cess, and atrophic wasting, does not attack the whole cortical portion at once, but spots, here and there over the surface,

Cellular hyperplasia of the interstitial connective tissue. Section made from the cortical portion of a kidney in an advanced state of contraction. Colberg; Ziemsen.)

from which it spreads, gradually encroaching upon the surrounding tissue, and spreads more deeply among the curling tubes. Sutton and Gull describe it as growing around the

Fig. 8.

Section of kidney in a very advanced stage of interstitial nephritis. a. Connective tissue formed by fibres and flat cells. b. Section of an atrophied uriniferous tube, presenting, in the middle of its lamina the section of a small colloid cast. h. A uriniferous tube, also containing a colloid cast, the epithelial cells of which are flattened. g. Uriniferous tube, c. Flat cells of the covering of a cyst, formed at the expense of the uriniferous tubes, and containing a colloid substance, with concentric lamina and a granular central mass. f. Formed of granulations of hæmatine, v. Blood vessel, magnified 200 diameters. (Cornell and Ranvier; Charcot.)

Fig. 9. Section of two cystic uriniferous the midst of which are seen hyaline casts

tubules filled with colloid matter, a., in

arterial branches and the urinary tubules, cutting off, to a large extent, the blood supply in the former, and, in the latter, leading to atrophic wasting. (See Fig. 8.) The capsules of Bowman are particularly liable to injury, and it is dilatations of these, and portions of the convoluted tubes, that cause the cyst-like formations in the cortical portion. These cysts are filled with a colloid material which is formed by liquifactive destruction of epithelial cells. (See Fig. 9.) This disease process, these observers (Sutton and Gull) believed to be only a part of nutritional changes throughout the organism. Bartels says that he has not been a able to confirm their observavations as to these lesions, and he thinks they have confounded the changes incident to senile of the same nature, b. b', (Chorcot.) decay with the pathology of this affection, though he says that he has frequently seen a very marked thickening of the skull cap, or dura mater, and is disposed to thus account for the violent headaches from which these patients suffer, rather than the arterio-muscular fibrosis of the cerebral arteries, as had been suggested by Sutton and Gull. That these structural changes are not due to any contamination of the blood is evident from the perfect state of the nutrition of these patients until near the close, in this respect being in marked contrast with those suffering from chronic parenchymatous nephritis or amyloid degeneration, particularly the latter. Even for years this may continue, after the disease has been recognized; and how long it may have been gradually developing, before its recognition, is a matter of conjecture. Though there is daily a small loss of albumen, yet so long as the assimilation and digestion remain good a very fair state of health may be exhibited.

And here it is, that the hypertrophy of the heart becomes so essential to the conservation of the general nutrition. As

we have stated, here and there, scattered throughout the cortical portion, the true secreting structure, we have these centres of atrophic destruction gradually, but surely, reaching out and invading new portions of the kidney structure; while in the immediate neighborhood of these are portions of the kidney whose structure is normal.

Of course, to perform the same functions which had been required of the whole organ, would demand more rapid and constant action in the part that still remained. Most certainly, the heart is hypertrophied. This hypertrophy causes an increased blood pressure throughout the body, but nowhere is it so quickly felt as in the kidney. If the conclusions of Heidenhain and Bowman be true, that the epithelial cells of the convoluted tubes and Henle's loops are charged with the function of eliminating the waste elements and salts of the urine, under increased activity these little bodies would soon become clogged with the elements of their own excretion. This increased blood pressure in the kidney causes an increased quantity of water to be poured from the Malpighian tuft into the tubes, and, flushing them, removes these urinary waste elements as fast as secreted. If the blood pressure is sufficiently high at all times, the loss of more or less albumen will be continuous, or, if the pressure be not so high it may only be present at certain times, when the tension is temporarily augmented, just as in Leübe's experiments on the healthy soldiers. Bartels has noted cases in which albumen disappeared from the urine which was secreted by these patients while quietly lying in bed; but, to get up and move actively about, would cause it again to appear. The albumen is poured out in these cases solely as a result of the abnormally high pressure, and not from any changes in the glomerulus. If we will bear this fact in mind, we will be prepared to account for the anomaly of albumen at one time in the urine, and at another, none. Bartels even reports a case in which no albumen was secreted at any time in the history of the case, though carefully sought for.

Diagnosis.-The chief points in the diagnosis is to test the urine daily, and examine the heart often and carefully; weigh each of the factors which are embraced in the etiology and symptomatology already detailed.

Prognosis. Recent study and investigation have only confirmed the assertion of Granger Stewart, "that this is the most hopeless of all the forms of Bright's disease." We can not hope to restore those portions of the organs that have already undergone atrophic wasting; the best we can hope to do, is to arrest the slow processes which are gradually destroying the kidney; to keep our patients in statu quo as long as possible, and this is usually a forlorn hope. We must remember that the usual course of this disease extends over many years not unfrequently, however, it is already approaching the termination before its discovery. If the heart becomes too powerful, it may lead to apoplexy and sudden death; or, on the other hand, the heart may break down, and be no longer able to flush the tubules, as described; or, the kidneys may become so extremely wasted as to be incapable of performing the duties required of them. In either case, the urine may fall below the normal quantity. Other symptoms may be, either a slight effusion in the cellular tissue, viz: a puffiness of the eyelids or ankles, dyspepsia and vomiting or diarrhoea. Cough and dyspnoea, or other more marked symptoms of uræmia, may make their appearance, and rapidly carry off the patient. Diarrhoea and vomiting, associated with marked diminution of the urine, indicate that the end is near.

Treatment.-Not much can be done in the way of treatment, except to guard the patient against any extra heart strain; to regulate his habits, and warn him of his restricted vitality, and the care he must exercise against cold, etc. Iodide of potassium, in 20 to 30 grain doses, has been given to prevent further extension of the neoplastic growth, or promote absorption of that already produced. Bartels, though he could not detect anything in the urine except the iodide, thought he had seen benefit follow. When the urine dimin

ishes in quantity, the iodide will again cause it to become more abundant, and, perhaps, give the patient a new lease of life. When the patient shows signs of anæmia, the preparations of iron may be used with benefit. For the obstinate vomiting, which towards the last sometimes intervenes, not much can be done, except of a temporary character.

As we have said, these patients, more than those of any other form of renal disease, are liable to suffer from uræmia, and, usually, they are not benefited by venesection, or other means which are of use in the eclampsia of pregnancy. If the uræmic symptoms have followed a temporary depression of the heart, the administration of digitalis, and water in the intervals, may increase the flow of urine, wash out the kidneys, and temporarily avert the danger. If the uræmia has come on gradually, as the result of an insufficiency of secreting structure remaining to the kidney, of course every resource of medicine is powerless.

APPENDIX.

Since the foregoing was written, a typical case of the genuine contracted kidney has passed through my hands, in which the diagnosis was verified by post mortem examination. Patient, a black male about thirty years of age, was admitted to the Port Hospital April 21, 1879; said that he had not felt quite well for some time; had never suffered from dropsy, except the slight oedema of the ankles and eyelids, which he now exhibits; was found to be quite deaf, which was only partly accounted for by a profuse suppuration from both ears, as there was more or less confusion in his answers, and evidences of mental obfuscation, which, only slightly marked at first, gradually became more pronounced. The patient denied ever having syphilis, and there were no external signs of the affection. He complained, on admission, of diarrhoea and cough, which had troubled him for some time, and of great weakness and prostration. Appetite ravenous; urine was scanty, and contained a moderate