THE URINE. 807 



'Such casts will not be seen against the views of recent writers 

 unless waxy degeneration has been established in the kidneys. 



Sometimes hyaline and epithelial casts exhibit spiral wind- 

 ings, probably from having originated in the spiral portion of 

 the ascending branch of the loop-tubule. They have no special 

 significance. 



Besides, a great prognostic value attaches to the size of the 

 'casts. As a matter of course, casts formed in the convoluted 

 tubules of the first order will never appear in the urine, as they 

 cannot pass the narrow tubules. The mildest degrees of the dis- 

 ease are indicated by casts from the narrow tubules, the narrow- 

 est casts, and a small number of casts from the convoluted 

 tubules. Not infrequently we meet with pedunculated casts, 

 viz. : formations from the place of transition of the narrow 

 tubules into convoluted tubules of the second order. Casts from 

 the convoluted tubules justify the diagnosis of croupous nephri- 

 tis in the cortical substance ; casts of all the three sizes the 

 largest arising from the straight collecting tubules permit of a 

 conclusion of croupous nephritis in the whole organ, and upon 

 this condition a very unfavorable prognosis can be established. 



Based on these simple facts, I was enabled to give a prognosis, even where 

 no danger was suspected by the attending physician. Dr. X., a prominent 

 practitioner, brought me some fresh urine passed by his son, six years old, 

 who had just recovered from a slight diphtheritic attack of the throat. The 

 question was, whether in the fresh urine there could be seen moving micro- 

 cocci and bacteria. I really found these low organisms, but, besides, also 

 numerous tube-casts of all the three sizes. I told the father that his son was 

 in danger. He laughed at me, and asserted that there was nothing from the 

 clinical stand-point to justify such an alarming diagnosis. This happened on 

 a Sunday, and I did not hear of the child until the next Wednesday, when I 

 was informed that the boy had died in an ursemic fit. The physician now 

 began to believe in microscopy, and a year afterward brought me some urine 

 of his wife, containing a moderate quantity of albumen. In this urine I found 

 fatty casts from the convoluted tubules, and, as the gentleman wanted to have 

 a prognosis, I told him that his wife could not live longer than one or two 

 years. In this case I was mistaken, as three months afterward the lady was 

 carried away by uraemia. 



Stress must be laid on the general constitution of the patient, such 

 as can be positively recognized by the appearance of the pus-corpuscles 

 present. We can tell how much the constitution had been lowered by the 

 disease, and, of course, the prognosis will be the more unfavorable the more 

 living matter the patient has lost the worse, therefore, his constitution is at 

 the time of examination. 



Dr. R. E. Swinburne, in 1878, examined, in my laboratory, urine contain- 

 ing numerous casts, and both kidney epithelia and pus-corpuscles having very 



