into the intestine through the duct. com. choled.; the bile then accumulates in the larger ducts and distends them: it continues to be secreted for some time, but afterwards accumulation of yellow matter takes place in the cells, from which it is no longer freely extracted by the elaborating ducts; (2) when inaction of the elaborating duct occurs. This is the commonest case; the cells become filled with yellow matter, as before, because it is not withdrawn from them; (3) when, with or without impairment of the action of the excretory ducts, an increased quantity of yellow pigment is formed in the parenchyma of the liver.

I may quote here some remarks from Prof. Lehmann's work on Physiological Chemistry, which seem to me not only to bear out the opinion he adopts, that the components of the bile are not formed in the blood, but also to support the view I have maintained, that the bile is not completely formed in and by the hepatic cells, but that this is effected by the action of the ultimate ducts. Lehmann says, "It is just in disease of the parenchyma of the liver that jaundice very seldom occurs; in fatty liver, bacony liver, and the rare tuberculosis of the liver, certainly never; even in granular liver and inflammation of its substance but seldom. Jaundice only presents itself constantly in diseases of the gall passages, and in acute yellow atrophy."

Now, if with these various alterations of the parenchyma of the liver bile can still be formed, as we know it often is, it seems highly probable that some other apparatus besides the cells has a large share in the formation of this secretion, or at least is capable of taking such.-Medico-Chirurgical Transactions, 1852, p. 259.

55.-On the Effects of Cholagogue Medicines, and some Remarks on the Morbid Changes in the Liver. By DR. C. HANFIELD JONES, F.R.S.-[After alluding to some of the remarkable peculiarities with regard to the structure of the liver, Dr. Jones proceeds to relate a large number of experiments, illustrating the action of this class of remedies upon various animals, and the general result is briefly as follows:]

Mercury, muriate of manganese, and colchicum, are the only ones which seem to increase the production of yellow matter in the cells of the liver. I have placed them in the order of their potency. That they also increase the production of glycocholate and taurocholate of soda I think very probable; but unless we were assured that the quantity of these principles is always proportionate to that of the yellow pigment, which does not seem to be the case, the above experiments say nothing as to this point. It is clear that the cholagogue action of a medicine, its emulging effect on the ducts, is distinct from that which it exerts in the production of biliary pigment. Jaundice has been known to come on during a mercurial course, and apparently an effect of the medicine. I have at present a patient under my ob servation (one of Dr. Chambers in St. Mary's Hospital), who reports her jaundice to have appeared after taking a six grain calomel pill. These statements are in accordance with the experiments I have detailed, the animals to whom I gave mercury had jaundice of the liver.

One very important effect to be noticed of the administration of mercury on the liver is, that it certainly produces very great congestion of the organ; this is an argument for rather forbearing the use of this remedy in inflammation of the substance of the liver, a practice which would otherwise be recommended by our analogical experience.--Med.-Chirurgical Transactions, 1852, p. 258.

56.-On the Treatment of Dysentery. By DR. CAMERON, Surgeon 37th Regiment.-Dysentery is generally seen as colonitis in Ceylon, and very rarely attended with that hepatic complication so much talked of elsewhere. The treatment pursued has been local depletion by leeches to the abdomen and anus, the internal use of Dover's powder and ipecacuanha, in doses of three grains each every third hour during the early stage, and afterwards combinations of opium with kino, chalk, tannin, acetate of lead, &c., according to circumstances.

In all severe cases, I have for many years past conjoined quinine in moderate doses

with the other remedies, giving to the extent of twelve or sixteen grains in the twenty-four hours, and, I am persuaded, with the best results as regards the patient's strength and the prevention of sloughing of the mucous membrane. I attach much importance, also, to the support of the patient from the commencement. Sick men often die of starvation as much as anything else. I generally give a cup of arrowroot twice a day for the first three days, and after that continue it, with chicken broth, for dinner and drink. Opiate injections are commonly used. I have occasionally derived benefit from strong solutions of nitrate of silver thrown into the colon; but with the ordinary apparatus it is nearly impossible to use the remedy effectively, owing to decomposition. Med. Times and Gazette, Oct. 8, 1853, p. 366.

DISEASES OF THE URINARY ORGANS.

57.-ON DISEASES OF THE KIDNEY.
By DR. GEORGE JOHNSON.

[Dr. Johnson correctly remarks, how very frequently acute renal diseases, with dropsy and albuminous urine, are preceded by chills upon the surface, produced often by working or standing in wet clothes. The same in cases occurring after scarlatina: hence it is, that the chief means of preventing consequences ensuing after scarlet fever, are protection from cold until the period of desquamation has passed by.]

A consideration of the circumstances under which these attacks of acute renal disease occur, and of the appearances observable in the urine and in the kidneys, warrants the inference, that the renal changes are the result of an effort to eliminate some abnormal products, which have been conveyed to the kidneys by the blood. In cases of scarlatina, for instance, it is probable that exposure to cold has the effect of checking the process by which the fever-poison, or ferment, or the product of fermentation, is eliminated from the skin, and that the morbid materials are then transferred to the kidney, in accordance with the well-known tendency to vicarious action of the skin and kidneys. An instructive illustration of this principle is afforded by the fact of several medicines, such as, for instance, the acetate or citrate of ammonia, acting either as diaphoretics or diuretics, according as the tendency is imparted to them by the skin being kept warm, or the contrary. These facts may assist our comprehension of what probably happens when a patient is exposed to cold too early after the onset of scarlatina. The work of elimination is then transferred from the skin to the kidney; and, as a result of this, there is, in some instances, a free desquamation of the renal epithelium, analogous, as it appears, to the cutaneous desquamation which follows the eruption of scarlatina. That the cells of renal epithelium which are thus freely shed do actually carry with them a portion of the abnormal material with which the blood is infected, is, I think, as nearly certain as any position which is chiefly based upon probable evidence can be. In the urine of a girl named Robinson, who died in King's College Hospital in the year 1847, there were numerous cells of renal epithelium completely filled with crystals of oxalate of lime, while other cells contained oil; the urine was highly albuminous, and had in it many tube-casts. In this case, it is evident that the renal cells were conveying away abnormal products. The hypothesis which assumes, that the free shedding of epithelium from the uriniferous tubes is a means of eliminating_morbid materials, is quite consistent with all the facts of the case, which cannot, I think, be said of any other explanation of the phenomena which has been suggested.

The process of renal desquamation, although primarily and essentially beneficial in its tendency, is not unproductive of mischief; for the secreting structures of the kidney being arranged in the form of minute tubes, which are of great length, and very tortuous, it is evident that the epithelial cells which are thrown off cannot escape with that rapidity with which the epidermic scales are cast off from the cutaneous surface; the consequence is, that the cells, and the fibrinous materials which accompany them, frequently fill, distend, and obstruct the tubes, and thus greatly impede, if they do not entirely arrest, the secretory process. And thus it happens, that many tubes being rendered inefficient, either for the further elimination of the

morbid products, or for the discharge of their normal excretory functions, the urine is greatly diminished in quantity, and the patient may die from some of the secondary consequences of an accumulation of poisonons excrement in the blood.

To illustrate these phenomena by an analogy, I would remark, that the relief from urgent symptoms which is afforded by the appearance of the small-pox eruption, is evidence, as we suppose, that some mysterious poison has been thrown from the blood into the skin. The non-appearance of the eruption is often associated with the most rapidly fatal symptoms; and, on the other hand, the patient may be killed by the very abundance of that eruptive process which nature intended, and which was, indeed, essential for his preservation.

In like manner, it is a matter of almost daily observation, that those cases of acute dropsy with albuminous urine are, in general, most certainly and easily cured, in which there is a copious renal desquamation; while the most rapidly fatal case which I have met with, was one in which there was neither desquamation nor fibrinous effusion into the kidney-tubes.

It must be remembered, that, as the eruption of small-pox may be scanty, in consequence of the blood being infected, as we suppose, by only a small amount of the specific poison, or in consequence of the blood being changed by the same poison in a less degree than ordinary, so the degree of renal desquamation may be slight from an analogous cause. In both cases, we draw this conclusion from the observation of similar facts-namely, the comparative mildness of the general symptoms. These doctrines are obviously, in a certain degree, hypothetical; but auy one who rejects them merely because they are hypothetical, and not because they are inconsistent with established facts, can scarcely have reflected as he ought to do upon the fact, that it is upon probable and not upon demonstrative evidence that we are often bound to act-if we will act at all-not merely in the practice of medicine, but in the most important concerns of our daily life.

With regard to the duration of an acute renal attack, it is to be observed, that very much depends on the nature of the cause. As an illustration of this, I may mention, that the renal disease which occurs in connexion with cholera, often terminates within two or three days from its commencement; while the duration of that which results from scarlatina is rarely less than the same number of weeks. Yet, in both instances, the local phenomena are precisely similar. The prognosis, therefore, is not to be based exclusively upon the condition of the urine.

In thus briefly passing in review the leading facts in the pathological history of that form of acute renal disease which is always associated with albuminous urine, and in most cases with dropsy, my purpose has been to indicate the primary object of treatment, which is, to guard against exposure to cold. As exposure to cold, whether acting alone, or in conjunction with other influences, is among the most frequent exciting causes of inflammation of the kidney, so there is nothing which has a greater tendency to perpetuate the disease, and to render it incurable. Attention to this point of treatment is as indispensable for the patient's welfare as a steady position for a broken bone, or rest for an inflamed knee-joint. I am confident that the neglect of this precaution has been the means of converting more acute and curable attacks of renal disease into a chronic and incurable malady than all other causes combined. Within the last few months several instances have come to my knowledge, in which the life of a patient suffering from acute renal dropsy has been sacrificed, by his being permitted to go out, day after day, to visit his medical attendant.

In a cold season, confinement to the bed is absolutely necessary for the patient's well-being and safety; and, even in warm weather, it appears to favour and hasten the recovery. Rest in the horizontal posture tends to quiet and equalize the circulation; and the uniform warm temperature of the bed favours the action of the skin, and prevents the risk of a check to perspiration. The result is, that the dropsy quickly subsides, and the urine becomes more copious and less albuminous.

The diet should be scanty; for the patient has little desire for food, and the digestive powers are much impaired. The passage into the blood of imperfectly-digested food will surely irritate the kidneys; the urine is often more albuminous after meals, and I once saw a return of hæmaturia follow a meal of potatoes. Alcoholic drinks should be prohibited, unless required for some special purpose.

Having secured the two primary objects of treatmeut-a moderate uniform tem perature, and a scanty diet-we must be guided by the nature and urgency of the

symptoms in the choice of additional remedies. In every case it is desirable to pro mote the action of the skin and bowels; the first by diaphoretic medicines and th hot air bath, and the latter by saline aperients, or by the compound jalap powde The free action of these great excretory surfaces is a very efficient means by whic to lessen the injurious over-work of the kidneys. It scarcely need be said, tha however scanty may be the urine, no stimulating diuretic is to be given; indeed, th more scanty the secretion, the more injurious would be the effect of any irritating drug. This is so obvious, from a consideration of the pathology of the disease, a to require not a word of comment or explanation. During the convalescence the urine is usually twice as abundant as in health, in consequence, probably, of the naturally diuretic influence of the urea and other urinary products which, having accumulated in the blood during the acute stage of the disease, find a free outle when that stage is passed. A practitioner who has been perseveringly giving diuretics, and who is ignorant of this pathological fact, will be likely to attribute to the influence of his drugs this abundant flow of urine, which is, in fact, only a natural and a spontaneous diuresis. It will be understood, that, in deprecating the use of diuretics, I am speaking only with reference to cases of acute renal disease. When the disease has become chronic, and when an excessive dropsical accumulation constitutes the most distressing and dangerous symptom which other means have failed to remove, "we must incur the risk of one possible and contingent evil for the chance of obtaining what, if obtained, is a certain and positive benefit; we must endeavour to remove the dropsical accumulation by means of diuretics, whether these accelerate the progress of the disease in the kidney or not." In such circumstances the hope of entirely removing the renal disease has been abandoned, and the chief object of treatment is to relieve the most urgent symptoms, and to prolong life to the utmost.

[After the acute stage of nephritis has passed, Dr. Johnson recommends that the patient, especially in winter, be kept in-doors, until no albumen can be detected in the urine. If he rebels, he will very probably bring on a relapse, of which he should be warned. If, after every precaution has been taken, and the period of confinement prolonged, still the urine contains albumen, though natural in other respects, gallic acid may be given; and if after this the quantity of albumen continues, Dr. Johnson advises that he should be removed to the sea-side, and allowed to take a daily airing. If the malady still persists, and assumes a chronic form, the patient must be urged to take a sea voyage as early as possible. As to the treatment of cerebral symptoms, consequent on acute inflammation of the kidneys, as after scarlatina, or exposure to cold, we must relieve the congested state by cupping over the region of the kidneys, and abstracting a moderate quantity of blood, and by exciting free action in the mucous membrane of the bowels, by means of elaterinm or pulv. jalap. eo., with a few grains of calomel sometimes added.]

If we can excite copious discharges from the mucous membrane of the bowels, we shall by that means eliminate some of the excreta which are poisoning the blood, for urea has been detected in the watery stools produced by elaterium. There is not much to be hoped from cupping over the kidneys, but dry cupping can certainly do no harm; and, if the patient's appearance be not decidedly anæmic, we may venture to abstract a small quantity of blood; but we shall do this with much caution, if we bear in mind Dr. Watson's suggestion,-sanctioned, too, by the high authority of Dr. Todd,—that an impoverished condition of the blood may favour the tendency to coma and the poisonous action of urea. Cold lotions may be applied to the head when the scalp is hot, and blisters when the skin is cool. Since, in any case, it is a more hopeful task to prevent drowsiness from passing into coma, than to bring a patient out of a comatose condition when once he has fallen into it, it is important to keep a watchful eye upon the premonitory symptoms. In some cases, it appears that the most successful mode of keeping them in check is to give a nutritious but unstimulating diet, with moderate doses of steel, and, at the same time, to keep up a free action of the bowels.

[Can the kidney perfectly recover from an acute inflammatory attack? Dr. Johnson answers, yes, if the case has come early under treatment, and yielded to it in moderate time. No harm wil result, except the spoiling of a few of the tubes and wasting of the parts, unless the disease has been so long prolonged as to de

stroy the epithelial lining of the tubes and render them liable to be converted into cysts.]—Med. Times and Gazette, July 16, 1853, p. 53.

58.-INFLAMMATION OF SEROUS MEMBRANES IN CHRONIC RENAL

DISEASE.

By DRS. GEORGE BURROWS and W. SENHOUSE KIRKES.

[Examinations after death prove the frequency of the complication of inflammatory affections of the serous membranes with chronic renal disease. Generally in such cases, one or more of these structures present evidence of having been formerly or recently inflamed.]

The liability of the serous membranes to become secondarily affected in the course of chronic disease of the kidney, was recognised and pointed out by the eminent physician to whom we are indebted for so much that we now know on the subject of renal disease. In the first volume of his Reports, Dr. Bright says: "When the secretion of these organs [the kidneys] is greatly deranged, the serous membranes seem always ready to become the seat of inflammatory action." And again, at page 18, he speaks of the "disposition which exists in this disease [renal dropsy] to severe inflammatory affection of different structures, but more particularly of the serous membranes ;" and such secondary serous affections he elsewhere speaks of as among the chief sources of danger in chronic renal disease. The truth of these statements has been amply confirmed by later observers, and the liability of the gerous membranes to become inflamed in the course of Bright's disease may therefore be regarded as a fact well established.

Although it may be considered as a settled truth, that the serous membranes, as also other tissues, are prone to inflammation in the course of Bright's disease of the kidney, yet there are certain peculiarities in the serous inflammation which have either not yet attracted particular attention, or have not been sufficiently dwelt upon; and as these peculiarities seem calculated to throw some light on the cause of the inflammatory process, and so to be beneficial in treatment, an inquiry into them here may not be out of place. In the first place, then, it may be observed, that in every stage of chronic renal disease there seems to exist a tendency to the effusion of an excess of serum into the serous cavities, as well as into the loose cellular tissue of the body. The cffused fluid, in this disease, differs in its nature, as well as in the cause producing it, from that exuded in cardiac dropsy. In the latter, it results from mechanical distension of the capillaries; in the former, from an unhealthy state of the blood, especially of its serous parts. In cardiac dropsy, the exuded serum is usually clear, and of a colour varying from pale straw to deep yellow; in renal dropsy it is almost always slightly turbid or opaline, sometimes whey-like and milky, and usually of a pale tint, almost colourless. Moreover, the dropsical fluid in cardiac disease is free from urea; while that in renal disease has been found to contain urea in appreciable, often considerable quantities. Simon met with it in the fluid from dropsical legs in a case of Bright's disease; and Marchand found "an extraordinarily large amount in the fluid removed by tapping from a woman with ascites." Simon, therefore, is probably correct when, speaking of dropsical fluids in general, he says: "If the kidneys are affected, urea is generally present" in them. For, since it is well known that the blood, especially the serous part of it, is charged with urea in Bright's disease, it may be readily believed, that in transuding the walls of the blood-vessels, the serum of the blood carries with it some of the urea, as well as other materials which it holds in solution, and that this ingredient may be detected in the dropsical fluid accumulated in the serous cavities, or exuded into the cellular tissue of the body.

To the presence of this excrementitious material in the serum exuded from the blood may probably be ascribed the inflammation which is apt to ensue in the serous cavities in renal disease. Highly delicate and sensitive, as we know the serous membranes to be, we can scarcely be surprised that they should be irritated and excited to a kind of inflammatory process by the substitution of a fluid charged with urea, for the simple unstimulating secretion by which their interior is naturally moistened. And this is the more likely to be the case, since the fluid exuded into