43 Autopsy showed broncho-pneumo- The arterioles were healthy; there nic phthisis.

The arterioles in some cases were free from thickening, and the heart was not hypertrophied; whilst there was chronic disease of the kidney, viz. large white kidney and so-called scrofulous pyelitis.

CASE 56.-This occurred in a patient named William E-, æt. 33. He was in the London Hospital many weeks with great and general œdema, and the urine contained a large quantity of albumen. While in the hospital he had attacks of great dyspnoea, also of vomiting; and a week or two before he died he had convulsions alternating with coma.

The autopsy showed that the kidneys were larger and much heavier than natural. Their capsules separated readily; their surfaces were smooth and white, and very few vessels were seen. The kidneys had the peculiar, general, marble-white appearances so well represented by Dr. Bright in one of his drawings of Bright's disease. The cortical parts were much increased in size, and appear to be infiltrated with similar white material. Heart was normal. The arterioles of the pia mater were not thickened.

CASE 57.-In the case of a man who died in the London Hospital, under the care of Dr. Andrew Clark, there was general oedema; the urine contained a large quantity of albumen, and there were symptoms of uræmic poisoning. The kidneys were in the morbid condition known as "large, white, and mottled." Heart was normal. The arterioles of the pia mater were carefully examined, and there were no indications of thickening.

CASE 58. In a third case, a girl æt. 7 years, who died in the London Hospital under the care of Dr. Down, February, 1872, there were large white kidneys and general edema. Heart was natural. The arterioles were not thickened. The disease in this case was of considerable standing, for the patient had been under Dr. Down's observation with albuminuria for more than twelve months, and she was in the London Hospital with kidney disease on more than one occasion.

CASE 59.-A fourth case was that of George G-, æt. 18. He was in the London Hospital several weeks with general oedema and a large quantity of albumen in the urine. He died with symptoms of uræmic poisoning. The autopsy on May 6th, 1872, showed the kidneys weighed 14 oz. They were much larger than natural, and their capsules separated readily; their surfaces were smooth and contained no cysts. They were of a pale fawncolour, and a large number of yellow spots were seen scattered in the cortical parts. The cortex was greatly increased in size, and converted into similar fawn-coloured substance. These organs were good examples of large white kidneys in an advanced stage of disease. Heart weighed 8 oz.; there was no dilatation or hypertrophy; its valves and orifices were healthy. Liver, spleen, and lungs were healthy. The walls of the arterioles were not thickened. In the minuter ones the muscular nuclei were situated close to the outer edges of the vessel.

CASE 60.-A fifth case was that of William L—, æt. 27, who died in the London Hospital. It was stated that he had been under the care of Dr. Thorowgood, at the Victoria Park Hospital, for many months, with symptoms of phthisis and strumous pyelitis. The capsules of the kidneys were very much thickened and the right kidney was adherent by old tough fibrous bands to the liver and intestines. On section this kidney seemed almost completely destroyed. It contained several cavities filled with thick puriform matter. There was very little kidney structure remaining. The left was similarly affected, but not to the same great extent. Heart healthy.

The arteries of the pia mater were injected with Beale's Prussian blue solution, and afterwards carefully examined by aid of the microscope, and there were no indications of arterial thickening.

In other cases (see case No. 13, James P—, æt. 49) the kidneys were large, white, and mottled, the arterioles were thickened by hyaline-fibroid changes, and the left ventricle of the heart was dilated.

In the latter case we cannot conclude that the kidney disease induced the morbid changes in the arterioles and heart; for there is no evidence to show that the cardiovascular changes did not precede the renal disease; and the case of James B-, æt. 50 (see Case 18), tends to show that the cardio-vascular changes may be the primary and antecedent disease, and the renal changes subsequent. In this case the kidneys were highly congested and mottled, and a quantity of greyish-looking material was lying amongst this highly congested tissue. These kidneys were large and their cortex was much increased in size, and their surfaces were smooth. The morbid appearances were such as are usually seen when death has occurred in an early stage of acute nephritis, and they appear to show that the kidney disease had probably set in a few weeks only before death. The left ventricle of the heart was much dilated and hypertrophied, and many of the arterioles and capillaries were greatly thickened by the hyaline-fibroid changes. The cardio-vascular disease had, therefore, evidently preceded the acute renal changes.

The arterioles are sometimes much thickened, whilst there is no kidney disease or very little morbid change in the kidneys. In support of this statement we may first mention the case of John C―, æt. 34, who died of aneurism of the aorta. His kidneys were carefully examined, and

they presented no signs of disease. The arterioles of the pia mater were much thickened by the formation of fibroid material external to the muscular nuclei. The kidneys were healthy and the arterioles thickened in the case of Sarah S-, æt. 63 (see Case 2); also in the case of Samuel C-, æt. 62 (see Case 19); also in the case of James D, æt. 77 (see Case 3); also in Case 2.

In other cases there was little morbid change in the kidneys, no morbid change to indicate that their excretory power had been greatly diminished; whilst the heart was much hypertrophied and the vessels much thickened. is shown in Cases 7, 10, and 20.

This

Note.-A reply to the above paper was published in the Medico-Chirurgical Transactions,' vol. lvi, 1873, entitled "The Pathology of Chronic Bright's Disease with Contracted Kidney, with special reference to the Theory of Arterio-capillary Fibrosis," by George Johnson, M.D.-(ED.)

DESCRIPTION OF PLATE V.

FIG. 1. The microscopical appearances seen in very granular contracted kidneys. (From a girl aged nine years.)

The letter A points to six Malpighian bodies which are lying clustered together, and surrounded by a quantity of fibroid material. These bodies contain numbers of fat and other granules. A convoluted tubule indicated by D is seen coming down from one of the Malpighian bodies with its epithelial cells destroyed. The letters B mark tubules which are lined with epithelial cells for the most part healthy. c points to isolated wasted tubules, containing shrivelled, ill-defined epithelial cells, and in some, in place of epithelium, nothing but fat-granules remain.

FIG. 2.-Arteriole much thickened by coarse fibroid changes outside muscular layer; tunica intima thickened also.

FIG. 3.-Tunica adventitia and intima thickened by fibroid changes.

FIG. 4.-Arteriole of the pia mater. Fibroid changes outside the muscular nuclei.