CHRONIC BRIGHT'S DISEASE. 25 



At first the face and feet swell, the upper extremities, abdomen, and 

 scrotum not becoming affected until a later period. The oedema often 

 shifts its position in a peculiar manner, so that at one time the face or 

 upper extremities may be the more swollen, at another the feet, ab- 

 dominal walls, or scrotum, while the tumefaction subsides in the region 

 at first affected. Moreover, if the patient be out of bed, the feet gen- 

 erally show the greatest amount of swelling in the evening, while in 

 the morning the feet are smaller again, and the swelling involves the 

 hips, back, and hands. The more slowly the anasarca develops, so 

 much the more does the skin lose its elasticity, and so much more 

 slowly is the imprint of the finger effaced from the oedematous surface. 

 The addition of ascites and hydrothorax to the anasarca does not take 

 place until a more advanced period. In one exceptional instance, I 

 have witnessed the appearance of hydrothorax and cedema of the lungs 

 early in the disease, where previously there had only been a slight 

 cedema of the integujnent, a condition of apparent security thus sud- 

 denly becoming one of great danger. In cases which advance rapidly, 

 the dropsy may attain great magnitude in a few weeks. I have seen 

 a patient who weighed a hundred kilogrammes (i. e., two hundred 

 and twenty pounds), who affirmed that, eight weeks before, he did 

 not weigh fifty. Such extreme dropsical swelling, from the strain 

 which it exerts, may be the cause of inflammation and gangrene of 

 the skin, especially of the scrotum and labia majora. In the worst 

 cases, the skin often bursts at several points, and the liquid trickles 

 copiously from the rents. 



The pathogeny of the dropsy of parenchymatous nephritis is ex- 

 ceedingly difficult of explanation. As is already stated, the dropsy 

 often develops in the midst of a copious excretion of liquid from the 

 kidneys, and hence cannot be ascribed to any increase of pressure 

 upon the veins of this organ, although this must be regarded as the 

 main cause of the dropsy of acute croupous nephritis, in which disease 

 there is always a suppression of urine. It is true that, during any 

 check to the secretion of urine which may occur in this disease, the 

 dropsy makes rapid headway ; and when the urine is scanty through- 

 out the entire course of the malady, the dropsy soon becomes exces- 

 sive, and the malady runs a subacute course. There is no doubt but 

 that a " hydrsemic crasis," a lack of albumen in the blood, favors the 

 occurrence of dropsy. Owing to the continual loss of albumen, which 

 the blood is suffering, in Blight's disease, a liquid which contains but 

 little albumen flows through the capillaries of the system. Hence, an 

 abnormal transudation takes place from the capillaries into the inter- 

 stices of the tissues, and hence, too, the amount of serum returned to 

 the veins is abnormally small. It is not to be doubted that the ab 



