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degenerated epithelial-cells (6), epithelial-nuclei (c), and casts of the uriniferous tubes (d), filled with the preceding substances, and seldom any oil-granules. The sediment was frequently examined afterwards, and presented little variety, except in amount, and in presenting a few tube-casts consisting apparently of the fibrin. ous matrix alone (Fig. 3). The diuretics were then discontinued, and Dover's powder was administered twice a-day. Notwithstanding the opium, a tendency to diarrhæa occurred for four days after the 14th, but it was stopped by increasing the opium. The features having again become puffy, nitrous ether and oil of juniper were given ; but, in consequence of the urine becoming more red and more coagulable, all diuretics were permanently abandoned. On the 20th, she began to complain of pain and tension of both eyeballs, and in the course of a few days the sclerotic of both eyes became very edematous and swelled over the cornea ; but this new affection was quickly removed by a zinc wash. On the 24th, vomiting before breakfast occurred for a few days, and diarrhea threatened to return. Both affections, however, were arrested by morphia. Meanwhile a gentle perspiration had been maintained pretty steadily every night by Dover's powder. On the 27th, the improvement was very marked in every respect. The pulse had become natural; there was no cedema; the urine, which had never exceeded thirty ounces, had a density of 1017, much less turbidity and brownness, and much less coagulability; and her sense of general comfort was greatly increased. Three grains of gallic acid were then ordered thrice a-day, but without seeming to pass by the urine, until the doses were doubled, when it was easily detected by the salts of iron causing a bluish-black precipitate. On the 6th March, the urine was forty ounces in quantity, 1015 in density, less turbid, and no longer red or brown. From this time there were occasional fluctuations, but on the whole an appreciable amendment, until the 31st March, when the urine presented very few tube-casts, little turbidity, and little albumen; but for three days the potash test indicated the presence of some sugar, although the density was only 1012. On April 16th, there was only a mere trace of albumen, and on the 30th none. On the 16th May, she was dismissed. The albumen had never returned ; the urine had been constantly clear, abundant, from 1019 to 1022 in density, without sugar and tube-casts. She had become florid, sufficiently plump, vigorous, and active, and she had the appearance of perfect health. I have not heard of her since.
Every circumstance here unites to prove this a case of subacute inflammatory desquamation of the uriniferous tubes. It may fairly be held an instance of complete cure, accomplished mainly under the influence of diaphoretics. Diuretics certainly seemed to be injurious, on at least one occasion; but this is the only instance in which these remedies have ever appeared to me to aggravate the symptoms. I have met with various cases of the same kind in the same circumstances, most of them equally favourable in the result. Another will be detailed under the head of the treatment.
CASE 3.—To these I shall only add for the present one case of the other form of Bright's disease. Frequent examination of the urine constantly presented characteristic microscopic fields of oleiferous epithelial cells, and oleiferous tube-casts. If the doctrine sketched above were good for anything, there could be no doubt of the intimate condition of the kidneys. And accordingly they displayed, after death, appearances which Professor Gluge and Dr Johnson themselves could not desire to see surpassed. The patient was a labourer, James Wood, aged 35, ad. mitted into the surgical department of this hospital for necrosis of the left thighbone, but transferred to the clinical ward in a few days with coagulable urine and ascites. In November 1849, while suffering for some weeks from pain along the left thigh and lameness, he was seized with rigors, in consequence of sitting in a chilly apartment without a fire. Swelling of the abdomen and limbs followed. Little farther information could be obtained of the progress of his illness. When admitted into the infirmary, there was a sinus at the lower part of the left thigh, communicating with the necrosed femur. When received into the clinical ward, he had moderate edema of the limbs, slight ascites, trivial catarrh, a sallow countenance, considerable emaciation, little appetite, much thirst, a frequent feeble pulse, and great debility. The action of the heart was barely audible, but otherwise natural. The urine was moderate in quantity, 1012 in density, without sediment, and distinctly coagulable. Dr Bennett, who then had charge of him, relieved the catarrhal symptoms with squill and opium, and the dropsical effusions, first by Dover's powder, and afterwards by bitartrate of potash. But nevertheless he got constantly weaker and weaker, and became subject to vomiting in the morning, which bismuth, however, seemed to relieve. Soon after taking charge of the wards, I found him, on February 7th 1851, extremely weak, with a thready pulse, and coldness of the feet and hands. There was again anasarca of the legs, and now also of the scrotum, a little ascites, no great bronchitis, but a labouring respiration, and vomiting before breakfast. The urine was fifty ounces in quantity daily, 1015 in density, cloudy when just passed, slightly albuminous, and abounding in lithates and phosphates. It had been necessary to order him both wine and spirit, on account of his extreme weakness. In a few days the urine was more carefully examined, when it was neutral, and free both of phosphates and lithates, but otherwise in the same state as before. The sediment presented many epithelial cells enlarged and gorged with oil-globules (Figs. 4 and 5, e); numerous
casts of the uriniferous tubes, entire or broken, and full of oleiferous epithelial cells and independent oil-globules (f); and also occasionally a few octaëdral crystals of oxalate of lime (g). On February 18th, as there was more ædema and dyspnea, squill and digitalis were substituted for bitartrate of potash, and with the effect of increasing the urine. A mixture of chloroform and spirit of ammonia greatly relieved his breathing. Creasote often checked the liability to vomiting. But, although the urine was soon raised to 120 ounces daily, the dropsical effusions did not for some time recede. At length they began to give way. On March 7th he was every way better; and on the 20th, the urine having been for three weeks at 120 ounces daily, there was very little ædema of the limbs, no ascites, no catarrh, no vomiting, and a tolerable appetite; but still he remained very weak, and seemed to be picking up little strength, and no flesh. Afterwards a watery diarrhea returned, and became gradually more and more attended with vomiting. On April 7th, both of these affections were urgent, in spite of acetate of lead with opium, catechu, morphia suppositories, and creasote. Consequently the exhaustion soon became extreme, and ended fatally on the 15th.
For four or five days before death the urine did not exceed ten ounces daily, yet to the last there was no coma.
On dissection, the kidneys were found somewhat enlarged, their surface mottled with little vascular patches, their interior mottled irregularly with deep grayishpurple spots on a light fawn ground, the medullary part highly injected. Opaque yellowish granular spots were visible on many parts of a longitudinal section. The
fluid scraped from the surface of a section presented before the microscope oleiferous epithelial cells (Fig. 6, e), and oleiferous tube-casts(f), exactly like the sed ment of the urine examined during life. Thin sections of the medullary part of the kidneys
made with Valentin's knife, both in the direction of the uriniferous tubes (Fig. 7), and across them (Fig. 8), showed these tubes everywhere gorged with oil-globules,
while the malpighian bodies seemed free of such obstruction (Fig. 8, i). The supra-renal glands were enlarged The mesenteric glands had a bluish marbled
appearance. The intestinal mucous membrane was everywhere thickened, and its folds were in many parts dark brown, but there was no ulceration. The spleen was enlarged and firm. The heart was rather small and pale, the endocardium opaque, the aorta atheromatous at its commencement. The lungs were somewhat emphysematous, and presented here and there, especially just under the pleura, nodules of condensed pulmonary tissue, about the size of a cherry stone, grayishpurple in colour, generally softened in the centre, and passing insensibly into the surrounding healthy texture. The left femur presented interesting appearances; but as they were those of necrosis generally, they need not be detailed here.
The appearances in this case were characteristically those of stearosis of the kidneys. I endeavoured to ascertain by chemical analysis, whether oil could be
obtained from the kidneys in proportion to the microscopic indications. Au accident prevented the weight of oil from being determined, but it was plainly much greater in proportion than in a comparative analysis of a healthy kidney. From the first the symptoms presented a character of adynamia, which could not be referred to the necrosis merely, but seemed to betoken the presence of a malignant disease. The abundance of the watery part of the urine, and the facility with which it was very much increased, together with the want of oily degeneration of the malpighian bodies, rather favour the notion that these bodies are concerned less with the proper secretion of the kidneys than with the secretion of watery fluid.
VI. TREATMENT.-The treatment of Bright's disease of the kidneys is partly directed to the removal of the fundamental disease, and in part to the cure of secondary diseases.
The main remedies for the fundamental disease are general depletion, topical depletion, local counter-irritation, diaphoretics, diuretics, and astringents. In acute cases general bloodletting is an essential measure, if there be decided general re-action; and in the young, robust, and plethoric it must be practised freely, as in ordinary acute inflammations. Local depletion is resorted to in subacute cases, or when the constitution is impaired, but, according to my observation, not with the advantage we might expect, unless its amount produces a general impression. Counter-irritation of the loins is probably too little resorted to. It is improbable that any benefit can be derived from depletion or counter-irritation in stearosis, uncomplicated by inflammatory desquamation. In all cases, acute or chronic, stearotic or inflammatory, diaphoretics are of essential service. The best are Dover's powder, the warm bath, warm clothing, and, for convalescents especially, a moderately warm climate. Diaphoretics have always appeared to me most serviceable when they are so given as to excite a gentle perspiration during a part of the night. Diuretics are seldom necessary for the fundamental disease ; but they are sometimes advisable when the urine becomes very scanty, even al. though there is no dropsy; and they are undoubtedly the most certain and speedy remedy when the dropsical effusions are considerable. I am convinced that the fears entertained by some of injury being produced by the stimulus of diuretics on the kidneys are visionary. Case 2d is the only instance in which I have ever witnessed any apparent harm; and in numberless instances, as in case 3d, I have seen dropsy quickly removed by diuretics, not only without increase of the other symptoms and secondary affections, but likewise with manifest improvement in them all. The stimulus caused by diuretics may well be supposed to differ entirely from the peculiar irritation which gives rise to either inflammatory or stearotic desquamation; and in that case the induction of the one may not of necessity tend to induce, keep up, or increase the other. Besides, is there no likelihood of advantage from diuretics sweeping out the tube-casts, and other matters obstructing the uriniferous tubes ? The best diuretics, in my experience, are digitalis, squill, and bitartrate of potash taken simultaneously. Nitrous ether, broom tops, acetate of potash, oil of juniper, have seldom succeeded in my hands when the three former failed; but after all these had failed, I have seen diuresis speedily established by Hollands. I doubt whether astringents, even in chronic cases, are of the service which we might expect. I have seen a few cases, in which the albuminous impregnation ceased under the use of acetate of lead, or under that of gallic acid; but the good effects have not been so frequent as to entitle me to speak positively in their favour.
The treatment of secondary diseases does not materially differ from that which is applied to the same diseases in other circumstances. All of them are more difficult of cure when secondary to Bright's disease. Inflammations must be treated with activity in the usual way. I repeat that, after frequent careful watching, I can find no objection to the use of diuretics for removing dropsy, but quite the reverse; but in this affection we should avoid the cathartic plan, as being apt to excite a permanent diarrhæa; and mercury should be shunned as a mercurial on account of the facility with which in this disease it produces exces.