CHEMIC AND MICROSCOPIC CONDITION OF THE URINE IN TYPICAL CASES OF THE THREE VARIETIES OF KIDNEYS SEEN IN CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS. Color Yellow; yellowish-red. Light yellow; turbid. Reddish-yellow. The Urine. The specific gravity varies from 1015 to 1040. It is light yellow in color, often cloudy, and acid in reaction. The amount of albumin contained in the urine is large, from 1% to 5%, more albumin being passed after exercise than after rest. The urea is diminished in amount. Microscopic examination reveals granular large and small hyaline casts, and occasionally epithelial and fatty casts. There are also observed granular debris, leukocytes, and degenerated epithelial cells. Dropsy. This is a most constant symptom, affecting the face, the extremities, the scrotum, and the serous cavities. Gastric Symptoms.-These are common. Nausea and vomiting often occur, the appetite is lost, the tongue is coated, and there is constipation alternating with diarrhea. Blood.-An anemia of the chlorotic type often occurs. The erythrocytes may be diminished to 800,000 per cubic millimeter. The tendency to hemorrhage is marked. Changes in the Circulatory System.-Some changes take place in the heart, such as hypertrophy with dilatation, especially with the secondary cirrhotic kidney. The second aortic sound is often accentuated, and hemic murmurs may be heard over the base of the heart. Eye Symptoms.-Often there is dimness of vision, and specks and mists float before the eyes. Albuminuric retinitis occurs, but is not so common as in chronic interstitial nephritis. Complications.-Pleurisy, pneumonia, pericarditis, meningitis, erysipelas, gangrene of the skin, and edema of the lungs are of common occurrence. If cardiac hypertrophy becomes marked, apoplexy is liable to result. Uremic phenomena are frequent. Differential Diagnosis.1 Large White Kidney. Edema extensive and tenacious; anemia marked. Heart shows no hypertrophy. Urine of highest specific gravity; largest amount of albumin; microscopic elements show fatty changes. Chronic Hemorrhagic Edema excessive and ob- Urine has abundant al- constant. Mottled or Secondary Cirrhotic Kidney. Edema varies, often nearly disappears; anemia marked. Heart hypertrophied; often dilated. Albumin in urine varies; the specific gravity is lower; casts often disappear. Prognosis. Complete recovery is extremely rare. The disease may be delayed for years, but even the mildest cases may terminate in uremia. The great liability to complications should always be borne in mind. Treatment. The patient should be protected by warm clothing, flannels being worn during the entire year. If possible, the patient should live in a warm, dry climate, remaining in the sun the greater part of the day. The functions of the skin must be maintained. Warm baths followed by friction and rubbing of the skin are useful. The diet is most important, milk being the best food. Kumiss and buttermilk may also be given, or milk and Vichy water. In mild cases the following articles may be allowed sparingly: Fish, white meats (such as veal and white meat of chicken), green vegetables, and small quantities of bread. Alcohol and malt liquors 1 Modified from Loomis-Thompson, “American System of Practical Medicine." should be strictly prohibited. Water must be taken in large amounts. Tobacco, if used at all, should be indulged in sparingly. Moderate exercise, avoiding fatigue, is of advantage. Bicycling is to be strictly forbidden. The functions of the body require careful attention. Constipation can best be treated by the administration of broken doses of calomel from time to time, followed by a saline. When the amount of urine has been markedly decreased, the use of digitalis is found beneficial, as is also Basham's mixture. One-drop doses of the tincture of cantharides three times a day in Basham's mixture will be found of advantage when the amount of the urine has become small. Complications must be treated upon general principles. CHRONIC INTERSTITIAL NEPHRITIS. Synonyms. Chronic contracted kidney; granular kidney; cirrhosis of the kidney; gouty kidney; small red kidney. Etiology. The disease occurs most frequently in males between the ages of forty and sixty. It arises particularly in the lithemic or gouty diathesis, and in those subjects who early show a tendency to fibroid changes in the arterial system. Alcohol is one of the principal predisposing causes. Partaking of rich food, with very little exercise, is also a causative factor. Gout and syphilis are important causes. Pathology. In this form of nephritis the kidney is usually markedly reduced in size, sometimes weighing as little as fifty grams; however, when this change occurs, both kidneys are not liable to be affected to the same extent. When the kidney is very small, the perirenal fat is often extensive. If the process be of short duration or of slow development, it may be of almost normal size, so that in a measure it may quite closely resemble the secondary cirrhotic kidney. The surface of the organ becomes granular, this varying from a finely granular to a somewhat hobnail appearance. The fibrous capsule is drawn down in many points, giving rise to a granular appearance, is firmly adherent to the kidney substance, and anastomosis between the blood-vessels of the cortex and the capsule may take place. The color of the surface is reddish or reddishgray, sometimes red-brown, intermingled with lighter reddishyellow areas. Frequently retention cysts are visible under the fibrous capsule, which vary in size from a pinhead to a pea, or occasionally they may be larger. These are filled with |