CLINICAL LECTURE

ON

CHRONIC BRIGHT'S DISEASE WITH CONTRACTED KIDNEY

(ARTERIO-CAPILLARY FIBROSIS).1

THE subject I have chosen for your attention to-day is one for which the clinical wards of Guy's Hospital are particularly famous. To use an expression of our German friends, Guy's Hospital is the "fatherland" of this disease. It was here that Dr. Bright pursued those investigations which have made his name immortal. "Bright's disease" is, however, but a generic expression, and appertains to many affections of the kidney which, though more or less allied by the character of their morbid anatomy, so far as the kidneys themselves are concerned, are probably distinct in their cause and clinical history. It has long been felt that the term "Bright's disease" must either be discontinued, or be more strictly limited to one given pathological state.

The object which I have in view on the present occasion is to make some remarks on that general condition which is perhaps more properly Bright's disease, and which is associated with one form of fibroid contraction of the kidneys. And here it should be observed that the kidney may undergo fibroid contraction and disorganisation, and 1 Delivered at Guy's Hospital June 6th, 1872. Reprinted from the 'British Medical Journal,' December 21st, 18-2.

cause death by uræmia, without being associated with that change in the heart and arteries upon which I desire to discourse in this lecture. In such cases the renal disease is probably due to some hereditary or congenital defect in the kidneys themselves, and is more strictly a local affection; and although the results, so far as the kidneys are concerned, may be very much like, or even apparently identical with, the more morbid conditions arising under other circumstances, what constitutional accompaniments there are, are widely different from such as occur in the disease now spoken of.

The form of chronic Bright's disease with contracted kidney, now under discussion, is, it would seem, a more general affection: it occurs chiefly at or after the middle period of life. Some of its various phases were, no doubt, recognised by the physicians of former times, and vaguely assigned, even so early as the Greek physicians, to special epochs of life, denominated by them "climacterics." It is chiefly between what they would have termed the seventh climacteric and the ninth-that is, between the forty-ninth and sixty-third years-that this morbid condition occurs. I do not quote these terms to give any support to the idea that there are climacteric epochs; but I may affirm that the state of which I am speaking is a mode of decline from the climax of health and vigour of a special kind.

As the facts of disease came to be more and more the objects of inquiry over mere symptoms at the bedside, and as morbid anatomy in support of such clinical observation was pursued more accurately after death, there would naturally be at first a tendency, with increased precision, to a somewhat narrow pathology; for instance, the investigations of the intestines in typhoid fever led Broussais and his followers, as we know, to maintain that fever was a local intestinal affection. A similar error seems to have been committed in respect of this form of chronic Bright's disease. The common change in the urine during life, and the morbid state of the kidneys after death, have so closely confined the attention of physicians, that they have often looked no further than the kidneys and their failing function for the grounds of their pathology, and their patho

logical views have been limited to the line thus indicated. Now, though no one will deny the almost paramount importance of keeping fully in view the results on different parts of the organism of defective renal excretion, and the tendency to death by uræmia, still we believe it can be no less maintained that the fundamental clinical facts of the disease in question are not included in such limited causation, and cannot be understood by the conditions of a merely renal pathology.

The constitutional form of chronic Bright's disease with contracted kidney, or, as Dr. Sutton and myself have desired to designate it, arterio-capillary fibrosis," is, it would appear, a primary and general change in the capillaries and arterioles of the body, and corresponds, therefore, in its seat in the adult to the "area vasculosa " in the embryo. And as it is the object of the embryologist to elucidate the changes through which the ovum proceeds upwards to the perfect development of its tissues and organs, so it may be broadly stated to be the object of the pathologist to set forth the steps which lead downwards to death. There are occasions which make it advantageous for the pathologist to enlarge the scope of his considerations by admitting this comparison; for it is obvious that what is generally expressed by the term "vis formativa," whose resultant changes we see in development, is represented by the "vis conservatrix" in the adult, which failing, we have senility and death.

Apart from accidental disturbances in the course of life, we might, perhaps, with due knowledge of the inherited forces, be able to predicate somewhat of the course of their failure. The curve of the ascent and the curve of the decline would, in other words, have some more or less exact correspondence, and we should be able to realise fully the truth that there is not only a time to be born" and a time to die," but death might be predicted for a given individual to come in a certain time, say of any particular organ or of any particular system for instance, we might be able to foretell that the failure would first appear in the nervous, or the vascular, or the secreting system. The form of chronic Bright's disease with contracted kidney is, it seems to us, one example of such (senile ?) decadence.

Its clinical history varies in every case, according to the organ which suffers most and earliest. In one case, sleeplessness, headache, and other slight brain disturbances, may be the first symptoms complained of; in another, the altered condition of the heart may first draw attention; in a third, loss of appetite, dyspepsia, sickness, and failing digestion, are most prominent; in a fourth, diuresis; in a fifth, a liability to bronchitis, with attendant emphysema; in a sixth, a state of general malaise, loss of strength, some emaciation, &c.

These various phases, separately or in combination, constitute the earliest ailments for which the physician is commonly consulted. They are for the most part vaguely referred to a gouty condition; and it must be admitted that the general morbid state of which we are speaking, though distinct from gout, is especially common in those whose ancestors have been gouty. It is often more erroneously referred to suppressed gout. This is less appropriate, since, except the vague flying pains to which such patients are liable, and the occasional deposit of uric acid or urates in the urine, there have often been no phenomena which could properly be termed gouty.

In a large number of cases which come daily before the physician, no doubt the disturbances in question are no more than a mere variation in the general equilibrium of nutrition, which, by due care as to diet and exercise, and the other general conditions of health, are easily corrected; but in a considerable number of persons they are the early signs of a general change in the vascular area, of which disease of the kidneys may or may not be an early and prominent part.

And here I may refer to the evidence supplied by the urine at the outset of chronic Bright's disease with contracted kidney. Hitherto it has been the habit of the clinical physician to take the specific gravity of the urine, and to test it for the presence of albumen. Should the specific gravity be normal (1020 to 1024), and should no change in the fluid be produced by heat and nitric acid, whatever ailments have been present, they have not been referred to the early stages of Bright's disease, but have been explained, as I have said above, by reference to some