SANITARY DISSERTATIONS AND REPORTS.

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of his patient. Its evolution is relatively rapid, three to six months, or a year suffice for its development. In its earliest stage no marked symptoms betray its presence; there is only a feeling of general malaise, a diminution in the daily quantity of urine, and the presence of albumen in the latter. Edema and dropsical effusion is a very constant symptom, and the patient may insist that he is perfectly well and only complains of the dropsy. More often, if complaint is made at all, it is general weakness, and sometimes pain of a dull character in the back. The dropsical effusion and anasarca may reach an exteme degree, and is more marked in this than in any other form of renal affection. The appetite is usually impaired, but there is not so much a tendency to vomiting or diarrhoea as in some of the other forms of renal disorder. The urine, as we have said, is scanty, usually high colored, defective in water, the prime cause of the dropsy, and contains albumen. Under the microscope it shows the presence of hyaline, granular fatty and waxy casts. The affection may be complicated; the complications not unfrequently causing a fatal termination, viz: by oedema or purulent inflammation of the lung tissue; by gangrene or erysipelas of oedematous parts; uræmia is not a very frequent complication.

Anatomical Characteristics.-The kidney is large, much larger than in health, if the patient succumb at the height of the disease, as is usually the case. If secondary atrophy has supervened, they may be smaller than in health. The enlarged condition is well described by Bright. I show you a plate after one of his drawings. The enlargement is due mostly to the thickening of the cortical portion. This structure is pale and exceedingly anæmic, and contrasts well with the distended venous radicles on the surface, and with the pyramidal portion which, though somewhat enlarged, is usually red. Klebs likens the consistence to caoutchouc. Pathologists are not altogether agreed as to precisely what the changes are that produce the foregoing appearance.

14

*Charcot, objecting to the term parenchymatous nephritis, says: "It prejudges the process, which is far from being understood." He and the French school under Lacorché believe that it is an inflammatory process, principally involving the epithelial elements which distend the tubes, though he acknowledges a thickening of the latter. Microscopical examination of the cortical portion shows the same changes that characterize the acute, except that they are more marked. The tumefaction involves the epithelial cells-the tubuli uriniferi-and the intertubular structure.

Some of these tubes retain their normal caliber, others are enlarged and filled with detritus and oil globules, their normal epithelial lining being entirely destroyed. These often appear dark by reflected light; in others the epithelial lining is only partly preserved, the cells that remain being filled with oil particles so that their nuclei are invisible; others retain almost entirely their normal appearance. I would here attention to the drawing,

Fig. 4. Section through a kidney affect- I call d with parenchymatous nephritis. The cells which line the tubes are granular,

ulations. In the centre of the tube is

your

filled with protienform and fatty gran: Fig. 4. The interspaces between seen the section of the hyaline casts, the tubuli are, according to Klebs, Magnified 420 diameters (Cornell and from two to three times as broad as in the normal condition, and may become as thick as the tubes themselves. [See Fig. 5.]

Ranvier) Charcot.

The renal vessels are, no doubt, more or less structurally and functionally altered. Colberg thought he could positively demonstrate this by anatomical and structural changes in the glomeruli. Here is one of Colberg's drawings, as given by Bartels. [See Fig. 6.]

The bodies exhibiting these large white kidneys are always dropsical; other characteristics will depend upon the exciting cause.

Diagnosis. When blood casts and epithelial cells are found in the urine, the case is acute; if evidences of chronic affection accompany, it demonstrates that an acute inflammation has been developed in a kidney already affected with chronic disease. When these elements are absent, while the urine is scanty, of high specific gravity, contains a large percentage of albumen, and deposits

a

sediment composed of masses of detritus and numerous dark granular casts, the case is quite certainly chronic nephritis. Urine of .1030 specific gravity, and

ment of intertubular spaces; the walls of the containing 3 or 4 per cent. thelial cells, chronic parenchymatous nephritis of albumen, is rarely found

tubuli are covered with a new growth of epi

(Colberg), Ziemsen.

in other affections. When complicated by amyloid degeneration of the vessels, and when the history is such that either state of the kidney might result, it is difficult to say to which class it should belong, and Bartels is frank enough to acknowledge that he cannot always diagnose the conbination during life. I have adopted the arrangement of Bartels, which contrast the main facts by which this affection is to be diagnosed from amyloid degeneration.

CHRONIC NEPHRITIS.

There is constantly a history of dropsy, even if not at the time present; effusion is general.

Urine scanty, is always more or less turbid; large deposit; an abundance of casts of every variety.

Albumen abundant; specific gravity high; a few blood-corpuscles usually found.

Fig. 6. Proliferated glomerulus from chronic parenchymatous nephritis X 350 diameters (Colberg), Ziemsen.

AMYLOID DEGENERATION.

Dropsy rare and usually of small extent-confined to lower extremities and abdomen.

Urine scanty, rarely deposits a sediment, highly colored, contains very few casts, mostly hyaline.

Albumen abundant; specific gravity high; blood corpucles absent.

Amount and character of urine sub

Character of urine remains same ject to great variations. for a long period of time.

Liver and spleen normal in size.

Prognosis.-The course of the disease is variable. It may reach its full development rapidly, and prove fatal in the course of a few months from some of the complications already detailed. Or, if the exciting cause be removed in time, complete recovery may ensue; at least there will be a sufficient amount of healthy kidney structure left to subserve all the purposes of renal excretion, for the bold surgeon and the ravages of pyelitis teach us that one healthy kidney will suffice for the economy, and though extensive destruction may be scattered here and there throughout the kidney, there may still be enough to fulfill the specific duties required. More often the recovery is not complete, the urine becomes more

abundant, the dropsy disappears, but instead of being restored to the healthy condition, fatty degeneration and atrophy supervene; more or less albumen is still lost in the urine, and the patient is left in a condition of feeble vitality, and falls a ready prey to any intercurrent affection. The kidney then presents the appearance depicted here,* and is liable to be confounded with the chirotic kidney, unless very carefully examined. It will then be seen that the smallness of the organ is not due so much to contraction of intertubular structure as to the wasting and almost entire disappearance of the cortical portion of the kidney.

Treatment. If the exciting cause be malarial intoxication, syphilis, chronic suppuration, or bad hygienic surroundings, these should be, as far as possible, cured or remedied. After this, means should be tried to excite the activity of the skin, and increase the flow from the kidneys, and combat the anæmia. To accomplish the first indication, the same means are to be used as in the acute stage. Bartels recommends confining the patient continuously to bed, as was recommended by Bright, the warmth and equable temperature promoting activity of the skin, and the patient being only allowed to get up on warm, sunny days; great benefit sometimes results from this treatment alone. Large doses of acetate of potash, in infusion of digitalis, and large doses of iodide of potash, seem to be most relied on as diuretics. The anæmia is to be treated on general principles.

In this class of cases, the various mineral waters possessing diuretic properties have been recommended. These waters, however, seem to possess no special merit as curative agents, unless associated with certain climatic conditions. The waters in and around Waukesha, Wisconsin, have acquired great reputation, and I must say that I have seen excellent results follow a resort to this section for the summer months, but, fortunately, the climate is exactly such as is needed in these cases; the air is cool, dry and bracing, pro

*Illustrations of Pathology, Sydenham Society, 1877, plate 5, figs. 4-5.