With this brief outline, I shall bring before you cases illustrative of chronic renal disease.

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The first case is a girl aged eighteen, a domestic. The countenance of this patient is quite typical. It is pallid, showing anæmia; and puffy, showing dropsy. There is a certain amount of anasarca present, not marked, but sufficient to show that the dropsy is diffused through the areolar tissue. A very reliable method of determining whether diffused dropsy is present or not, even in a very slight degree, is to make pressure over the sternum. there be oedema, it can be recognized at that point. An important question to be decided now is, does the dropsy in the present case arise from an affection of the kidneys, or from an affection of the heart? It may be laid down as a general rule that, if there be much general dropsy, unaccompanied by difficulty in breathing, the dropsy can hardly arise from cardiac lesion. There is no evidence of heart disease in this case. Examina

tion of the urine gives a s. g. 1018 acid; it contains considerable albumen, epithelial and granular casts and

urates.

It

Let us now turn to the history of the case. Her family history is good. Patient is temperate; no evidence of specific disease. Two years agoand this is a point of much interest -the patient had scarlet fever. will be recollected that, while studying the acute form of Bright's disease, your attention was called to the fact that a great majority of the cases of acute albuminuria, or tubal nephritis, are cases in which the affection is a sequel of scarlet fever. It was also remarked that the acute affection rarely terminates in a chronic condi- | tion. But it seems probable that the case before us is a chronic affection, and that it dates its commencement from the occurrence of the scarlet fever; in other words, that we have here a chronic affection of the kidney following an acute tubal nephritis. Since she had the scarlet fever, her feet, face and body have occasionally become puffy, and the amount of

urine passed has been sometimes quite scanty. Her face has never regained its natural color; and her strength has been very much diminished. She dates her present sickness at four days before her admission into the hospital. While in a profuse perspiration she sat down in a current of cold air, and she was seized with slight chill, with severe pain in the left side, and afterwards in the right side. Upon admission the pulse was frequent, the temperature raised, and the respirations rapid. To-day a physical examination of the chest reveals fluid in both pleural cavities. Now, a question of interest is, is this hydrothorax dependent upon the renal disease, or is it a case of double pleurisy? I do not hesitate to say that it is a case of double pleurisy. It is a case of double pleurisy which proceeds from renal disease, without much general dropsy. With but little general dropsy, and with no disease of the heart, it is out of all experience to have as much dropsical effusion within the chest as in this case. This case may therefore be regarded as an illustration of the occurrence of chronic affection of the kidney following acute tubal nephritis, and also an illustration of double pleurisy produced by renal disease. Her pleurisy has been treated by the application of dry cups to the chest; she has had, in addition, ten grains of quinine once a day, and pills of iron, aloes, and strychnia.

The second case gives us the following history:

Mrs., aged thirty-three, English, and admitted to the hospital September 22d. Family history good. Patient was healthy until one year ago, when she began to suffer from attacks of dyspnoea, without cough, which were probably asthmatic in character Vomiting and oedema of lower extremities first occurred about six months ago. During the past two weeks she has suffered from some pain in the back; and her urine has been scanty and high-colored. The vision has always been good. Upon admission the patient presented an

anæmic appearance, the breath was short, and the appetite poor. Examination of the urine gave s. g. 1010, albumen and casts. Physical examination of chest negative.

Sept. 26th.-Under the influence of diuretics and tincture of iron the pa tient's urine became more abundant, but giving same results by chemical and microscopical examinations.

Oct. 28th. The patient does not pass much urine; complains of pain in her back and shortness of breath.

Upon physical examination of the chest, the area of cardiac dulness is found to be very much increased, and with this there is a murmur with the first sound of the heart, at the base. This patient now has pericarditis, with considerable effusion of serous fluid into the pericardial sac. There is considerable edema of the lower extremities, and also considerable fluid in the abdominal cavity. Her face does not show any dropsy, and there is but slight indication of its diffusion by making pressure over the sternum. The question may arise here, is this a case of pericarditis, the inflammation giving rise to the effusion into the pericardial sac; or is it a case of hydros-pericardium, due to the chronic renal affection? There is a slight, but a sufficiently distinct, friction. murmur occasionally heard, and this sign, be it ever so slight, indicates pericarditis, with a single exception. Sometimes, when there is a pleurisy of the left side, the action of the heart causes the exterior of the pericardial sac to rub against the pleural surface, causing a friction murmur with the cardiac rhythm, and this is called a cardiac pleural friction murmur. If the murmur were of this kind, it should be heard at the left lateral portion of the pericardium. But the friction murmur is more to the right, nearer to the base; it is superficial in character, being a slight grazing sound.

Taking into account the existence of pericardial effusion, there can be no doubt that the murmur denotes pericarditis. Pleurisy can be excluded because an abrupt line of dulness

denotes the boundaries of the distended pericardial sac, good resonance on percussion being found everywhere without these boundaries. A simple enlargement of the heart would not produce the dulness which is here found to extend above the base of the organ. The increased space of dulness in cardiac hypertrophy is downwards and to the left. This patient is not suffering much pain, nor is pain a constant symptom of pericarditis. Pain in this disease is sometimes extreme, and sometimes almost entirely wanting. We have, then, in this case another example of serous inflammation developed in the course of chronic renal disease, belonging among the grave secondary affections.

As regards the measures of treatment addressed to the pericarditis, in this case some soothing applications should be made to the præcordia; a light poultice, or the water dressing covered with oiled muslin, and an abundance of flannel. If the kidneys are found to respond to diuretics, these are indicated for a twofold purpose, as follows: to eliminate urea, and to promote the absorption of the liquid in the pericardial sac. Rigid quietude is to be enforced. There is danger of sudden death by syncope on exertion in cases of pericardial effusion. The condition of the patient will not admit of the employment of the active hydragogues with a view to the absorption of the effused fluid; but if the kidneys do not respond to diuretics, saline cathartics, or perhaps the pulvis purgans, may be advisable. The patient should be well nourished. Digitalis will be likely to be useful, by increasing the power of the heart's action.

The third case illutrates a condition associated with, but probably not dependent upon, the renal disease.

The patient's name is Miss C., aged twenty-two. She was admitted to the hospital on the 2d day of September. Family history good. Since last May she has had more or less oedema of the lower extremities. The dropsy extended up the limbs, appeared on

the face, and then about the body. She has had occasional nausea and diarrhoea. Exercise gives rise to palpitation of the heart and want of breath. This patient has a pallid countenance, but this is not as marked as when first admitted. Examination of the urine at the time of admision gave a low specific gravity, with albumen and granular and epithelial casts; subsequently, hyaline casts were found.

September 5th, hydro - peritoneum made its appearance, which has continued and somewhat increased up to this date, October 30th; and at the present time there is, as you see, considerable dema of the lower extrem ities. No oedema of the face. The

question arises in this case, is this hyro-peritoneum due entirely to the renal disease, or in part to some other cause? Although we have evidences of renal disease, I am quite sure that there is some other affection to account for the hydro-peritoneum. The hydro- peritoneum in renal disease sustains a relation to the dropsy in other parts of the body. But the general dropsy in this case is not an important feature, and this leads us to conclude that the hydro-peritoneum is due to some other disease than the renal disease. It is probably due to disease of the liver. But the expiration of my hour prevents further consideration of the case.

the first time in England, a surgical procedure which has been practiced for some time past by Professor Dittel, of Vienna. It consists in substituting an innocent - looking elastic thread for the formidable array of knives, tourniquets, artery - forceps, and other paraphernalia with which the surgeon ordinarily approaches the patient. Before proceeding to perform the operation, Sir Henry related the curious accident by which Professor Dittel was first led to appreciate the extraordinary results which may be produced by the slight, yet continuous, pressure of a simple elastic thread. He was called to see a girl about eleven years of age, who was suffering from acute and severe, but somewhat anomalous brain-symptoms. The case was altogether obscure; the girl seemed in other respects healthy, but could give no account of herself-she was, in fact, at the point of death-nor could any satisfactory history be obtained from

necropsy. It was then found that the India-rubber band of the hair-net which she was wearing had ulcerated through the whole thickness of the calvarium, and had set up meningitis. On further inquiry, it was ascertained that the girl, having been constantly scolded by her stepmother on account of the untidy state of her hair, had, about three weeks before her illness, purchased an ordinary hair-net, and the elastic thread of this net, tied around the head, and worn day and night, had, in less than a month, cut through skin and bone and penetrated to the brain; and this apparently without causing any pain to the patient.

Professor Dittel at once proceeded to reduce to practice the idea suggested to him by this unfortunate accident. He first applied it to a case of nævus of the scalp in a child; then, finding that the plan quite answered his expectations, he applied it to the removal of the testicle, penis, etc., and finally to the ampu

tation of limbs. He has now performed, by means of the elastic ligature, a large number of operations of all kinds, including five amputations of limbs.

It is not understood, however, that he proposes to apply his method to the performance of the larger amputations; these were done rather with the view of testing the capabilities of the process. The time required for the completion of an operation varies according to the amount and density of the tissues which have to be divided, e. g., for the separation of the mamma from eight to twelve days.

The chief advantage which Dr. Dittel asserts this plan to possess is, that patients so operated on are less liable to pyæmia than those treated in the ordinary way. He bases this assertion on the experience of the numerous cases referred to above. Remembering also what a morbid dread of the knife many nervous patients have, the depressing mental effects of an operation may often be greatly diminished. Lastly, the operation itself is absolutely bloodless.

Among the operations for which it is admirably adapted may be especially mentioned fistula in ano, which Dr. Dittel now invariably treats in this way. One end of the India - rubber thread is passed in the eye of a probe up the sinus into the bowel, then caught, brought out at the anus, and tied; it cuts out in a few days.

The patient on whom Sir Henry Thompson operated was a stout, middle-aged woman, who was suffering from an ulcerating fibro-cystic tumor (cystic sarcoma) of the right breast. She had had a lump in the breast for twenty years, but it caused her little inconvenience till two years ago, when it began to enlarge rapidly, and finally the skin over it gave way. At the time of the operation the tumor was of the size of a large orange, and somewhat pendulous, the breast itself being wasted; it was crowned by a large, sloughy, fungating ulcer. The ligature used was

tublar, about one - twelfth of an inch in diameter, the calibre of the tube being about one-third of this. A large nævus needle was threaded with this and with a piece of twine (the use of which was explained afterwards) and passed under the base of the tumor; the elastic was then cut, the needle withdrawn, and the halves of the pedicle tied separately.

Sir Henry Thompson remarked, after the operation, that, although this was a very suitable case for the method adopted, it was not a severe test. The only accident that could happen was the snapping of the elastic when stretched; in that case, another length was tied to the twine, which had been passed under the tumor with the elastic and drawn by it along the track of the needle; otherwise, the twine was removed as soon as the ligatures had been properly tied. The best way to avoid the occurrence of this accident was always to use freshly-prepared elastic; if kept only a month, it was very liable to become brittle.

He

The skin over the tumor should be tightened just before tying, so that as little as possible might be included. Sir Henry added that, as that was the first time he had operated by that method, he had been anxious to comform in all respects to the practice of Dr. Dittel; but he thought that, another time, he should be disposed to make a superficial incision through the skin along the course of the ligature, so that it would be in a groove, and would not be liable to slip. thought, also, that this would obviate the pain which Dr. Dittel said that patients sometimes experienced during the first two or three hours after the operation; in most cases, however, the pain was slight. This patient complained of pain, apparently not very severe, for about twenty minutes after she recovered from the chloroform. Dr. Dittel's paper in the Allegemeine Wiener Medizinische Zeitung, 1873, has furnished very full details respecting this mode of treat

ment.