the kidneys; urine scanty, red, and sometimes bloody; scanty and red, or clear and profuse urine; complete suppression of urine; the urine deposits a thick. muddy, light-yellow sediment, like wine, and has the smell of violets; the urine deposits a slimy sediment twelve hours after micturition; hæmaturia; profuse menstruation; albuminous urine.

PATHOLOGY.-Inflammation and congestion of the cortical portion of the kidneys; kidneys somewhat enlarged, softened, and of a darkred color, (on animals).

CLINICAL REMARKS.-Professor Henderson has cured several cases of both acute and chronic albuminuria with this medicine. Several medical gentlemen of our acquaintance are in the habit of using it as their principal remedy in the acute form of the disease, and commend it in the highest terms.

We have found the second dilution of this remedy of eminent service in many cases of both acute and chronic albuminuria. It will be observed that we have designated the second dilution. A large experience in this malady, with almost every strength of the medicine, has convinced us, that the best results can be obtained from this dilution. We regard Terebinthina as one of the very best remedies in Bright's disease.

3. CHRONIC DESQUAMATIVE NEPHRITIS. (JOHNSON) Second Stage of Bright's Disease. Inflammatory Exudation. (Frerichs.) Large White Kidney.

This form of the disease not unfrequently exists for many months without attracting any special attention, and without any apparent renal symptoms. We have known cases to advance within a few days of a fatal termination with no abnormal phenomena except slight pallor of the skin, lassitude, and the occasional occurrence of dyspeptic symp

toms.

In allusion to the insidious manner in which it sometimes becomes fully established, Dr. Johnson remarks as follows:* "A reference to case No. 13, will show that a patient may go to bed apparently in good health, and without having experienced any symptoms which had led him to suspect that his kidneys were unsound. In the night he is seized with symptoms of suppression of urine, and of severe abdominal inflammation. After an illness of a few hours he dies, and his kidneys ire found to be so far disorganized by a disease, evidently of a chronic nature, that the wonder is, not that they ceased to act when they did, but that they had continued to discharge their functions so long.

"Again, in case No. 14, there was precisely the same disorganization of the kidneys as in the instance just alluded to. The patient was

*"Diseases of the Kidney," pages 170 and 171.

seized, after a slight indisposition, with palsy of one side, followed by complete insensibility, which soon ended in death. There was no appearance in the brain which would explain the symptoms, but the kidneys were in precisely the same state of chronic disease as those in the case just alluded to. The bladder was empty; no urine had been passed for several hours before death; and the patient's friends had often noticed that his urine was scanty, but he had appeared to be in tolerable health, and his medical attendant was not consulted before the last fatal attack."

These slight ailments may continue for an indefinite period-usually from two to eight months, when shortness of breath is observed after ascending a stairs, or other exertion, either accompanied or soon succeeded by the following symptoms: pale and waxen appearance of the skin; considerable emaciation; oedematous condition of the face, limbs and often of the entire body; usually some tenderness in the region of the kidneys on pressure, though this symptom is sometimes (always according to Becquerel) absent; dull aching pains in the lumbar region are occasionally, but by no means generally, present; frequent desire to pass water, especially during the night; gastric, intestinal, cardiac, and pulmonary disorders are quite prone to obtain; rapid and difficult respiration on making the slightest exertion, and often very distressing paroxysmal attacks occurring every evening and night, lasting from ten to fifteen hours, and rendering it impossible to retain a recumbent position for an instant during a paroxysm; debility; nausea; occasional vomiting; urine variable in quantity, color, and chemical and microscopical characters (See below); drowsiness; obtuseness of the mental faculties; convulsions; coma and death.

During the course of the disorder, a great variety of symptoms, not strictly pertaining to the malady, are often observed. Among these we have noticed, burning heat in the head, particularly on the vertex, relieved by copious applications of Bay-rum, Cologne, &c.; a peculiar white appearance upon the tongue, mostly on the sides and under part, looking as if it had been par-boiled,-sometimes accompanied with burning, smarting, and soreness of the furred part, appearing and disappearing, and generally accompanied with an amelioration of the other symptoms during its continuance, and for a short period after its disappearance; putrid, sickening odor of the breath; pulse sometimes frequent, weak and irregular (in cardiac complications), and at other times normal in frequency and volume; spasmodic twitchings of the muscles of different parts of the body, usually worse at night; severe paroxysms of pain at the pit of the stomach, apparently of a spasmodic character. Johnson alludes to the frequent occurrence of nose-bleeding and menorrhagia, and believes them to be in some way connected with the renal affection.

Becquerel asserts that the disease has usually the following three modes of commencement:

a. Chills, fever, vomiting, lumbar pains, pulmonary congestion, cough, rales, dyspnoea.

b. Fever and infiltration, which shows itself in all parts of the body at once. This mode of attack he considers most frequent.

c. The disease advances stealthily, and would remain unknown even though mortal, without an examination of the urine.

Alterations of the Urine.-In quantity it is variable-usually more abundant than in health, but sometimes less. In color it is mostly light, or colorless, varying from a smoky water-color to a dirty brown hue. It very rarely contains blood-globules, but when it does the urine assumes the color of dirty broth. Its density is less than that of the acute form, although greater than that of normal urine. The specific gravity varies from 1005 to 1015. It has an acid reaction, and the usual tests precipitate albumen.

By the microscope we may detect epithelial cells, amorphous granular fragments, granular epithelial cylinders (the fall of the epithelial sheaths of the tubuli), termed by Dr. Johnson "granular casts," and in a very few instances, blood-globules. These blood-globules, according to Johnson, become more unfrequent the farther the disease advances from the acute stage, until in the third stage (small contracted kidneys) they are never to be found. Robin asserts that epithelial cylinders are occasionally found in normal urine, so that these appearances alone would not determine the existence of Bright's Kidney. Becquerel supposes that the quantity of albumen in these urines varies from T to TOT.

Prominent Concomitant, or Secondary Phenomena. Dropsy.As soon as the normal epithelium of the convoluted tubes has become so far degenerated and disintegrated as to be incapable of separating from the blood urea, uric-acid, and the other normal solids of the urine, they accumulate in undue quantities in the blood, and nature strives to eliminate them through other channels-the skin, the serous-membranes, the intestines, the lungs, the liver, and all other available outlets. During these vicarious processes of elimination, the capillaries of the tissues acted on, become obstructed, and their circulation impeded in such a manner as to permit exudations of serum through their walls, and thus dropsical effusions in various parts of the body. At the same time the congested Malphighian bodies allow the escape of undue quantities of serum, thus causing disalbumination of the blood from the normal standard of 70 or 18 to 10 and even T. It is evident then that two morbid conditions constitute the most direct causes of dropsical effusions,-by retention of excrementitious urinary constituents and disalbuminution of the blood. Further on we shall

again allude to this subject. Dropsy is not invariably present in this form of the disease, especially when the renal secretion is abundant, or when there are frequent and copious discharges from the bowels, by which the poisonous blood accumulations may be evacuated. In other instances the constitution appears to possess the power to resist for a long time the deleterious action of the retained urinary constituents, without the supervention of dropsy or other troublesome symptoms. But in general, nature asserts her rights, and opens every available channel in order to expel the noxious matters from the vital fluid, even at the risk of irritating, and of producing serous effusions from these new and unused tissues of elimination. The water appears to accumulate in one or another place without apparent cause. Perhaps it is earlier and oftener observed in the face than elsewhere; and in patients of active habits we generally find infiltration of the limbs and ascites. Effusion into the cavity of the chest is an early and rather frequent result of this disease; but we very rarely meet with ventricular dropsy.

The composition of the infiltrated water is the same as that of the serum of the blood diluted with much water. Of one thousand parts, the solid constituents constitute only from ten to fifteen parts, instead of eighty to one thousand, as in the serum, and forty to fifty to one thousand, as in affections of the heart.

In health, the proportion of albumen in the blood is from seventy or eighty to one thousand parts. In acute desquamative nephritis, the proportion is reduced below 185, at which point infiltration must occur. In the chronic forms this disalbuminution must be still greater, to give rise to dropsy.

These dropsical accumulations sometimes become so extensive as to cause very serious inconvenience, and not unfrequently danger to life. Pleural, ventricular and peritoneal effusions are the most dangerous. Infiltrations of the extremities and of the scrotum often become very extensive and troublesome; but they may be readily and safely relieved by delicate scarifications. We have often adopted this mode of temporary alleviation, and always with success and safety.

Respiratory Apparatus.-Among the vicarious channels for the elimination of the excrementitious renal accumulations in the blood are the pulmonary structures. In the act of elimination the capillaries of the pleura, the pericardium and of the cellular structure of the lungs often become engorged, and effusions more or less extensive occur.

Some of the first symptoms, therefore, which arrest the attention of both patient and physician, are shortness of breath, increased to a painful extent from the slightest exertion, and a sense of oppression throughout the entire thoracic region. In the first instance there is only pulmonary oedema with effusion into the air-cells of the lungs; but

in more advanced stages of the disorder, large and dangerous accumalations occur in the thoracic cavity. In robust and plethoric individuals, pneumonias and bronchial affections are likely to be superinduced. In scrofulous subjects hemoptysis and tubercular consumption are not unfrequently developed.

We have already alluded to the periodical recurrence of evening and nightly paroxysms of dyspnoea. This symptom has been observed in both the second and third stages of the malady. It usually commences in the afternoon and evening, and continues with such severity as to prevent the patient from taking a moment's rest in the recumbent posture, until some time in the morning, when there is generally a remission for a few hours.

During the existence of this stage, if the patient takes cold, or is subjected to the influence of a cold and humid atmosphere, pleurisy or pericarditis may occur; although these attacks are far more common in the stage of absorption.

Albumen has often been detected in the urines of children suffering from membranous croup. The rationale of this phenomena has not yet been fully explained.

Digestive Apparatus.—Another channel for the elimination of the retained urinary excrements, is the gastro-intestinal mucous membrane. The influence exerted upon the stomach is two-fold; firs in the form of irritation of the gastric mucous membrane, and consequent symptoms of indigestion, like nausea, occasional vomit. ing, eructations, acidity, flatulent distention, heart-burn, oppression gastric sensitiveness, &c., and secondly upon the nervous apparatus of the stomach, producing a train of severe neuralgic symptoms. The stomach sometimes becomes so seriously involved that the mucous membrane becomes thickened, softened, and in rare instances, ulcerated to a considerable extent. Severe paroxysms of neuralgic pains-usually at the pit of the stomach, are not an unfrequent attendant upon the malady. We have known cases run through the entire second and third stages to a fatal issue, with scarcely a pain or other unpleasant symptom, except those which have been referred to the stomach-sometimes by both patient and physician.

The action of the urea, ammonia, &c., upon the intestinal mucous membrane produces flatulency, sensitiveness of the bowels, and diarrhoea, and post-mortem examinations now and then reveal redness, ulcerations, and softening of portions of this structure.

Bernard detected ammonia in large quantities in the stomachs and intestines of dogs whose kidneys had been extirpated. This ammonia is supposed to arise from the conversion of urea, either in the bloodvessels or in the digestive canal, from contact with the secretions it here meets with.