are blocked up by exudation. That it is not owing to lessened formation of urea, but to impeded exit, is evident from the uræmic symptoms which are always present in such cases, and which increase and prove fatal, if the elimination continues deficient. A case observed by Mosler gives the best example of this I am acquainted with. A man aged forty-five, never before sick, had great anasarca brought on by cold. When admitted at the height of the disease, the action of the eliminating organs was as follows (average of three days): Insensible perspiration, skin and lungs Urine Fæces 675 grammes. 1196 The fæces were thus increased, but not sufficiently so to compensate for the diminution of the urine and insensible perspiration. Some elimination, however, took place from the stomach; for there was vomiting to the mean extent of 200 grammes (6 ounces) in twenty-four hours. As the patient was very thirsty, he drank largely. The egesta Daily increase in weight دو 4164 grammes. In three days, therefore, the body gained 11 pounds in weight, simply from deficient elimination. The composition of the urine was On the following day, the chlorine disappeared altogether from the urine; the urea fell to 8.2 grammes, or 126 grains. For the next three days, the mean was— Quantity Urea CINA. Phosphates Albumen, still increasing. Archiv des Vereins für wiss. Heilk., Band ii, p. 535. The symptom of uræmia then became extreme; there was dry tongue, great thirst, and uræmic bronchitis. Before death, the urea diminished to 3.6 grammes, or 555 grains, in twenty-four hours. In this case, the cause of death was simply the mechanical impediment to the exit of the urinary constituents; the number of casts in the urine was extremely small, and the channel for the urine was not freed by their elimination. 3. The uric acid is increased (except in great retention); and owing partly to this, partly to lessened water, sediments of urates are common. The exact amount of increase is not known. 4. Nothing is known about the hippuric acid. 5. The pigment is often in large amount, and the scanty urine is very deeply coloured. In many cases, however, the presence of transuded hæmatin hides the colour of the pigment. 6. The chlorine is lessened, and often disappears altogether (Mosler and Heller). Like the urea, it is retained, and appears in large amount during recovery. 7. The sulphuric and phosphoric acids and bases are lessened. Abnormal constituents. Albumen is always present in large amount. When the urine is very scanty, it becomes almost solid by heat. Frerichs (p. 55) gives the range as between 5 and 25 grammes (77 and 386 grains) in twenty-four hours. The sediments are usually characterised by the large amount of blood-corpuscles, of renal and vesical epithelium, of pus and granular cells; the cylinders are sometimes very numerous, and are intimately mixed with blood-cells or with sediments of urates or oxalate of lime (Johnson). From the great amount of epithelium which often adheres to these casts, Dr. Johnson calls them "epithelial casts." These characters (viz., the epithelium, blood, and urates) distinguish the casts of acute Bright's disease almost perfectly from those of the chronic form. When the disease is about to end fatally, the quantities of water and of the solids decrease, the diminution in the solids being more considerable than that of the water; the albumen decreases least, and often is very abundant till the last. When recovery is about to take place, diuresis usually occurs; and often an enormous quantity of water is passed, containing much urea and chloride of sodium. As the diuresis thus arising does not appear to differ from that seen during 1 In one of Brattler's cases (Urologie, p. 50), the water during recovery amounted to 7920 c.c. (= 255 fluid ounces) on one day, and was little below this on several other days. recovery from anasarca arising from other causes, it is described under one of the forms of " Diuresis, or Diabetes insipidus." During recovery, the albumen frequently disappears altogether, and the kidneys then recover perfect health; sometimes the urine remains albuminous for some time. Effect of Remedies. Alkalies appear to have a beneficial and eliminating effect, and not to be injurious. Hoppe,1 in a case which came on after delivery, and in which the quantity of urine was 825 c.c., and the amount of albumen 3-4 grammes, or 52.5 grains, in twenty-four hours, found the bicarbonate of soda increase the water to 1100, to 2000, and finally to 3000 c.c.; the albumen gradually disappeared. The acetate of potash has sometimes the same effect. Fomentations of infusion of the leaves of digitalis, as recommended by Christison, have been found by Prof. Vogel to increase enormously the amount of urine in a case with suppression of urine.2 In a case in which the dropsy had disappeared, and the diuresis had diminished, I tried the effect of gallic acid for fourteen days, and of the tincture of sesquichloride of iron for nineteen days; the following was the result: In twenty-four hours, in ounces and grains. The gallic acid had no effect on the albumen or on the other constituents of the urine. The amount of albumen lessened from the use of the iron, and in a greater degree than would have been expected from the natural progress towards cure alone; the other ingredients were not affected by it. The beneficial effects of iron are particularly noticed by Basham and others. 1 Deutsche Klinik, 1854, No. 14. 2 Quoted by Mosler, Archiv des Vereins, Band ii, p. 531. SECTION II. CHRONIC DISEASES. Chronic Bright's Disease.1 Normal Urinary constituents. 1. Water. At the very commencement of the chronic disease, the water of the urine is either normal in quantity or slightly lessened; with its progress, the water, as a rule, decreases (especially in cases with dropsy and uræmia (Christison, Rayer, Rees, Frerichs, Johnson, Vallon2). Sometimes, in uræmia, the urine is almost suppressed (Christison). At the same time, there are certainly many exceptions to this general rule; and in some cases the urine is more abundant than usual, either at the onset or throughout. Thus, I have measured more than 100 ounces; and Rosenstein gives a case in which, on an average of eight days, 5400 c.c., or 174 ounces, were passed daily. The urea was not at all augmented. The causes of such varying excretion can be partly made out. (a) The anatomical condition of the kidneys might be conjectured to have a predominant influence on the amount of water: in some kidneys the renal vessels remain pervious; in others many vessels are obliterated: in some, the walls of the vessels in the Malpighian corpuscles are normally thin; in others thickened excessively, particularly in the waxy kidney. In fact, we might have anticipated that in such conditions as these the principal cause of the variation in the water would be found. Yet, when we seek for decided evidence on this point, it is not very satisfactory; for in cases in which the after-death condition is given, the amount of urine has been measured 1 This term is employed in its ordinary symptomatological sense, as indicating an organic disease, denoted during life by persistent albuminuria, and by the frequent appearance in the urine of blood, renal structures, and exudation and desquamative renal products, and having for its usual secondary symptoms dropsy and uræmia. The diseases thus grouped together by their symptoms are anatomically different; as the kidneys may be large or small, atrophic or not, with fatty, or albuminous, or lardaceous (amyloid) degeneration, and altered as regards vessels, tubes, and lining epithelium, in various ways. But as the conditions of the urine have not yet been perfectly connected with these anatomical states, I have not attempted to separate them. 2 Vallon, Wien Zeitschrift, 1856, in twenty-five out of twenty-nine cases. with care, in scarcely any instance, a sufficient length of time to permit a true conclusion.1 If from the table given below there is some reason to infer that in the highly atrophic kidney, when many vessels are obliterated, the urinary water is on an average lessened, it does not follow that on one particular day a large quantity may not be excreted; thus, in a most atrophic case, I have known on a single day as much as sixty ounces passed: (b) An advanced period of the disease, and the co-existence of dropsy and uræmia, appear to be associated with lessened water ;3 while, on the other hand, an improvement in dropsical symptoms is attended by more or less profuse diuresis. 1 The following are the only cases I can safely place here; three are taken from Frerichs, and six are my own: 2 The statement of Rayer (op. cit., p. 143), that the water lessens when dropsy comes on, appears to be correct; but it is quite certain that many cases with scanty urine are not attended with dropsy. Thus, in twelve of my cases— Mean amount of urine in twenty-four hours, and mean specific gravity. 3 The following table, taken from twelve of my cases, shows an obvious connexion |