I call vividly to mind the unhappy results of treatment so directed the vapour-baths and antimonials of former times for eliminating through the skin; the compound jalap powder and elaterium, to call forth the vicarious functions. of the intestinal mucous membrane, et cætera similia,—such or similar treatment tended, no doubt, to exhaust the already failing nutritive powers.

Although, in respect of the uræmic state, the faulty condition of the blood and its treatment by eliminants cannot be neglected, still it must be admitted that there is an important distinction between the uræmic state and its consequents, and that general fibroid cachexia (?) which exhibits itself in the arterioles and capillaries of the different organs, as now under discussion. The two may no doubt be combined, and indeed are often combined, in the same individual; but still, for therapeutic purposes, it is of no small importance to the sick man, that as exact a perception as possible of the distinction here insisted on should be acquired.

Whilst we cannot leave out of consideration the changes in the blood, neither can we safely forget that there are important antecedent and comcomitant tissue changes which are independnt of mere uræmia.

I have not time fully to discuss, even if it were my duty to do so on this occasion, all the clinical bearings of this subject. My colleagues, your present teachers, are as fully alive to the necessity of extending our views on this subject as I myself can be. They will, I am sure, tell you that many of the diseases of the brain, of the lungs, of the heart, and of the stomach, are associated with, and form part and parcel of, this great malady. When treating of apoplexy, they will say that over and above the cerebral affections which are due to uræmia, and which were first of all so well described in this place by my late colleague, Dr. Addison, the brain tissue is liable to subacute or chronic lesion, from disease of its capillary vessels; that acute pneumonia, or bronchitis, at the period of life of which I have spoken, is often due to already commencing vascular disease; that dyspepsia, and especially the so-called gouty dyspepsia, is not the result of a materies morbi floating in the blood, but

of a subacute or chronic degeneration of the mucous tissue.

Here, as elsewhere in the therapeutics of disease, the limitation of our thoughts to the conditions of the moment, or to the special organ affected, cannot but be productive of either fruitless or dangerous practice. It is always dangerous to rest in a narrow pathology; and I believe that to be a narrow pathology which is satisfied with what you now see before me on this table. In this glass you see a much hypertrophied heart, and a very contracted kidney. This specimen is classical. It was, I believe, put up under Dr. Bright's own direction, and with a view of showing that the wasting of the kidney is the cause of the thickening of the heart. I cannot but look upon it with veneration, but not with conviction. I think, with all deference to so great an authority, that the systemic capillaries, and, had it been possible, the entire man, should have been included in this vase, together with the heart and the kidneys; and then we should have had, I believe, a truer view of the causation of the cardiac hypertrophy, and of the disease of the kidney.

ON CHANGES

IN THE

SPINAL CORD AND ITS VESSELS IN ARTERIO-CAPILLARY FIBROSIS.1

BEFORE entering upon the morbid changes which are the subject of this communication, it may be permitted us to state some general conclusions on arterio-capillary fibrosis to which our observations have led us.

In May, 1872, we recorded in the Transactions' of another Society a series of observations on the morbid state commonly called chronic Bright's disease with contracted kidney, and affirmed that there are (1) not only the wellrecognised, and we may say, notorious cases in which the kidneys are contracted, the heart much hypertrophied, and the vessels diseased, but there are (2) others in which the kidneys are but slightly affected, and yet in which the heart is equally hypertrophied and the vessels diseased, and (3) other cases in which the heart is hypertrophied, the vessels diseased, but without disease of the kidney of the kind in question, or merely the congestion of the dying. In all these three classes of cases we have observed fibroid changes in the arterioles, capillaries, and interstitial tissue of various organs.

1

On these grounds we expressed the opinion

By Sir William Gull, Bart., M.D., and H. G. Sutton. Reprinted from the Pathological Society's Transactions,' vol. xxviii, 1877, p. 361.

that the pathology of the state commonly called chronic Bright's disease with contracted kidney was not essentially renal, and that for its full comprehension a wider investigation of concomitant or even antecedent changes in other organs was called for. Since the time named we have prosecuted these investigations more or less continuously throughout the several organs-stomach, spleen, liver, lungs, heart, cord, brain, skin.

If further inquiry should establish, as it seems to us assured that it will, that after the middle period of life, there is very commonly a pathological condition of the body which leads to fibroid changes, not only in the kidneys, but more or less generally in other organs, then we may conclude that the renal affection, being of the same kind and character, is probably but a more pronounced local expression of a general disease or degeneration.

Clinical medicine from this point of view would recognise the significance and bearing of many now supposed unimportant ailments; and might find that these ailments are signs of commencing tissue-changes of the kind in question, springing up in one or more of the several organs, it might be in advance of renal changes, and foreboding their advent. But lest we should be misunderstood as too much limiting this inquiry, we would state that our investigations lead us to think that these tissue-changes may in some cases result from the renal disease; whilst in others they may follow the renal changes in respect of time, but not be dependent upon them, but upon a general cachexia of which the renal disease is part.

Everyone will admit that the progress of pathology must be made by retracing the steps which lead to morbid anatomical results. In chronic Bright's disease with contracted kidney, the kidneys and the thickened heart, the two most prominent features, have mostly occupied and satisfied the attention, whilst antecedent or attendant changes in the other organs have been but little considered; or, further, indeed, when such changes with hypertrophy of the heart have occurred without the prominent lesion in the kidneys, they have been too much regarded as isolated facts. We believe it will be proved that these collectively indicate

in common a state having arterio-capillary fibrosis as its basis.

Respecting the objection which was raised by Dr. Johnson, that what we had regarded as a pathological change in the arterioles and capillaries was a merely artificial result, we have only here to state, with due respect to him, that continued investigations have but strengthened our views; and the observations we have now to submit on the cord will probably leave little doubt in the minds of others that the changes in the arterioles and capillaries are morbid. As to the hypertrophy of arterioles, we may say, as we did in our earlier communication, that though the muscle in some of the larger arterioles especially seemed to be increased, yet we are still sensible of the difficulty of giving a true interpretation to such an appearance. As to the question whether the muscular layer of the arterioles in any particular instance be hypertrophied, assuming the several elements to be normal, or whether the thickened appearance in such a case is the result of unusual contraction of the vessel, we have not, as we say, been able fully to satisfy ourselves. The problem is beset with special difficulties, and obviously greater ones than can arise in determining whether the arterioles be the seat of morbid changes in their tissues or not. Moreover, we know of no observations showing that the muscular layer has a constant thickness in arterioles of equal calibre.

Nor is it always easy to say whether the adventitia of an arteriole is thickened if it be separated from its surroundings. At all events, in a doubtful case, we are much aided by seeing how the apparently thickened adventitia is in continuity with the increased connective tissue about it, and how the fibroid changes spread from the vessels to the surrounding textures.

But whatever conclusion shall be arrived at respecting the hypertrophy, we maintain that the muscle layer in many arterioles in chronic Bright's disease and the general state associated with it, is atrophied, and associated with a hyalinefibroid change in arterioles and capillaries.

In submitting our observations on the spinal cord, we desire to add that we have extended our inquiries to other