Columbia <Bntoet#ttp 
 
 mtljeCttpofifrmgork 
 
 College ol $i)pgicians; anb burgeons! 
 
 Hifcrarp 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/contributiontohyOOdero 
 
CONTRIBUTION 
 
 HYDROLOGICAL TREATMEN 
 
 m 
 
 BRIGHT'S DISEASES. 
 
 DrT A. W. De roal des, 
 
 Resident Physician, Waukesha Springs, Wisconsin. 
 
 Read before the New Orleans Medical and Surgical Ass'n. 
 
 Reprint from New Orleans Medical and Surgical Journal. 
 
 SEW ORLEANS: 
 L. GRAHAM, STEAM BOOK PRINTER. 127 GRAYIER ST., 
 
 18 79. 
 
CONTRIBUTION 
 
 Hydrological Treatment of Bright's Diseases. 
 
 By DR. A. W. db EOALDES, Resident Physician, 
 Waukesha Springs, Wisconsin. 
 
 Read before the New Orleans Medical and Surgical Association. 
 
 In bringing the discussion to bear upon Bright's diseases, 
 our confrere and friend Dr. Loeber has chosen, with great pro- 
 priety, I think, to limit the wide field of albuminuria, which is 
 too vast to run over in one evening. Limited as the question 
 may be, it still affords room for different views. 
 
 ]S"o one will dispute that, in some cases of albuminuria, the 
 disease is entirely constituted by a renal lesion, as, for exam- 
 ple : Albuminuria resulting from exposure to cold, or again 
 cantharidian nephritis. But what constitutes Bright's dis- 
 eases"? There lies the question. For some physicians it is 
 merely and primarily a local renal lesion ; for others, and this 
 seems to be a more philosophical view, Bright's diseases are in 
 their very incipiency general affections, constitutional disor- 
 ders, dyscrasise, as scrofula, gout, rheumatism, syphilis, of 
 which albuminuria, at the start, is only a symptom. The ex- 
 cretion of albumen may in these conditions be the initial phe- 
 nomenon without being accompanied, in the beginning at least, 
 by any lesion of the kidneys. Albumen may be excreted by 
 these organs as sugar is. The only difference between diabetes 
 and incipient albuminuria of Bright's diseases, lies in the ex- 
 creted substances. If it be sugar, a hydro-carbon possessed of 
 dialysable properties, the excretion will be affected without 
 producing any local disorder in the parenchyma or stroma of 
 the kidney ; if, on the contrary, it be albumen, a colloid sub- 
 stance, the kidney will soon become affected. This transuda- 
 tion of albumen is accompanied by renal congestion ; if it be 
 moderate, the disease may run a very slow course. There are 
 cases of Brightic albuminuria, which may have a very long 
 
duration, ten, fifteen, twenty and. more years. I was consulted 
 two months ago, by a medical gentleman, who has been passing 
 albumen ever since 1874. It is only in the last two years that 
 the examination of his urine has revealed the presence of 
 casts, and it is only since this comparatively short time that 
 his general health has become affected. Last summer, at the 
 springs, I had under my charge a lawyer from Paris ; his phys- 
 ician. Dr. (rubier, stated in his letter to me, that our patient 
 had been passing albumen ever since 1853. This slow progress 
 of the disease is witnessed only in such constitutions as are 
 free from a diathetic influence. Take, for instance, a scrofu- 
 lous, a syphilitic, a rheumatic, or a gouty patient, whose con- 
 stitution shows a tendency to the evolution of morbid products 
 of a retrogressive character. The congestion, in such cases, 
 will soon lead to the formation of neoplasms, to the poliferation 
 of new cellular elements, etc. Simple albuminuria will then be 
 of very short duration and will soon result in Brightic diseases. 
 
 But I shall not stop to enquire the cause, by reason of which 
 albumen escapes from the blood to mingle with the urine. Is 
 it the kidney which just becomes diseased, or is this organ 
 secondarily affected ? Must we, on the contrary, look for the 
 incipiency of the malady in a functional disorder of the liver 
 and stomach ? Or is it the blood which is primarily affected ! 
 
 1 particularly desire to-night to direct your attention to a 
 few special points of therapeutics of Blight's diseases. In con- 
 tending with these affections, you must with me have observed 
 the striking discrepancy in the results obtained in the treat- 
 ment of hospital patients, as against those obtained in the 
 treatment of patients of a better class — the former, as a rule, 
 are extremely discouraging, whilst the latter afford, at times, a 
 reasonable degree of satisfaction. I am aware that the dis- 
 crepancy may, in a measure, be due to the fact that, in the 
 former instance, we are called upon to see our patients when 
 the disease has reached an advanced stage. But are they not 
 also measurably due to the tact that we are, unfortunately, 
 limited almost exclusively, I may say, to the use of pharmaco- 
 d\ mimic agents I 
 
♦Medical hydrology, climatology, hygiene and electricity now 
 seem to take precedence in the treatment of chronic diseases. 
 And I am inclined to the belief that in Bright's diseases you 
 will often obtain more satisfactory results if, with due regard 
 to the indications furnished by the etiology of the affection, 
 you give a greater weight when possible to these powerful mod- 
 ificators. I have had occasion during the past few years to 
 obtain some happy results by the use of medical hydrology 
 applied to Bright's diseases. You will, therefore, before I pro- 
 ceed further, permit me to condense a few observations which 
 will enable me to draw some conclusions in regard to the use 
 of this, therapeutical method. 
 
 OBSERVATION I.— CASE OF CHRONIC PARENCHYMATOUS 
 NEPHRITIS. 
 
 Mr. C, a gentleman about 47 years of age, was directed by 
 his physician, Dr. L'heritier, of Paris, to follow a water cure at 
 the calcic springs of Yittel. Mr. C. had an attack of cholera 
 in 1871, and of rheumatism in 1872. With these exceptions, 
 his health has been good up to 1877, when he began to lose 
 flesh and strength without any apparent cause. In September 
 of the same year, he suffered from intense dyspeptic troubles, 
 with marked dysphagia and shortness of breath. In March, 
 1878, got wet in a very heavy rain, and had a spell of acute 
 desquamative nephritis, followed by two relapses, at short in- 
 tervals. Fever, general pains over the body, with marked sen- 
 sibility over the lumbar region, gastric symptoms, oedema of 
 legs and thighs, urine heavily loaded with albumen, were 
 among the characteristic symptoms. Patient arrived at the 
 springs June 5th. His urine presents an acid reaction, it is 
 frothy and clear, except at the bottom of the vessel, where a 
 white yellowish sediment is observed. His urine of the day 
 contains 5 grammes 18 centigr. (a little over 80 grains) of albu- 
 men ; the one of the night, 3.13 gr. (about 49 grains) ; area, 
 15.30 gr. (about 228 grains). Microscopical examination of 
 sediment shows numerous large, dark colored crystals of uric 
 acid, broad granular casts in large number, a few narrow, pale, 
 
 * Medical hydrology treats of the internal and external use of water in disease, and 
 comprises mineral springs, sea-bathing, douches of all sorts, medicated baths, Turkish 
 and Russian baths, etc. 
 
slightly curved casts with some renal opaque epithelial cells 
 adherent. ]STo fatty globules nor any waxy cylinders. Blood 
 corpuscles numeration gives 3,490,000. Weight of the body 
 152 pounds. 
 
 Patient was advised to drink from 8 to 12 glasses of mineral 
 water, to take one bath a day of one hour's duration at 39° 
 Centigr., followed by frictions and kneading, and a hot revul- 
 sive douche at 42° Centigr. of five minutes over the lunibar 
 region. 
 
 On the 8th day the quantity of albumen is reduced to 1.90 
 gr. (about 30 grains) in the day. and 1 33 gr. (about 20 grains) 
 in the night's urine. On the 25th day the urine shows but a 
 trace of albumen and contains but a few hyaline casts. Upon 
 departure, July 12th, 37th day of the water cure, the urine is 
 entirely free from albumen and casts. The numeration of blood 
 corpuscles gives 3,900,000. Weight of the body 161 pounds. 
 The microscopical examination, which was repeated several 
 times during treatment, has shown a disappearance of the 
 casts parallel with the diminution of albumen, until at last, a 
 careful micro-chemical test revealed the absence of both. The 
 quantity of urine, which during treatment was increased to 
 1700 C. 0., has fallen back to 1290 C. C, upon departure; 
 specific gravity=1017 and urea=19 grammes (about 289 grains.) 
 
 OBSERVATION II.— CASE OF INTERSTITIAL NEPHRITIS. 
 Mr. E., a merchant, 14 years of age, was prescribed by Dr. 
 Gubler, of Paris, a water course at the Springs of Yittel, 
 where he arrived June 20, 1876. When 29 years of age, patient 
 had an attack of double urethro-orchitis, which has left as a 
 sequela some weakness about the genital organs. His father 
 was subject to gout, and died in epileptiform tits. Mr. R., him. 
 self, has been attacked three or four times with articular gout, 
 the last time in May, 1874. During past 1 or 5 years, patient 
 has noticed in his urine a frequent deposit of a yellow-pinkish 
 liu.'. On January 10, 1876, was laid in lied for a fortnight with 
 erratic pains of the whole body, fever, epistaxis, bronchitis, 
 Lumbar pains greater on the right side. His sputa were 
 streaked with blood. Urine was diminished in quantity, 
 highly colored, albuminous and containing few casts, but 
 
wholly deprived of its deposit of urates or uric acid. This 
 acute spell subsided gradually, and patient was finally relieved 
 by the appearance in his urine of a copious, brick-colored, 
 sandy deposit. However, he never since enjoyed his ordinary 
 health, and his urine has kept albuminous. 
 
 Condition upon arrival at the springs : The skin is dry and 
 branny, appetite poor, thirst normal, digestion torpid and sleep 
 impaired. Patient experiences a very uncomfortable sensation 
 of prickling about the inferior extremities. Slight oedema of 
 the ankles and feet ; frequent micturition. Passes 1600 C. 0. 
 of a cloudy, acid urine, containing 22 grammes of urea, 1.75 
 gr. of phosphates, 7 gr. of chlorides, 2 gr. of albumen. Uric 
 acid and urates are diminished. There is a slight hypertrophy 
 of the heart, but no valvular lesion, no palpitations. Bespira- 
 tory murmur normal. Blood corpuscles=3,600,000. Micro- 
 scopical examination shows numerous granulo-fatty cylinders, 
 some few hyaline casts, some others dotted over with fine dark 
 granulations. Bare, waxy-like casts. 
 
 Patient was directed to drink 12 to 14 glasses of mineral 
 water a day, 1 glass of Pulna water every fourth day, to over- 
 come costiveness. Tepid bath at 37° €., followed by frictions 
 and kneading of the whole body. Hot revulsive douche at 
 12° C, over the lumbar region. 
 
 About the 7th day, albumen began to diminish ; on the 20th 
 day, the quantity was reduced to gr. 80 centigr * on the 37th 
 day, when patient left the springs, a trace of albumen, some 
 hyaline cylinders and a very few granulo-fatty casts only are 
 to be found upon close research. During the first week of 
 treatment, the quantity of urine passed daily was increased 
 from 1000 C. C. to 2300 C. C, and was heavily loaded with 
 uric acid. General neuropathic symptoms have subsided ; the 
 sleep is improved and patient no longer experiences his trouble- 
 some cerebral lassitude. Numeration of blood corpuscles gives 
 4,200,000. Patient has gained o pounds ; and a slight exercise 
 will promote perspiration. 
 
 OBSERVATION III.— CASE OF CHRONIC PARENCHYMATOUS 
 NEPHRITIS. 
 Mr. H., aged 38 years, a banker, arrived at La Bourboule 
 Arsenical Thermal Springs, June 26, 187s, sent by his Paris 
 
physician, Prof. Chauffard. Has attended, him during - 1 years. 
 In his letter, after rapidly going over the history of the case, 
 lie remarks that Mr. H. was forced to abandon Constantinople 
 in 1 874, on account of obstinate intermittent fevers, accom- 
 panied with enlargement of the spleen. The type of fever was 
 at first modified by the change of climate, and patient, after 13 
 months, was entirely free of malarial attacks. His health, not- 
 withstanding, was far from being restored to its normal stand- 
 ard. Patient remained anemic, although iron, quinine and 
 strychnia were administered. Complained of general weak- 
 ness, of palpitations, accompanied with repeated attacks of 
 bronchitis, characterized by intense dyspncea, mostly noctur- 
 nal, and by sputa occasionally tinged with blood. Sleep dis- 
 turbed by cough and frequent desire to micturate. Urine clear 
 and frothy. A close investigation led Dr. Chauffard to diag- 
 nose the case as one of incipient parenchymatous nephritis 
 from malarial poisoning. During two years, various treatments 
 were uselessly employed, the disease following a progressive 
 course. 
 
 At last Dr. C. decided upon removing his patient from the 
 confined and hot sn aimer atmosphere of Paris, and he was or- 
 dered to resort to a water cure, with the hope that the change 
 of climate and the use of arsenical springs would help to re- 
 build bis general constitution and put a check to the pulmonary 
 and renal congestions. Upon arrival at the springs Mr. H. is 
 in the following condition : General appearance is bad, whether 
 tin's be the result of his journey or not; mucous membranes 
 are unusually pale, the skin is dry, and the seat of a marked 
 epithelial desquamation (pityriasis), marked emaciation, pa- 
 tient weighing 137 pounds, waxy appearance of the teguments. 
 Liver and lungs are normal, spleen slightly enlarged. The 
 eyelids are somewhat bloated. Patient is troubled with fre- 
 quenl micturation at night (8 to 10 times). Quantity of daily 
 urine 1410 G. C. specific gravity =1001). Night urine contains 
 3 gr. <>!> ceutigr., and day urine about gr. 19 centigr. of albu- 
 men. Quantity of urea exceedingly small=ll gr. 70 centigr. 
 Phosphates and chlorides are in normal proportions. Micro- 
 scopical examination shows: Numerous and thick crystals of 
 
uric acid, granule-fatty casts with oil globules, numerous nar- 
 row cylinders with fine granulations, some broad waxy casts 
 and degenerated epithelial cells with irregularly defiud edges. 
 Mr. H. is advised to rest a week before beginning treatment. On 
 the third day I am called to see him. Patient is laboring under 
 an attack of severe bronchitis, with slight pulmonary oedema. 
 Heart is normal, but rather impulsive. Feet cedematous. 
 Next day the oedema has reached the scrotum ; thighs and legs 
 are considerably swollen. Quantity of urine diminished to 900 
 C. 0. Sp. gr=1014. 
 
 Patient feels pretty well on the tenth day of this attack, with 
 the exception of the anasarca of the inferior extremities. The 
 swelling is such that patient's weight has been raised from 137 
 to 172 pounds. Obtaining no result from purgative plan, ad- 
 vised him to begin at once hydropathic treatment, consisting 
 in hot air baths — Turkish baths — which were administered for 
 a period of two weeks (one bath every other day). Patient 
 gradually reached a temperature of 176° F. As much as 1200 
 grammes of water (nearly 2£ pounds) were abstracted from the 
 system in one bath ; urine passed in 24 hours, averaging 950 C. 
 O. After the eighth bath, patient was nearly relieved of his 
 anasarca; his weight fell down to 130 pounds, or 1 pouud less 
 than he weighed upon arrival. 
 
 The hydromineral treatment was then instituted, and patient 
 advised to drink from 2 to 4 glasses of mineral water. Baths 
 at 39° C. were also ordered, and were followed by a hot revul= 
 sive douche applied over the splenic and lumbar regions. 
 
 This treatment, kept up for a month, brought on a most re- 
 markable improvement. The condition of the patient upon de- 
 parture, August 18th — that is, 92 days after his arrival, was 
 as follows : Appetite restored ; sleep interrupted but once or 
 twice for micturation ; patient has made frequent excursions in 
 the mountains with comparative ease ; the functions of the skin 
 are normal; no cedema ; complexion darker, but still retaining 
 an anaemic taint ; only a trace of albumen in the urine. Casts 
 are few in number, broad and granulo -fatty, no waxy cylinders 
 nor any oily globules. Some renal epithelial cells with natural 
 dull tint. The quantity of urea has been raised up to 15 gram- 
 
mes, and amount of urine daily excreted=1370 C. C. lias 
 gained 15 pounds. Patient left the .springs after being advised 
 ro sojourn in the south of France or Italy during winter, and 
 to return next summer to the springs. 
 
 Had occasion to 1 1 ear from Mr. H., through his physician. 
 He lias wii tered at ('amies, and during January has drank the 
 transported waters. Has followed, otherwise, no special treat- 
 ment, but exercised in the open air. Has had no recurrence of his 
 brouchitic attacks : his general health, which is very good, has 
 allowed him to enjoy ordinary life. His urine still shows a 
 trace of albumen, detectable only with Heller's test. The 
 microscope shows the presence of a few broad granulo-fatty 
 easts, with degenerated epithelial cells. 
 
 OBSERVATION 1 V.- CASE UF CHRONIC PARENCHYMATOUS 
 NEPHRITIS. 
 
 George Brungard, 27 years of age, entered Charity Hospital 
 March 8, 1879. A year ago, patient then living in Arkansas, 
 was attacked with malarial fever, of a tertian type. In October, 
 after exposure to rain and cold, was seized with rigors, followed 
 by lever, nausea, and pains in the lumbar region, and swelling 
 of the inferior extremities. 
 
 Upon admission, patient says he has been unable to leave his 
 bed for the past two months on account of excessive weakness. 
 Mucous membranes and teguments show a waxy hue, face is 
 bloated, appetite impaired, bowels loose. Inferior extremities 
 and scrotum are the seat of considerable serous effusion. 
 Heart normal, but spleen is enlarged. Patient's sleep is often 
 interrupted by cough, due to slight (edema of the lungs. 
 
 Patient is put under observation for a few days. The urine 
 is very pah-, frothy and acid ; average about 2000 0. 0. a day, 
 with a sp. gr. of HKI7. It contains a large quantity of albu- 
 men : 7 gr. '.»<» v<^y. Urea=14 gr. 75 cgr. At the bottom of the 
 jar, there is an opaline deposit of formed elements, which, 
 under the microscope, proves to be composed of small and nar- 
 row hyaline casts, with very few granular cylinders, and some 
 renal epithelial cells, with a number of uric acid crystals. 
 Patient was ord< fed L5 drops of dilute phosphoric acid three 
 
9 
 
 times a clay, and 10 to 12 glasses of Waukesha water (Crescent 
 Spring). From March 18th to April 28tb, microscopical exam- 
 ination and analysis of urine were made daily ; from these tab- 
 ular records, I condense the following : Urine rapidly became 
 ueutral, with marked tendency to ammoniacal decomposi- 
 tion after being voided. 
 
 March 21st, Day urine=1490 C. C, with sp. gr.==1010. 
 
 Night urine=1090 C. C, with sp. gr.=1009. 
 April 7th, Day urine=600 C. C, with sp. gr.=1018. 
 
 Night urine=1240 C. 0., with sp. gr.=1009. 
 Albumen passed in 24 hours=4 gr. 22 centigr. 
 Microscopical examination shows a few hyaline casts, and 
 renal epithelial cells, with amorplius earthy phosphates. 
 
 April 13th, Day urine=400 C. C, with sp. gr.=1022 
 
 Night urine=879 C. C, with sp. gr.=1011. 
 No casts, and but a few renal epithelial cells and amorphous 
 phosphates. 
 
 April 26th, Day urine=700 C. C, with sp. gr.=1018. 
 
 Night urine=900 C. C, with sp. gr.=1012. 
 Quantity of albumen in 24 hours=2 gr. 29 centigr. 
 
 Microscopical examination shows a complete absence of casts. 
 Urea=18.10 gr. During the time (38 days) patient has been 
 under treatment, he has had five attacks of malarial fever, for 
 which quinine was administered. The fever seemed to have 
 no other effect upon the urine except in diminishing its quantity 
 and deepening its color. Notwithstanding this, general con- 
 dition of patient steadily improved, appetite increased. Bowels 
 have become regular and digestion is normal. All liquid effu- 
 sion has been removed. His complexion looks healthier, and 
 auscultation reveals no abnormal sounds. Patient has been 
 able during the last two weeks to assist the nurse of the ward 
 in the discharge of his duties. Was last seen on May 14th. 
 Has had another attack of fi-ver, but his general condition con- 
 tinues very good. Quantity of urine about normal, so are its 
 reaction and color. No casts, but still contains about two 
 grammes of albumen. Urea=17.80 gr. 
 
 I will now be permitted to draw some conclusions, which 
 seem to me justified by the study of these observations. 
 
10 
 
 1st. Thei e is a marked diminution of tlie albuminuria as a 
 consequence of the diuresis produced by the use of calcic min- 
 eral waters. The renal congestion, instead of being exaggerated, 
 has on the contrary been diminished by this diuretic influence. 
 This result corroborates the statement of 01. Bernard, based 
 on actual experiment, namely : the disgorgement of glands by 
 increased functional activity. In observation No. 3, arsenical 
 waters having no marked effect on diuresis, we have to look 
 elsewhere to explain their eflicacy. The explanation lies, I 
 think, in the undoubted properties of arsenic to diminish con- 
 gestion by its influence on the vaso-motor nerves. We all 
 know the good results attained with arsenic in the treatment 
 of congestive headache, neuralgia, pulmonary congestion, etc 
 Besides this explanation, arsenic seemed to have filled a pre- 
 cise indication furnished by the fact of previous malarial intox- 
 ication, and the use of hot air baths by stimulating the func- 
 tions of the skin to their utmost capacity, certainly had the 
 effect of diminishing the tension of the blood in the renal blood 
 vessels. 
 
 2d. In all four observations the diminution of the quantity 
 of albumen has been progressive and very nearly parallel with 
 the diminution of the gravity of casts and epithelium of renal 
 origin. I will remark also that, as the worst form of cylinders 
 disappeared or were modified, there seemed to have been a 
 species of substitution of hyaline casts. 
 
 3d. The general health and strength of these four patients 
 were remarkably improved by this course of treatment. The 
 numeration of blood corpuscles was resorted to in two in- 
 stances, and showed a marked increase. Corresponding to this 
 an increase in weight, ranging from five to fifteen pounds was 
 also obtained, except in case 4, where this observation was 
 neglected for want of scales. 
 
 I feel consequently justified in saying that the treatment has 
 fulfilled what should be considered the principal indications in 
 Bright's diseases, viz : 
 
 1st. To uphold the constitution and rebuild the impoverished 
 general conditions. 
 
11 
 
 2d. To diminish, if not to suppress the congestion of the 
 kidneys. 
 
 3d. To clear, and if possible to modify the tubuli nriniferi. 
 
 Before closing, allow me to direct your attention to the influ- 
 ence gout holds in the production of interstitial nephritis. It is 
 such that the gouty kidney is, with English writers, synony- 
 mous with contracted kidney. This etiological influence is well 
 exemplified by Case II. It is in those cases that the calcic 
 waters of Vittel in France, Wildungen in Germany, Capon and 
 Poland in this country, will prove efficacious. Those of Buffalo 
 and the Waukesha Crescent Springs containing, in addition, 
 bicarbonate of lithia, are specially indicated. Their first effect 
 is to render the urine alkaline, and then to favor the elimina- 
 tion of uric acid — accumulated in the blood — under the form 
 of urate of lithia, the most readily soluble combination of uric 
 acid. It frequently occurs, when, in gout, or in Bright's dis- 
 eases, the urinary secretion is scanty, that uric acid, and even 
 urate of soda, will be deposited in the tubuli uriniferi, in the 
 shape of what Bayer has termed microscopic gravel. In these 
 cases, these diuretic calcic and lithia mineral wateis, filtering 
 rapidly and in abundance through the kidneys, will have a sort 
 of lixiviatiug result, and thus favor the solution of these infarc- 
 tions, open and keep free the tubuli uriniferi. It is useless to 
 insist upon this beneficial effect, for, in a contracted or gouty 
 kidney, it is preparing the way for uremic poisoning, not to 
 avail ourselves of every possible means to prevent those tubuli, 
 which are still sound, and through which the urea, uric acid, 
 and extractive matters are excreted, from being blocked and 
 clogged by this microscopical gravel. 
 
 I will lastly recall the influence of chronic malarial poison- 
 ing in the etiology of Bright's diseases. Case ~$o. Ill and ]So. 
 IV exemplifies this point, and, although I have had, this win- 
 ter, in my wards of the Charity Hospital, three cases of chronic 
 parenchymatous nephritis, in which the disease was clearly at- 
 tributable to malaria, I am not prepared as yet to assert that, 
 in the majority of such cases, we will be more apt to meet with 
 parenchymatous than with interstitial nephritis. 
 
12 
 
 In those cases we will have to administer quinine, even it' 
 the patient is tree from paroxysm. But when it has led to un- 
 doubted disorder of the kidney, we will, I think, lind in arsenic, 
 hydropathy, mineral springs, with change of climate, lnodifica- 
 tors which will act in a more direct manner upon the lesion, 
 provided, of course, it be not too far advanced. 
 
 If Bright's diseases present themselves in a decided scrofu 
 lous constitution, we may, with advantage, advise a course of 
 treatment by the saline alkaline and iodo-bromine waters, as 
 Kxeutzuach, Hombourg, Darkheim in Germany, Solies, Brides, 
 in France, Saxon in Switzerland, and St. Catherine's Wells and 
 Caledonia Springs in this country. If, on the other hand, our 
 patient is subject to rheumatism, or has had syphilis, if the 
 kidneys are but recently involved, and we believe rheumatism 
 or syphilis has had an etiological influence, we will then find- 
 in thermal waters, of the indeterminate class, as Hot Springs 
 of Arkansas, or of the sulphur class, as those of Virginia, a 
 valuable adjuvant. 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the library rules or by special arrangement with 
 the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C28(842)MSO 
 
 
 
 
EC907 m 
 
 De Roaldes