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tempting alike in a theoretical point of view and in its practical bearings. I shall now state this doctrine in a series of propositions. You are not to suppose I insist on these as matters of assured medical faith; but I already regard them as probable; and it is therefore well to have them distinctly enunciated as the basis of future investigation in these wards, as well as elsewhere:

1. The congeries of alterations of the kidneys, described by Dr Bright and his more immediate followers in this line of inquiry, depend on at least two distinct morbid processes.

2. One of these is of the nature of inflammation, chronic or acute. The other is a morbid degeneration, always chronic, not inflammatory, analogous to what occurs in various other important organs, and consisting of the morbid accumulation of oil or fat globules.

3. The inflammatory disease in its acute form, although known to originate under various circumstances, and even independently of any pre-existing disease, is best and most frequently exemplified in the phenomena which occur in many instances subsequently to scarlatina, or in the puerperal state.

4. The chronic form of the inflammatory disease always originates obscurely, insidiously, and so gradually that, except in favourable circumstances, it escapes notice for a long time. But it ought always to be looked for by a prudent practitioner in cases of protracted or frequently-recurring dyspepsia, diarrhoea, neuralgia, chronic rheumatism, catarrh, anasarca, and those chronic cutaneous diseases which exhaust the constitution. And it is apt to present itself intercurrently with most other chronic diseases of the greater viscera, especially phthisis, diseased liver, and hypertrophy of the heart.

5. The inflammatory process, according to most observers, consists in a preternatural formation of epithelial cells in the lining mucous membrane of the minute uriniferous tubes of the kidneys, and the detachment or desquamation of these cells; so that, by accumulating in the interior, they obstruct the tubes and choke them up. There are also found in the obstructing matter, blood-discs, pus-globules, uric acid crystals, and sometimes crystals of oxalate of lime. But the greater part of the mass consists of epithelial cells, entire, or much more commonly degenerated, so as to be irregular in their edge, contracted in size, or sometimes reduced actually to their nuclei. According to Gluge, the morbid formation rather consists of the more ordinary secretions of inflammatory action, such as fibrine, pus-globules, and exudation-corpuscles; which not only accumulate in the uriniferous tubes, but are likewise thrown out in greater abundance throughout the surrounding interstitial texture.

6. The consequence is great obstruction to the secretion of the ordinary solids of the urine, and therefore a diminution of these solids, while the watery part may be long secreted as usual, or even in much more than the usual quantity. And the explanation of this interesting double phenomenon, which all must have often witnessed who are conversant with Bright's disease in practice, is that while the epithelial surface of the uriniferous tubes, considered by most physiologists to be the proper secreting tissue of the kidneys,-is grievously injured and diminished, the malpighian bodies, supposed by some good authorities to secrete rather the watery part of the urine,-remain for a long time little or not at all affected. This doctrine is a beautiful part of the pathological theory of the disease; but it rests on an insecure foundation, as several microscopic observers maintain they have seen the malpighian bodies oppressed by congestion within and pressure outside from the distended uriniferous tubes, at an early period of the morbid process.

7. As a result of the secretion of the water of the urine, the obstructed urine-tubes are often swept free of the obstructing material. But it does not always follow that the tubes thus regain their secreting function; for they may have been permanently deprived of their epithelial cells, no longer renewed, or only in diminished number and in a degenerated form.

8. But an important consequence of this sweeping-out of the urine-tubes is, that we find in the sediment of the urine their morbid contents; and these are

blood-discs [Fig 2, a], degenerated epithelial cells, much resembling pus-globules, and still more mucous corpuscles [b], also nuclei of epithelial cells [c]; and above all, as characterising this particular form or variety of Bright's disease, entire or broken-down casts of the urine tubes [Fig. 1, 2, 3, d], consisting of blood-discs, nuclei, and especially epithelial cells, all united together in cylinders and portions of cylinders by a transparent agglutinating medium, which can scarce be anything else than fibrine. This is one of the most important practical observations yet made in the course of the whole microscopic inquiry. For if exact, it enables us to discover most readily with the microscope, the nature of any particular case, and to refer it to inflammatory action as its fundamental source. 9. The other morbid affection of the kidneys, constituting also what is comprehensively called Bright's disease, is a peculiar degeneration, unconnected with any form of inflammatory action, and consisting in deposition of oil-globules in preternatural quantity in the epithelial cells of the urine-tubes, distending these cells, detaching them from the epithelium-wall, distending consequently the tubes by their accumulation, bursting the tubes here and there, and so escaping into the interstitial tissue.

10. The pathological consequences to the structure of the kidneys are here much the same as in the inflammatory form of the disease. The urine-tubes, gorged with oleiferous epithelial cells, become useless themselves in the process of secretion, and by pressure around impede the function both of the unaffected urine-tubes and of the blood-vessels. The secretion of urine is therefore much disturbed, in respect of its proper solids, and often too its watery part; but sometimes the watery portion is unaltered, or even superabundant. And whether abundant or scanty, it sweeps out from time to time the morbid contents of the tubes, without thereby restoring, however, the healthy organisation of their basement membrane, or the healthy discharge of their function.

11. An important consequence, in a practical point of view, is that in the instance of oily degeneration, as in that of inflammatory deposition, the urine contains characteristic microscopic ingredients in its sediment. Detached oil-globules may be found, though they are difficult to detect, because they do not subside. But degenerated epithelial cells, loaded with oil-globules, and distended often to a considerable size, are more easily found [Figs. 4, 5, e]. And there are broken, as well as entire, cylindrical tube-casts consisting of oil-globules, and epithelial cells gorged with oil-globules, and all connected by a transparent and probably fibrinous matrix [f]. In this affection of the kidneys, the tube-casts present few degenerated epithelial cells, in which there are not many oil-globules. In the inflammatory affection again, oil-globules are either wanting altogether in the degenerate epithelial cells, or at all events they are very scanty and minute. Oil-globules are always easily distinguished from nuclei, blood-discs, and epithelial cells, by their rounded uniform shape, and their broad black margin, produced optically by their strong refracting power.

12. Such are the pathognomonic characters by which the two very different organic alterations of the kidneys may be distinguished during life. But the two affections may concur. After the inflammatory form has subsisted for some time, and many urine-tubes have become gorged, or empty and functionless, oil-globules may be secreted into the empty ones, together with a fibrinous matrix; so that oleiferous tube-casts may be afterwards seen in the sediment of the urine, as well as those which are simply inflammatory. Dr Johnson first noticed this combination; Dr Gairdner has observed it often; I saw it several times during last spring clinical course; and some have suspected it to be so frequent as to render a diagnosis between the two forms of organic disease for the most part impracticable. I am satisfied, however, that the two affections do occur independently of one another; and in particular I have repeatedly seen sediments presenting invariably the inflammatory character, or at least with only a few oil-globules in the degenerated epithelial cells. The occurrence of a few small oil-globules is no true source of confusion; because, according to the best observers, the healthy epithelial cell is not without a few of them.

13. To the affection which consists of fatty or oily degeneration, Gluge has given the unexceptionable name of stearosis, which expresses a fact but no theory. The nomenclature of the other affection is not so easy, and has not been so lucky. It has been called desquamative inflammation, because it consists essentially of inflammatory action, causing the epithelial cells to scale off the mucous membrane of the uriniferous tubes. But there is equally scaling of these cells in the oleaginous degeneration. So that if this process is to enter at all into the nomenclature, the one disease should be called stearotic, and the other inflammatory, desquamation. I do not think, however, that these terms will be long thought quite accurate, or if accurate, altogether convenient. But I shall use them in the sequel, without pledging myself to their exactitude.

The observations which have come under my notice since becoming acquainted with these microscopic inquiries, bear out on the whole the conclusions stated in the preceding propositions. During especially my period of service as Clinical Professor last spring, there were many excellent subjects of study in these wards, and the opportunity was not neglected. Of seven characteristic cases of Bright's disease, which we were able to observe for a considerable period, only one presented the characters of stearosis, four those of the pure inflammatory form, and two the mixed characters of both affections, in which, however, the inflammatory tube-casts and epithelial cells were greatly more prominent than the stearotic. My experience at that time, in conformity with what I have observed since, leads to the conclusion that the inflammatory is much more common in this city than the stearotic form of renal disorganisation,-Edinburgh differing in this respect from London and Brussels, where stearosis seems proportionally more frequent, but corresponding with Paris, in which that degeneration seems comparatively rare. Our case of stearosis was the only fatal one; and this variety is probably always fatal. The other cases either got quite well or were dismissed much improved; and I am now satisfied that many cases of the inflammatory form may, like these, do well under judicious treatment and subsequent careful regimen. In the case of the man Flint, now under your observation, the disease, which has commenced in the ward, and is plainly quite recent, because the urine is natural in density and quantity, and he never before had any signs of renal disease, whether primary or secondary,-seems to be of the inflammatory character. But as it will be advisable to examine the deposit of the urine more carefully than the rather imperfect specimens have hitherto enabled us to do, I shall defer the application of these general remarks to the special case until a future day, when I hope there may be other cases to take along with it; and meanwhile I shall exemplify what has been laid before you in general terms by the particulars of three important cases from those of last year; which I am enabled to illustrate by graphic and appropriate microscopic drawings, taken by Dr Saunders, then principal clinical clerk in the wards.

CASE 1. The first is an instance of inflammatory desquamation, commencing, like that of Flint, in the hospital during treatment for another disease, and subsequent to mercurialisation. The subject was a labourer of 22, William M'Millan, who had been cured of jaundice and diarrhoea a twelvemonth before in this hospital and was again attacked, fourteen days before admission, with the same unusual combination of diseases. When admitted on January 11th, 1850, he had no jaundice, but frequent watery diarrhoea, some pain across the lower belly, occasional vomiting, a sallow complexion, and considerable debility. The lungs were healthy, so was the heart, and the pulse was little excited; the liver was not enlarged; and the urine was ascertained at the beginning to be "natural in colour, without deposit, and not coagulable." Dr Bennett, who was then on duty, treated the case with leeches, calomel, and opium, till the mouth became slightly affected, then with catechu and potash, and also one blister over the liver, which was subsequently the seat of pain and some tenderness. When I took charge of the wards on February 1st, he was considerably better; and he continued to improve on the whole under the use of bismuth, opium, and hydrocyanic acid.

NEW SERIES.-NO. XVIII. JUNE 1851.

4 C

On the 20th February, his feet appearing somewhat oedematous, the urine was examined, and found to have become turbid even when just passed, very strongly albuminous, 1025 in density, not particularly scanty, and abounding with degenerated epithelial-cells [Fig. 1, 6], and urine tube-casts [d], which for the most

Fig. 1.

part presented the inflammatory characters, but occasionally a few globules of oil. Under the use of cupping over the loins, Dover's powders nightly, and the warm bath every other evening, he slowly improved, sweating every night, and nevertheless passing daily from 70 to 90 ounces of urine, between 1017 and 1019 in density. Repeated examination of the urine showed continuing coagulability, abundant fragments of inflammatory tube-casts, very seldom containing any oil-globules, but occasionally octaëdres of oxalate of lime. In the beginning of March, it was for the first time observed that the abdomen contained fluid; and from that time a moderate ascites continued to be the predominant dropsical affection. Gallic acid was now tried in the dose of three grains thrice a-day, but with no decisive benefit; nor did the acid ever appear in the urine. The man remained in the hospital till the middle of April, when he became tired of his slow progress, and left it for the country. The urine had been for some time 120 ounces daily, without the use of diuretics; it was 1018 in density, and moderately coagulable; and the sediment showed degenerated epithelial cells and broken-down tube-casts, always of the inflammatory kind. The oedema had been removed, except that the ankles swelled a little at night; but the ascites had not altogether disappeared. I have not heard of him since; but his state at dismissal was obviously very precarious.

It is clear, from the precursory jaundice and supervening ascites, that, although the liver was not enlarged, the affection of the kidneys was combined with an older disease of that organ; and in all probability this circumstance accounts for the little impression made on the renal disorder by treatment, and it certainly added greatly to the man's jeopardy.

CASE 2.-Not so with the next patient, who, as I consider, was radically cured of an uncomplicated attack of the purely inflammatory form of Bright's disease, occurring in connection with the puerperal state. This was a young woman, Elizabeth Birnie, 21 years of age, who had been delivered in the Maternity Hospital, without any accident, on the 25th January 1850, and was transferred to this hospital on the 8th February. For four weeks before her confinement she suffered from frequent scanty micturition, without any other complaint; and five

days after delivery the limbs began to swell. When she became my patient, the face was puffy and very leucophlegmatic; the legs were oedematous as high as the knees, and pitted on pressure; and the abdomen was rather full, but without distinct evidence of fluid in it. There was general tenderness of the abdomen, but none particularly in the loins or across the epigastrium. The heart was sound; so too seemed the liver; and there was only a slight catarrh. She had just ceased to nurse her child, and the milk flowed freely. The urine was scanty, dusky, cloudy when newly passed, acid, 1017 in density, and highly coagulable. She had a trivial fever, the pulse being 96, but small, and the skin dry, and in the night-time hot. She was ordered bitartrate of potash, spirit of nitrous ether, and Dover's powder. In three days the oedema had disappeared without increase of urine. The sediment of the urine consisted of blood-discs (Figs. 2 and 3, a),

Fig. 2.

d

Fig. 3.

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