and the therapeutical measures, were the existence of tubercle in these organs determinable, would be those indicated by the tuberculous affection of the lungs.

CARCINOMA OF THE KIDNEYS.

Cancer is very rarely seated in the kidneys, save when it extends to these organs from an adjoining situation. In the cases in which the affection is seated in these organs the form of cancer is usually the encephaloid. The cancerous deposit may be presented in one or more masses of variable size, situated in the cortical portion, without much enlargement of the organ, or the kidney may be greatly enlarged so as to form a tumor discoverable by the touch.

Hematuria, the source of the blood being evidently the kidney, with or without preceding and accompanying pains in the renal region, calculous pyelitis being excluded, and especially if an irregular painful tumor be felt, renders the diagnosis probable. The diagnosis, under these circumstances, is quite positive if cancer exists in some other situation.

Palliative measures of treatment only are indicated.

MOVABLE KIDNEY.

One of the kidneys is sometimes loosened so as to form a movable tumor which may be felt through the abdominal walls. This is to be recollected in determining the nature of obscure tumors within the abdomen. The right kidney oftener than the left is movable; it occurs in females oftener than in

males; it is not common. An example in the dead body has never come under my observation.

A movable kidney occasions pain in the lumbar region, especially after muscular exertion, and a sense of uneasiness in the abdomen. The diagnosis must rest on the situation of the tumor, a correspondence with the kidney in size and form, and tympanitic resonance on percussion, showing the presence of intestine posteriorly in the site of the kidney.

Mechanical compression of the abdomen by means of a bandage, belt, or abdominal supporter, obviates, in a measure, the inconvenience attending this anomaly.

DIABETES MELLITUS, OR SACCHARINE DIABETES.
GLUCOSURIA. MELITURIA. GLUCOHÆMIA.

The term diabetes signifies simply increased flow of urine, or diuresis. This is generally a notable feature of the affection now to be considered. The presence of sugar in the urine, however, is the distinctive feature of this affection. Hence the significance of the term mellitus. An excessive flow of urine devoid of sugar, constitutes another form of diuresis, which has been also called diabetes, and distinguished as diabetes insipidus. A better name for the latter is polyuria. This has been already noticed in connection with morbid thirst or polydipsia.' Glucosuria and melituria are names applied to the affection characterized by diuresis and saccharine urine, and they are to be preferred to diabetes mellitus. The term glucohæmia, denoting a saccharine condition of the blood, is, however, to be preferred to either. The affection is far from being of frequent occurrence, yet it is not so rare but that cases occasionally come under the observation of every physician.

Sugar in the urine, like albuminuria, occurs not infrequently as a symptom in various pathological connections. The sugar, under these circumstances, is usually not abundant, and it is a transient symptom, that is, the urine contains it for a brief period only. As the distinctive feature of an individual affection, the sugar which the urine contains is in greater or less abundance, and it continues persistingly in the urine. Even when the affection exists, the saccharine urine is, in fact, merely a symptom. It does not constitute the affection. It is incidental to, or an effect of, the real disease. The sugar exists in the urine because it pre-exists in the blood. Existing everywhere in the vascular system, it is excreted by the kidneys. But, with our present knowledge, the true seat and nature of the disease are not clearly established, and, therefore, provisionally, it is named as if it were a disease of the urinary system, and included, for the sake of convenience, among the diseases affecting this system.

ANATOMICAL CHARACTERS.-Aside from lesions belonging to concomitant or consecutive affections, this disease has no constant anatomical characters. The kidneys are often enlarged, without structural changes, that is, hypertrophied. This is doubtless a result of their long-continued increased functional activity. But this condition of the kidneys is not invariable. Various lesions of the kidneys are occasionally found, but they have no essential pathological connection with the diabetes, and are merely coincidences. Glucosuria and Bright's disease are sometimes associated, the association being accidental. In these cases, the latter is generally, if not invariably, developed after the former. Since the discovery by Bernard of the gluco

Vide page 377.