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of the epithelia of the tubules and in hyperplasia of the connective tissue, the glomerulus may for a long time, and when the inflam- mation is mild, remain unafiected. In glomerulo-nephritis albumin * Charcot, " Le9ons pathog^niques de ralbuminurie," Paris, 1881. f Anoxcemia, a deoxygenated state of the blood. THE DIAGNOSIS OF INTEIiSTITIAL NEPHRITIS. 453 is almost invariably present. The conclusion that nothino; is the matter with the kidneys because after several examinations of the urine no albumin is found, is sometimes literally a fatal error; yet how numerous are the instances where, after the ortliodox one or two chemical examinations, the kidneys are pronounced " healthy ! " These false conclusions are not reached, even as a rule, by the illit- erate and uneducated practitioner exclusively, but by medical men who are considered eminent. I cite the ibllowing instance, not in a spirit depreciatory of an honored and useful hospital, but to show how often, if such a case can occur in an institution whose medical staff belonii; to the better-educated class of physicians, cases of non- recognized nephritis must occur in practice generally, and how many patients march toward their graves, their medical advisers all un- conscious of the teterrima causa of broken health, until physical helplessness, convulsions, apoplexy, or death makes at last a diag- nosis for the perplexed practitioner. While visiting anotlier hospital, in 1879, as one of the medical staff, there was admitted. May 9th, a young man, J. W. B., aged twenty-three years. He had been for two months an inmate of the hospital first referred to, from which he had been discharged a week or two before, as being no longer ill enough to require medical treatment. He understood that the physicians of the hospital had pronounced his illness to be some malarial trouble, with debility. He had not been confined to his bed. His sallow appearance and anseraic condition easily suggested the existence of some such disease. I was led, however, to suspect the existence of interstitial nephritis. There were persistent headaches, great exhaustion, and slight nausea. There was hyper- trophy of the left ventricle, but no oedema nor anasarca. An examination of the urine showed the existence of a large amount of albumin, oxalate of lime, pus, kidney epithelia, and numerous hyaline casts. Repeated examinations gave the same result. The urine was abundant. My diagnosis was entered as chronic interstitial nephritis. The violent action of the heart, with certain cerebral symptoms, led me to predict that apoplexy or convulsions would soon occur, and, indeed, eight days after his admission he was seized with an epileptiform convulsion. These recurred several times, a settled condition of coma being at last established, and he died May 27th. His relatives would not allow a post- mortem examination to be made. Being curious to know what the diagnosis of his case had been at the hospital where he had been so long, I inquired of the House Physician, and was informed that it had been considered a case of " ana3mia and debility." At all events, it had not been entered nor treated as a case in which tlie kidneys were implicated. He stated that the urine was examined im- mediately after his admission, and that no alhnmin was found. I do not give the name of tlie hospital, though there is none in the city better known, because I do not consider that the purpose of my paper would be subserved by so doing. The case, however, is one of record. To test the urine simply for albumin, and that only once or twice, is often useless. It must be tested re2)eatcdly ; the quantity, 454 MILLAED: THE EXCLUSION OF ALBUMIN IN specific gravity, and chemical peculiarities must be carefnllv noted, and, most of all, tJte pJienomena disclosed hy the microscojpe must be considered. To assert that well-marked nephritis and cirrhosis may exist without the appearance of albumin in the urine, and without any marked variation from the normal urinary secretion, is a statement which might possibly be regarded as a theoretical assumption. Clinical and microscopic observations enable me, however, to dem- onstrate unequivocally the accuracy of my assertion. The following case will illustrate this: In the middle of November, 1881, while visiting the hospital as a member of the medical staff, a woman, Mrs. X., about forty years of age, was admitted. She had for many years been addicted to the inordinate use of stimulants — in fact, had been a drunkard. There was found to be great enlargement of the liver, and there was phthisis pulmonalis. There was considerable fever, with light delirium, and a dry, red tongue. There was neither anasarca nor oedema, but certain symptoms, as headache and a disposition to stupor, aud a peculiar complexion, made me suspect the existence of chronic nephritis. Buy Sildalis Examinations daily repeated showed albumin to be absent. The specific gravity of the urine was about 1"020; it was acid, and rather scanty. The microscopic examination showed : 1, oxalate of lime; 2, epithelia from the convoluted and straight tubules of the kidney; 3, epithelia from the pelvis of the kidney; 4, epithelia from the ureters; 5, pus. My diagnosis was chronic interstitial nej)hritis with cirrhosis. December 1st, my term of service having expired, imy successor took unusual interest in the case, but could recognize no evidence of nephritis, and heard with some incredulity my statement that the autopsy would demonstrate the existence of it with cirrhosis. December 7th the patient died. The autopsy showed the condition of the lungs and liver as stated. Kidneys : size normal ; capsule adherent ; surface smooth, with numerous small retractions indicating cirrhosis. I have made numerous sections of this kidney for microscopic examination, and studied them carefully. The microscope shows the interstitial nephritis to be well marked, and that the cirrhosis was con- siderable, though not great. The drawing, Fig. 3, in my article on " The Anatomy of the Epithelia of the Kidney," published in the "New York Medical Journal" for June, 1882, showing the action of chloride of gold on the epithelia of the in- flamed kidney, was made from this case. I found also in this case that there was some glomerulo-nephritis affecting a few of the tufts, and presenting a phenomenon which I had never before observed nor seen described. The capsular invest- ment was somewhat thickened, and the tuft was atrophied to a third of its normal size and pushed into a corner, as it were, of the capsule

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