acid and its salts is less than in health; but the diminution is much more considerable in the latter than in the former variety of the disease.

One of the most formidable consequences of nephritis is unquestionably the great diminution, or perhaps the complete suppression, of the urinary secretions, and the cerebral symptoms which are apt to ensue upon such a condition. In certain cases of typhoid and other fevers there is a tendency to this state of things supervening. We need not add that the most prompt and vigorous treatment is required to save the life of the patient. In the worst set of cases the kidneys become more or less decidedly gangrenous: this termination of nephritis has also been observed after death from certain poisons.

The chronic form of simple nephritis is probably of much more frequent occurrence than the acute. The descriptions hitherto given of the disease by different writers have generally been far from accurate; in consequence of their confounding inflammation of the pelvis and calices. with that of the tubular or cortical substance of the organ. Whenever the urine has been decidedly purulent, and pain and uneasiness in the loins, extending down along the course of the spermatic cord, have been felt, the case has been regarded as one of nephritis; whereas these, properly speaking, are the symptoms rather of pyelitis than of it.

According to the observations of M. Rayer, the diagnosis of chronic nephritis is often utterly impossible unless the urine is attentively examined. "Constant pains in one or in both of the renal regions, co-existing with a diminished acidity, or with a neutral, or still more with an alkaline state of the urine-whether there be a retention or not of this secretionand with a sense of feebleness in the lower limbs, are the principal characters of the disease."*

When the urine is alkaline, it is usually opaque or cloudy, unless the proportion of the phosphatic salts is very small indeed. The sediment is generally found to be composed of the ammoniaco-magnesian phosphate, and of phosphate of lime, with or without a small quantity of the urates, and with more or less mucous matter combined. "In fine," adds M. Rayer, "chronic nephritis is one of the most favourable conditions for the production of phosphatic calculi."

The effects of appropriate treatment will sometimes very beautifully confirm the diagnosis which we may have formed. Thus, after the application of the cupping-glasses and the use of a mild unirritating diet, the urine, which for some time before had been thick and decidedly alkaline, may be found to become transparent and to recover its normal acidityperhaps again to return to its unhealthy condition in consequence of some irregularity of diet, or of fatigue, or of exposure to cold, &c.

The symptoms of chronic nephritis being often so very obscure in themselves, and rendered still more so by their not unfrequent alternations of

The renal pain, which by-the-bye is in most cases obscure, and is felt only when pressure is made on the loins, seldom extends, according to the experience of our author, in the direction of the ureter, and is almost never accompanied with pain in the testicles. In general, the urine is voided frequently, and only in a small quantity at a time.

amendment and aggravation, it becomes the duty of the physician. to be much on his guard in his diagnosis of many cases. Often the disease has continued for months or even years, before the patient applies to a medical man for relief; and, even when he does, he is not at all aware that the primary seat of his distress is in the renal region. The pain there may be so trifling as not to attract his notice, unless firm pressure be made over it; and the increasing frequency of calls to urine may have come on so gradually that he has never thought it worth while to mention the cir

cumstance.

When chronic nephritis has attacked both kidneys, its principal symptom is the slow and progressive deterioration of the general health. This cachetic state favours the development of many other diseases, especially obstinate catarrhs and pulmonary consumption.

M. Rayer describes at great length the various morbid appearances which simple nephritis, both in its acute and in its chronic form, is apt to induce in the kidneys and in their coverings; but we cannot enter into this subject, as it would require much more space than we can allow to give an accurate idea of his, perhaps too elaborate, descriptions.

After discussing the diagnosis of the disease, he makes some good remarks on the prognosis which should be formed in certain cases. He dwells particularly on the danger of nephritic attacks in patients who have long laboured under any disease of the bladder, prostrate gland, or urethra; more especially if such attacks have come on after a surgical operation, such as lithotomy, lithotrity, or even the introduction of a sound. Under such circumstances the invasion of nephritis is often very sudden and proves very rapidly fatal. Many an old man, who may have been for years affected with an incontinence of urine, but whose general health had remained good, is carried off very quickly, if the kidneys once manifest the symptoms, of renal inflammation. This circumstance should therefore be strongly impressed on the minds of all medical men.

M. Rayer alludes to the occurrence of nephritis in parturient women in the following passage ::

"In recently-delivered women, an attack of nephritis is sometimes preceded or accompanied by inflammation of the ovarian veins. The existence of pain in the renal region requires that the state of the uterus and its appendages should be examined with the greatest care. Like every other sort of inflammation occurring in parturient women, nephritis has a great tendency in them to terminate in suppuration. In spite of the fatigue and exhaustion which follow delivery, we must have recourse to free blood-letting, and this with the greatest promptitude, as the disease is often overlooked for the first day or two after its invasion; the lumbar pains having been regarded merely as one of the effects of the labour."

In all cases of chronic nephritis, from whatever cause it may proceed, there is no remedy so decidedly useful as cupping over the loins. Even when there is co-existing disease of the bladder or of some other part of the urinary apparatus, the relief is often almost instantaneous after some ounces of blood have been withdrawn by means of the scarificator. The application of hot poultices afterwards, and the use of the warm bath may generally be recommended at the same time.

With respect to the use of acids, as means to obviate an alkaline state

of the urine, and to counteract the tendency to the precipitation of the phosphatic salts, M. Rayer informs us that his experience is by no means very favourable to the practice. He has repeatedly observed that they entirely failed in producing the desired effect, and, when continued too long, or administered in large doses, they often seemed to injure the state of the stomach and the general health of the patient.

"I have seen," says he, " in workmen affected with chronic nephritis, the urine become acid and transparent after a fortnight's repose, and enjoyment of a good diet, in conjunction with one or more applications of the cupping glasses to the loins, and again become muddy and alkaline when the food was less nourishing, or the patients had taken any extra fatigue. I have carefully compared the effects of a vegetable and of an animal diet in such cases, and am satisfied that the latter is to be preferred. Not only does the state of the urinary secretion become more normal under the use of nutritious food, but the general strength and health of the patient very decidedly improve."

When there is much distress from the frequent calls to pass water, the use of opium, of anodyne enemata, and of emollient hip baths, will often give relief for a time. The acidulated decoction of the Pareira brava, the extract of the Uva ursi combined with the extract of hop or of henbane, the infusion of carrot-seeds, or of the leaves of the Diosma crenata, have been given with benefit in some cases; but the use of these remedies should be suspended whenever any aggravation of the inflammatory symptoms takes place.

The establishment of a purulent drain from the renal region, and the exhibition of the milder preparations of steel, have seemed to produce good effects occasionally.

M. Rayer has, as we have said, described at great length the various complications, which have been observed to attend occasionally the existence of nephritis. One of the most formidable of them is the development of cerebral disease, indicated by the sudden supervention of stupor and coma, which unfortunately are generally the precursors of a fatal termination. In this form of nephritis, the vomiting is more than usually severe and obstinate; so much so as often to excite the suspicion in the mind of the medical attendant of the existence of gastritis or peritonitis. The pain, however, situated in the loins, and the diminution, or even the total suppression, of the urine, point out that the kidneys are seriously affected. Whenever there is a complete suppression of the urine-the ischuria renalis of authors-the tendency to cerebral disease is much to be feared.

Several cases are quoted by our author of the absence of one of the kidneys, and where the other became the seat of inflammation, with or without the presence of calculi at the same time. We cannot be surprised that under such circumstances the renal disease proves inevitably fatal. He has also collected several instances of what has been called fusion of the kidneys, in which the double organ became the seat of inflammation. Vesalius long ago remarked that lean persons, in whom the abdomen is prominent and the lumbar region depressed, are often found to have but one kidney placed transversely across the vertebral column; and M. Rayer thinks that he has been able, during the life of the patients, to confirm the truth of this statement in more than one case. He adds that this peculi

arity of the kidneys ought to be kept in mind by the physician, as the swelling caused by the irregularity of their position has been mistaken for a morbid tumor in the abdomen.*

Gouty Nephritis.

The connexion of renal inflammation with a gouty diathesis of the system has been pointed out by many practical writers from a very early period of medical literature. The well-known tendency, that exists to the deposition of sand and minute calculi not only in the pelves and calices, but sometimes even in the very substance and on the surface of the kidneys in gouty patients, is in itself sufficient to explain the frequent development of nephritis, usually of a chronic character, under such circumstances. As long as the calculi do not impede the free escape of the urine from the kidneys, the symptoms of the disease are usually indistinct and may not sufficiently attract the notice of the medical attendant; the patient complains rather of a dull heavy weight than of actual pain in the loins, extending sometimes down along the corresponding limb, and to the testicle, and attended with a sense of numbness in the same direction; the urine is almost always more decidedly acid than in health, even when its colour is not unusually deep; and the digestive functions are generally more or less disordered. The most important diagnostic symptom is unquestionably the state of the urinary secretion; and therefore, unless this be attentively examined and tested, the physician will necessarily remain in uncertainty as to the nature and cause of the malady. When first voided the urine sometimes exhibits minute grains of crystallized uric acid held in suspension in the fluid; if left for a few hours in a glass tube, we may generally detect a certain number of these crystals adhering to its inner surface. Even when the gouty diathesis is not very prononcé, the sediment, if examined with the microscope, often appears entirely composed of such crystals, which may, or may not, be blended with blood, or mucus or pus. This state of the urine is so inherent, so to speak, in gouty patients who suffer from renal pains, that I have known it to continue, says our author, after more than a year or two's use of alkaline baths and drinks.

If a calculus becomes impacted in the opening of the ureter, the symptoms assume a more active character, the pains in the loins become much more severe, and the urine is then generally more or less charged with albumen or globules of blood.

In simple nephritis, the urine is either very slightly acid, or it is neutral, or even alkaline and its sediment is usually composed of the urates or of phosphate of lime in an amorphous condition: in gouty nephritis, on the other hand, the urine is invariably more acid than in health, and the sediment is generally more or less decidedly crystallized. The symptoms in the latter case not unfrequently subside and disappear after the expulsion of a quantity of gravel or of a small calculus. The detraction of blood by leeches or cupping over the loins, or from the arm if there is much

In the Foreign Periscope of the present number will be found a series of extracts from M. Rayer's work, on the anomalies, &c. in the structure of the kidneys.-Rev.

feverish irritation of the system, will however generally be necessary; and if the pain should continue after the gravelly matter has passed, it may be prudent to repeat the loss of blood; employing at the same time warm baths, poultices to the loins, and diaphoretic demulcent drinks.

When the renal region remains tender on pressure, after the feverish symptoms have entirely subsided, and when the urine is found at the same time to contain either purulent matter or a large quantity of mucus with or without an admixture of blood, we have reason to suspect the existence of one or more calculi in the pelvis or calices of the affected kidney. In such circumstances, the quantity of the purulent or mucous secretion may usually be much diminished by the use of balsamic and terebinthinate medicines. Alkalis and alkaline earths should be administered as long as there is an excess of uric acid in the urine: their action seems to consist in combining with the acid of the urine, and thus forming salts which are much more soluble in the fluid than the acid itself. M. Rayer seems to have but little confidence in the decoction of the pareira brava, as an agent to restore a healthy state of the secretion. It has been, he says, from neglecting to test the urine and its deposits, that medical men have been so apt to attribute remedial properties to this and other substances for the relief of urinary complaints occurring in a gouty constitution.

Sir B. Brodie has drawn the attention of medical men to a set of cases, the symptoms of which very closely resemble those of nephritic colic, although differing from the latter in several respects. The disease, says this distinguished surgeon, usually attacks persons living a luxurious life, and prone therefore to the development of the gouty diathesis. The patient complains at first of a pain in the region of the kidneys, which afterwards extends towards the groin in the direction of the spermatic cord; at a later period, without any diminution of these symptoms, he finds that he has frequent calls to pass urine, and the effort to do this is often attended with sharp pains. The urine is usually scanty, of a deep colour, and more or less strongly acid, as indicated by its action on litmus paper. The symptoms will last for several days or even weeks, if no appropriate remedies are employed; but often they may be dissipated within a few hours by cupping over the loins, and by the use of frequently-repeated doses of colchicum. To prevent the return of such attacks, the most important precaution is to abstain from all wine and malt liquors,* and to use soda or Seltzer water, alone, or with the addition of a tea-spoonful of good brandy.

Rheumatic Nephritis.

This variety of the disease has hitherto scarcely been noticed by any writer. Even in those cases where patients have died from organic affections of the heart and other internal viscera consequent upon rheumatism, no mention has almost ever been made of the state of the kidneys.

M. Rayer is however quite satisfied that these organs are liable to serious

If the patient has not sufficient self-command to abstain from these beverages altogether, a glass or two of sound old sherry in water, or a tumblerful of the bitter East India ale-now so much in vogue-may be allowed. This ale, bythe-bye, is an admirable restorative during the convalescence from fevers, influenzas and such debilitating diseases.-Rev.