some mineral water like Poland.

The bowels should be kept freely open; the skin is to be kept active by daily baths and friction; and exercise in the open air should be encouraged in proportion to the strength. Much is gained by spending the winter months in some warm, equable climate. Severe mental or physical work should be avoided, so as to lessen the strain on the heart and the arteries. Anæmia is

to be treated by iron.

Heart and Arteries.-A certain increase in tension is allowable. Excessive tension should be reduced by an

occasional saline laxative and hot bath.

dilators, the best are nitroglycerin (gr.

Of the arterial three times a

day, increased, if necessary, until the desired effect is produced), potassium iodide (gr. x three times a day), and chloral hydrate (gr. v-viij three times a day). Not only is the tension thus reduced, but headache, dizziness, and dyspnoa are often relieved in a most satisfactory manner. For restlessness morphia in small doses at night may be used. Should the heart's power fail and the tension be low, stimulants are needed as in cardiac disease-caffeine, digitalis, strychnine, and strophanthus. Opium is contraindicated in these cases, as small doses frequently cause fatal poisoning.

Uræmia.-Acute uræmia being due to contracted arteries, arterial dilators are indicated in free doses. The bowels should be opened rapidly, and in case of convulsion or coma bloodletting is frequently followed by brilliant results. Hypodermic injections of from to grain of morphia may be used in convulsions or coma with benefit, and for the convulsions whiffs of chloroform may be needed.

Chronic uræmia being due to retention of excrementitious substances, effort should be made to increase their elimination. The kidneys should be stimulated by digitalis combined with the saline diuretics; cups and poultices over the

kidneys should be employed in bad cases. The bowels should be opened energetically, and sweating is to be induced by the hot pack or the hot-air bath.

Acute exacerbations should be treated on the lines laid down for acute nephritis.

WAXY DEGENERATION OF THE KIDNEY (AMYLOID KIDNEY).

Waxy degeneration of the kidney does not appear as a disease by itself, but as an added degeneration to the lesions of chronic diffuse nephritis, usually of the form with exudation. It occurs in cases with prolonged suppuration, especially of the bones, with syphilis and tuberculosis, occasionally with leukæmia, and in rare cases without apparent cause. It is associated with amyloid degeneration of the spleen and the liver.

Pathology. There are usually the appearances of the "large white," more rarely of the "small white," kidney. The glomeruli are distinct and have a bacon-like lustre, staining mahogany-brown with weak, watery solutions of iodine, and red with dilute solutions of methyl-violet. The amyloid degeneration involves the vessels of the glomeruli, of the vasa recta, and occasionally of the membrane of the uriniferous tubules.

Symptoms.-The urine is usually abundant, pale, and of a low specific gravity. Albumin is usually present in considerable quantity, and there may be globulin. Tube-casts frequently include hyaline varieties which give the amyloid reaction. The general symptoms are those of the associated nephritis, together with the original suppurative or cachectic disease to which the amyloid changes are secondary. The diagnosis is aided by the detection of waxy changes in the liver and the spleen.

TUBERCULAR DISEASES OF THE KIDNEY. TUBERCULOSIS OF THE KIDNEY.

Miliary tubercles are frequently found in the kidney in cases of general miliary tuberculosis. The tubercles are small, are unaccompanied by inflammatory changes, and do not give rise to symptoms.

TUBERCULAR PYELONEPHRITIS.

Etiology. The tubercle bacilli may infect the kidney through either the blood-vessels or the urinary passages. The infection may in rare instances be primary, but the ordinary cases are secondary to a tubercular focus elsewhere, especially in the bladder, the prostate, or the seminal vesicles. In many cases it is impossible to say whether a primary tuberculosis of the kidney has been followed by secondary tubercular lesions in the genito-urinary tract, or whether the kidney-lesions have followed infection creeping up the ureters from a primary focus below.

Tubercular disease of the kidney is twice as frequent in men as in women, and it is most frequent in those of middle age.

Pathology. The lesion usually begins in the pelvis of the kidney. The pelvis becomes dilated and is filled with pus and cheesy material; its walls are thickened, infiltrated by pus and tubercle-tissue, and its mucosa becomes increased in thickness. Tubercular infiltration extends to the kidneytissue and rapidly undergoes cheesy degeneration and softening, so that the kidney becomes honeycombed with cavities. In advanced cases the kidney is converted to a cyst containing inspissated cheesy matter infiltrated with lime-salts. Both kidneys are usually involved, but the disease is usually more advanced on one side than on the other. In other cases one kidney alone is involved, the kidney of the oppo

site side developing the lesions of chronic diffuse nephritis with exudation usually with waxy changes.

In the majority of cases tubercular disease of the kidney is complicated by similar tubercular changes in the ureter and the bladder, and sometimes in the prostate gland and the seminal vesicles as well.

Symptoms.-1. Urinary symptoms consist in the frequent appearance in the urine of pus, cheesy material, fatty epithelial cells, and shreds of kidney-tissue. There may

be occasional admixture of blood. These urinary changes also occur with calculous pyelo-nephritis, and so possess no absolutely diagnostic value. The discovery of tubercle bacilli, however, in the urine is an infallible sign of tuberculosis. The bacilli are best found in the small particles of cheesy matter present in the sediment. Albuminuria is usually more marked than can be accounted for by the pus. Tube-casts are of rare occurrence.

2. Local symptoms consist of pain and tenderness over the affected kidney. The pain may be dull and continuous or it may be paroxysmal, resembling renal colic; in the latter case it is due to the passage of lumps of cheesy material along the ureter.

3. An enlargement of the kidney may be appreciated in some instances, as in calculous or suppurative pyonephritis, but as the enlargement is rarely decided, it is with difficulty detected.

4. The constitutional symptoms are those of other tubercular diseases. Fever is rarely absent, and usually presents a remitting hectic character. Anæmia, emaciation, and weakness increase with the progress of the disease.

Acute

5. There may be complicating tubercular diseases elsewhere which add their characteristic symptoms. miliary tuberculosis not infrequently develops.

Diagnosis.-The diagnosis from calculous pyelonephritis

is made (1) by the presence of tubercular disease elsewhere, especially in the lower genito-urinary organs; (2) by the absence of a history of renal calculi; (3) by the presence of the tubercle bacilli in the urine.

Prognosis.-The course of the disease is progressive. The great majority of cases terminate fatally within two years, but it is possible for the disease to stop and the patient to recover.

Treatment.-Surgical treatment consists in the removal of the diseased kidney, and this should be done before other portions of the genito-urinary tract become infected; hence an early diagnosis is of the greatest importance, and it should be a rule to examine for tubercle bacilli in every case of persistent pyuria, so that incipient cases of tubercular kidney may thus be recognized.

SUPPURATIVE DISEASE OF THE KIDNEY

(SURGICAL KIDNEY).

Etiology. The germs of suppuration may gain access to the kidney-(1) through the abdominal wall, as with penetrating wounds; (2) by extension from neighboring abscesses; (3) through the blood-vessels, as in pyæmia and malignant endocarditis; and (4) through the ureter, as from cystitis or following operations upon the genito-urinary organs. The first two methods of infection are exceedingly rare. Infection through the ureter is favored by inflammatory conditions of the urinary passages, by pyelitis, whether simple, tubercular, or calculous, and by injuries. and contusions of the kidney.

Suppuration of the kidney alone is termed "suppurative nephritis," but as the pelvis of the kidney is almost regularly involved, the name "pyelo-nephritis" is often applied. Should the pelvis of the kidney be distended with pus, the term "pyonephrosis" is not inappropriately applied.