some cases of renal disease, and has been very largely prescribed by some physicians. The infusion (half drachm doses) or the powder (in doses of half a grain three times a day) may be given. The former is by far the most efficacious, and in some cases increases the quantity of water secreted without irritating the kidney. Many diuretics do not act disadvantageously in some forms of renal disease, and I think life is sometimes prolonged by their use. As a general rule, irritating substances, such as cantharides, should be avoided, but citrates, acetates, tartrates and nitrate of potash may be given.

Treatment of Vomiting in certain forms of Chronic Renal Disease. In fatty kidney in children and young people, and in some other forms of renal disease, frequent vomiting is often very distressing and difficult to deal with. If small pieces of ice are swallowed from time to time, it may sometimes be kept under control. Small doses of carbonate of soda with a few drops of hydrocyanic acid iced are also useful. A pill containing a drop of creasote with crumb of bread sometimes answers, and although the addition of small doses of opium or morphia may afford relief, such medicines must be used very sparingly, and only while the patient is most carefully watched. Beef tea iced should be given in teaspoonfuls at a time, or iced milk as long as the stomach continues in a very irritable state.

Pericarditis in the Course of Renal Disease.-Pericarditis is a very common complication of chronic renal disease. It is probably due to the altered state of the blood and its increased tendency to form fibrinous deposits. The affection does not usually occur until the patient has become very weak. This form of pericarditis may be treated by the application of external warmth, fomentation or a linseed meal poultice, or moderate counter-irritation; but leeches are scarcely ever necessary, and bleeding or lowering remedies would only hasten death. The affection is seldom accompanied by much effusion of serum, and in most cases the pericarditis will run its course without much effusion or serious derangement of the circulation. Its progress is usually slow, and it is better not to carry out any active depletive measures in the treatment of this complication.

Pleurisy and Pneumonia, when they occur in the course of renal disease, are to be treated on the same principles as when they occur under other circumstances, but no preparations of mercury should be given. It is the exception to meet with very severe forms of pleurisy and pneumonia in those who have long suffered from chronic renal affections, but slight and frequently recurring attacks are not uncommon.

Counter-Irritation.—There is, I think, little doubt that the action of the kidney is affected by counter-irritants, and, as is well known, the afferent nerve fibres distributed to the skin influence the state of the vessels distributed to an organ situated beneath, and even at a considerable distance beneath the surface, by reflex action. Blisters, mustard, turpentine, dry cupping over the region of the kidney, probably act in this manner.

Bleeding is seldom desirable in chronic renal disease. The quantity of blood in the body gradually becomes very much reduced, and in many chronic diseases of the kidney is considerably below what is required by the organism. If there is hemorrhage from the kidney we should endeavor to check it by the administration of tincture of perchloride of iron, or by gallic acid in ten or twenty grain doses five or six times a day, by tannin, or by turpentine. (See page 120.)

A well-nourished, burly man is more likely to die quickly from renal disease than a thin person. If the patient be very stout, appearing to be in rude health, florid, full blooded when the attack first appears, and especially when dropsy comes on early and is considerable, with nausea, some dyspnoea, quick pulse and irritable, weak heart, but without any evidence of the attack being acute-the prognosis is bad, and the case is likely to terminate fatally in a short time. Such cases often end in epileptic renal coma, or uræmia. If, however, the dropsy is only slight, and the patient begins to emaciate and grow pale in consequence of the quantity of blood being reduced, he may get into a state in which the disease progresses very slowly, and he may, with care, be kept alive for many years. The reader would, perhaps, conclude that if a full-blooded patient were bled it would be to his advantage, but such patients do not bear large bleedings, as

is proved by the circumstance that rapid prostration and death soon follow a violent attack of hemorrhage from the bowels or lungs when it occurs in such a case. Sometimes, however, moderate hemorrhage from the nose seems to do good, or at any rate improvement which was observed has been attributed to this circumstance. So that I am by no means certain that advantage would not result from oft-repeated moderate bleedings in wellselected cases, although I am unable to speak from actual experience. Such a plan of treatment, if carried out, should be tried cautiously, and the patient very carefully watched.

Of the Treatment of Albuminuria of Advancing Age.-The condition which gives rise to traces or to more than traces of albumen in the urine during advancing age is very closely allied to that which is so commonly, and one might almost say constantly, met with in the gouty state; and in order to bring those examples which affect the most temperate into the same category it might be suggested that the sufferers, although they have been very careful through life, have nevertheless exceeded as regards the amount of nitrogenous food they have habitually taken. Some organisms require very little meat, and actually flourish upon what would be really starvation diet to others; and if the first live according to a standard which the majority would call very moderate, the diet may for them be excessive as compared with the actual wants of their system. Nothing is more astonishing than the very small amount of food, and especially of flesh, that some healthy persons can live upon without losing weight or appearing to be weaker, or up to less work, bodily or mental, than their neighbors. To make invalids of all in advancing age whose kidneys are slowly changing, to condemn them to a purely milk diet or other very stringent regimen, to forbid them engaging in their ordinary duties, seems to me not only unreasonable, but quite unjustifiable from a medical standpoint for certainly many will live for ten or fifteen years or more, the albumen in the urine being constant, while some will fail on account of ailments which are in no way, directly or indirectly, connected with the renal degeneration. Such persons should be careful to avoid taking cold, should not go out to

parties in severe weather, and generally should be extremely cautious as regards their health. To lay down minute rules for the hourly guidance of such persons is needless. They may be as sensible as most of us, and as well able to manage themselves as the most learned of the doctors, and if only they can have their condition properly explained to them, will be able to preserve themselves in fair health without their lives being made wretched by carrying out a number of minute directions, compared with submission to which penal servitude would be enjoyable liberty. One may freely acknowledge the great importance of impressing sick people concerning the possible serious consequences of running risks of catching cold and disturbing the action of important organs when glands so necessary as the kidneys are damaged, as well as the very silly manner in which many of the well-to-do people of this country live in defiance of science and experience, and the teachings of history and common sense; nay, in spite of their own personal experience. But, allowing for all this, and fully recognizing the very great difficulty every right-minded medical adviser who loves his craft must feel, in steering between the one extreme of making too light of a serious malady, and the other of making too much of a slight one, I cannot help thinking that some, very popular among us in these days, in their desire to avoid the first fall into the last error.

Our clear duty is to caution our patients to avoid needless exposure, to clothe in woolen, to take life as easily as possible, to regulate and simplify diet, and to get as much air as possible when the weather is favorable. Residence in the South for the winter is most desirable, and should be enjoined wherever such a luxury can be enjoyed.

Mild purgatives should be recommended, and a warm bath twice a week is undoubtedly advantageous. Tonics, particularly preparations of iron, are of real use, and almost always improve the state of the blood, and in most cases cause a decided increase in the number of red blood corpuscles. Patients suffering from this state of kidney should, of course, avoid every kind of strain, particularly of the nervous and vascular system. That some

M

of them live to be very old in spite of advanced renal degeneration, is a fact. I have seen cases where albumen was detected between the ages of fifty and sixty, and was constantly present sometimes a mere opalescence only when coagulated by heat or by acid, sometimes amounting to a fifth or even more— the patient, nevertheless, living to be over eighty. Great care was taken to avoid over fatigue, strain and taking cold; and in the winter little going out was allowed; but in other respects no special treatment was adopted or needed.

Further Hints Concerning the Diet in Chronic Renal Diseases.* -In treating cases in which the kidneys are prevented from performing their functions with the usual activity, it is above all things necessary to reduce, as far as possible, the quantity of excrementitious substances resulting from the active changes in the various tissues and organs, and to arrange that the nutriment taken shall, as nearly as possible, balance the loss due to disintegration consequent upon the discharge of function. If the ingesta amount to more than suffices to make up the loss, undue work is thrown upon organs which have been, perhaps for long, working under grave disadvantages, and this is detrimental to the organism as a whole; it being obviously to the interests of the patient that he should consume only just the amount his tissues and organs use up. By acting upon this important principle we may be instrumental not only in adding months or years to the patient's life, but may enable him to enjoy the highest degree of health which is possible under the adverse circumstances. Το fulfill these objects is, however, more difficult in practice than would at first sight appear, because the stomach has often very marked idiosyncracies, and the quantity and quality of nutriment which is considered desirable may not suit that highly sensitive organ, while, in not a few instances, the patient may be quite unable to digest the food which theory would suggest as being appropriate, and which experience has shown has yielded the best results in many cases. And it often happens that in this, as in many other conditions, dietaries which have been arranged to the minutest detail, and in accordance with all the supposed re* An extract from a clinical lecture delivered at King's College Hospital.