with Bright's disease consists in the presence of albumen in the urine; and from this circumstance it has received, from Martin Solon, the appellation of albuminuria. A symptom no less common, consists in the retention of urea in the blood; from which fact other writers have employed the word uræmia to designate the malady. Others still regard the complaint as dependent not only upon a depraved condition of the blood, but of the entire organism; and, in accordance with this view, Professor Wood, of Philadelphia, has presented us with the term renal cachexia, to express the disease as a unit. Another constant phenomenon connected with the disorder is a more or less rapid production and detachment of the epithelial cells of the tubuli uriniferi; in consequence of which Dr. Johnson has named it desquamative nephritis. From the uniform presence of albumen in the urine Rayer employs the term albuminous nephritis. One form of the disease superinduces granular formations in the kidneys, from which the designation granular degeneration of the kidneys is derived by Dr. Christison. Another variety appears to be connected with waxy deposits, and these circumstances have given rise to the terms fatty and waxy degeneration of the kidneys.

When we reflect that the kidneys are effected only secondarily, and that all of the conditions we have cited are only isolated symptoms of quite different primary and deep-seated causes, we shall perceive that not one of the terms which have hitherto been employed to express the malady as a unit is strictly appropriate. For this reason, and until a more just and comprehensive appellation shall be devised, we shall still adhere to the original designation of Bright's disease.

A majority of authors have made a general division of the malady into the acute and chronic forms. This general arrangement we shall adopt in the present article, although we agree with Valleix "that it is impossible to say, precisely, what are the symptoms which correspond particularly to the three forms admitted by Bright, or to the three degrees of Christison, or to the five varieties of Martin Solon, or rather all of the symptoms of the malady corresponding indifferently to these forms, to these degrees, to these varieties." A single division has a real importance in pathology, like that which has been established by M. Rayer. This author has described an acute and a chronic albuminous nephritis. The first corresponds to the two first of the six anatomical forms admitted by M. Rayer, and the second to the four last.-Guide du Medicin Practicien, par F. S. P. Valleix, p. 100.

ACUTE FORM.-Acute desquamative nephritis is the appellation given to this affection by Dr. George Johnson of London. The convoluted tubules which compose the cortical portion of the kidneys are primarily and chiefly involved in this form of the disease, although the Malphighian corpuscles and the entire gland ultimately become con

gested and somewhat enlarged. The most notable results of this inflammatory congestion are: albuminous urine, retention of urea in the blood, and dropsical effusions.

SYMPTOMS OF THE DISEASE.-Rigors or chilliness, followed by febrile reaction; hot and dry skin, rapid and full pulse, thirst, dryness of the mouth aud throat; pain in the region of the kidneys, often extending to the groins, thighs, penis, and testicles, and tenderness of the kidneys on pressure; irritation at the neck of the bladder, and sometimes at the extremity of the urethra, giving rise to frequent desire to urinate, especially during the night; scanty, red, or smoky urine; loss of appetite, nausea, and sometimes vomiting, with other symptoms of gastric disturbance; dull or acute pains in the head and limbs; restlessness and lassitude. These phenomena are speedily succeeded by puffiness of the eye-lids and face, oedematous swellings of the body and limbs, and dropsical effusions into the serous cavities, more or less extensive. The pleura is exceedingly prone to become involved in the morbid action and to throw into its cavity undue quantities of serum, in consequence of which we often observe distressing paroxysms of rapid and difficult respiration, and palpitation of the heart from the slightest exertion. In all forms of the complaint these paroxysms are quite apt to recur at regular periods-usually every evening and night, and to continue for several hours with distressing severity.

Urine.-Much diminished in quantity and sometimes almost entirely suppressed, usually red, from admixture with blood, or cloudy and turbid, of a specific gravity from 1,016 to 1,025. If the urine be placed in a watch-glass and slowly heated by a spirit lamp to the boiling point, an albuminous precipitate will be discovered; or, if a few drops of nitric-acid be carefully added to a small quantity of urine, the albuminous cloud appears and is soon precipitated. When both of these tests develop the precipitate, we may safely count on the presence of albumen in the urine.

Under the miscroscope, the urinary sediment reveals coagulated fibrin, "epithelial casts," epithelial cells, blood globules, and fibrinous casts from the inflamed urinary tubes. After the disease has continued for two or three weeks, Dr. Johnson has sometimes observed oil-globules in the epithelial cells and on the surface of the epithelial casts. These appearances do not appear to be connected with fatty degeneration of the kidneys, and is deemed amenable to remedial measures, provided the oil-globules are in small quantities compared with the epithelial casts. Johnson asserts that this condition is far more common in adults than in children. Not unfrequently uric-acid crystals are observed in these urinary sediments, but they do not occur with sufficient uniformity to be regarded as peculiar to the disease.

The above symptoms, if promptly met with suitable remedies, may terminate in complete resolution and a restoration of the organs to a normal condition, or they may partially subside into a sub-acute inflam matory condition, which may eventuate in one of the chronic forms of the malady; or, if the acute symptoms continue to progress unchecked until a certain amount of urea has accumulated in the blood, chroni poisoning will ensue, and drowsiness, headache, general failure of mental and physical power, stupor, and convulsions will terminate life. MORBID ANATOMY.If a section of the kidney be made, it will be found somewhat enlarged, heavier than natural, soft, congested and bloody. The cortical portion is infiltrated with a dark, turbid fluid, and the blood-vessels are distended with a still darker fluid. Other dark spots from ecchymoses are observed in the tissue of the gland. (Rokitansky.) The cortical substance is usually thickened to the amount of half an inch. (Rayer.) The pyramids are also involved and their blood-vessels are distended with dark blood. The natural darkred color of the healthy organ is changed to a still deeper hue, and is dotted throughout its substance with the congested and dark Malphighian bodies. The convoluted tubuli are distended with detached epithelial cells, and are abnormally opaque. The fascia propria and the mucous membrane of the calices and pelvis are thickened, and their vessels injected with a brownish-red blood.

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CAUSES. By far the most frequent direct cause of the affection consists in the passage through the Malphighian corpuscles and the secreting tubes of the cortex, of effete and excrementitious matters derived from the blood. In the present state of knowledge it is impossible to determine the number of diseases which are caused or are connected with deterioration or contamination of the blood, and which give rise secondarily to renal affections during the efforts of the recuperative forces to eliminate them through the urinary organs. It is highly probable, however, that many more maladies than have hitherto been enumerated may safely be added to the list.

Retained effete matters from checked perspiration, whether arising from exposure to cold or from other causes, is a common cause of acute nephritis.

A less frequent, but by no means an uncommon cause of the disease, may be found in the elimination from the blood of poisonous drugs which have been administered by old-school physicians. Nearly all the resinous diuretics, like Copaibæ, Turpentine, and Cubebs, as well as most other diuretics, like Nitrate and Hydriodate of Potassæ, Digitalis, Apocynum-cannabinum, Petroleum, Cantharides, and the like, are capable of producing so much irritation in their passage through the secretory tubes of the kidneys, even in small quantities, as to produce albuminous urine. A similar effect has been observed from the elimina

tion of Mercury, Arsenic, and other mineral substances from the blood.

The abuse of alcoholic liquors, particularly those which are adulterated, is mentioned as a cause of the disorder.

Long-continued inflammation of the neck of the bladder, from stricture, enlarged prostate, calculi, &c., occasionally tend to develop albuminous nephritis from sympathetic irritation. Several cases of

this description have fallen under our own observation.

Mechanical injuries over the renal region may superinduce this variety of nephritis in scrofulous, syphilitic, gouty, and other subjects predisposed to the complaint.

PROGNOSIS.-In forming an opinion respecting the probable result of acute albuminous nephritis, it is necessary to regard the actual condition of the patient and the nature of the exciting cause. When it occurs in healthy persons, and is dependent on exposure to cold, or humidity, or abuse of spirituous liquors, diuretics or other drugs, or the elimination of effete matters during the later periods of mild diseases, we may generally count on a favorable issue, provided suitable remedial measures have been promptly adopted.

But when it appears as a sequence to malignant scarlatina, erysipelas, typhus, yellow fever, or cholera-asphyxia, and the system of the patient is much contaminated and reduced from previous disease, the prognosis must always be regarded as doubtful, and often positively unfavorable.

A scrofulous, psoric or gouty diathesis, constitutional syphilis, and cancerous, mercurial and arsenical cachexias are always unfavorable concomitants in this affection.

CHRONIC FORMS OF BRIGHT'S DISEASE.-Many attempts have been made to group together certain phenomena, and to classify them as characteristic indicators of the various forms of Bright's disease. Pathology, chemistry, and microscopy have all been called into requisition as aids in determining this classification, but the subject is still involved in much doubt and confusion. Many eminent continental physicians, like Frerichs and Reinhardt, regard the different forms of the disease as successive stages of one primary inflammatory congestion; the first link in the chain being inflammatory congestion, the second inflammatory exudation, and the third absorption. English and American writers for the most part recognize the existence of these stages, but deny that they have any necessary connection with each other. They assert that each of these forms is often met with as an independent malady, and without any previously existing acute disease either in the kidneys or elsewhere. This argument, however, loses its force when we reflect that acute desquamative nephritis sometimes

runs its course with symptoms so mild as scarcely to attract attention. Thus a cold, with slight febrile symptoms, high-colored urine, and tenderness and pain in the lumbar region may occur repeatedly with out exciting a suspicion of kidney disorder; and yet these very symptoms may be dependent on inflammatory congestion of the kidneys. It is so common a circumstance for patients to be troubled with what is vulgarly termed "crick in the back" during the existence of severe colds, that nearly all pains in this region are included under this general appellation, and are passed by unheeded. In this manner the first stage of Bright's disease often remains undiagnosed, and the more chronic stage of exudation gradually and insidiously establishes itself. How few there are who cannot recall one or more attacks of cold, with febrile reaction, scanty and red urine, nausea, and pain in the loins; and yet one of these unheeded attacks may constitute the first stage of this formidable disorder.

In several instances we have met with chronic albuminuria in individuals who were confident that they had never suffered from any affection of the kidneys; but who, after minute examination and careful reflection, have been able to call to mind previous attacks similar in character to acute desquamative nephritis. Adopting the views of Frerichs and Reinhardt, we proceed to describe

THE SECOND STAGE OF BRIGHT'S DISEASE.-Upon the supposition that all forms of chronic Bright's disease have been preceded by one or more inflammations of the cortical substance of the kidneys, we submit the following additional remarks:

It is a well-established fact that many serious chronic maladies are but sequences, more or less remote, of previous acute inflammations. Thus many cases of uterine displacements, fibrinous depositions upon the utero-genital structure, hypertrophies of mouth and neck of the uterus, and chronic ovarian disorders are distinctly traceable to previous inflammatory conditions of these tissues. These inflammations, either from negligence on the parts of patients, or insufficient medical treatment, are only partially subdued, and are allowed to subside into sub-acute or chronic states, and thus to remain as nuclei for the action of any future morbid exciting causes. One of the most common results of all acute inflammations is an exudation into, or upon the affected tissue, with a consequent thickening or hypertrophy. This may superinduce morbid irritations; or it may continue to exist for months or years almost unnoticed, when perhaps, some additional exciting cause will develop a new and more serious train of symptoms.

A pneumonia may run through its course and leave the patient well, with the exception of one or more points of hepatization. A future exciting cause, perhaps years afterwards, may develop in the affected parts softening and consumption. The first inflammation sows the