DISCUSSION ON THE RELATION OF RENAL DISEASE TO DISTURBANCES OF THE GENERAL CIRCULATION, AND TO ALTERATIONS IN THE HEART AND BLOOD- THE above thesis does not obviously raise the question of names as to what is or what is not Bright's disease. It does, however, challenge the long-prevalent views that the disturbances in the heart and general circulation occurring with renal disease are due to it. Of course there are to be eliminated all the cases of primary valvular and similar mechanical conditions of the circulatory symptoms, generally admitted to have an origin quite independent of kidney disease, and leaving on one side cures of accidental albuminuria which thus arise. Before proceeding to read the few condensed remarks we have put together, we will put in the forefront the abstract of our views, viz. 1. Kidney disease is associated with or causes changes in the circulation, heart, and blood-vessels variously, according to the kind and seat of the morbid changes in the renal 1 By Sir William Gull, Bart., M.D., F.R.S., and H. G. Sutton, M.B. Reprinted from the Transactions of the International Medical Congress,' London, 1881, vol. i, p. 374. tissues, e. g. vascular (arterial or venous) or tubular or mixed (parenchymatous nephritis). 2. Kidney disease may be dependent upon causes primarily weakening the circulation, e. g. causes of general malnutrition, phthisis, fever, scrofulosis, alcoholism, syphilis, &c. 3. Defective renal function has a weakening influence on the circulation and nutrition; tissues become choked by oedema, enfeebled by anæmia and uræmia, and generally wasted, e. g. mottled or large white kidney, surgical kidney, &c. 4. Kidney disease may be dependent upon causes primarily leading to thickening of heart and blood-vessels generally, and to obstruction of the interstitial circulation through the several tissues, e. g. arterio-capillary fibrosis, climacteric changes. 5. The question as to the effects of kidney disease on the circulation may often with advantage be reversed, namely, as to what is the influence of alterations in the circulation in producing kidney disease: e. g. abnormal venous tension, arterial tension. 6. Many of the changes in organs, hitherto considered uræmic, are referable to tissue changes, capillary and interstitial, atrophic, anæmic, effusive, fibroid, &c., and may be independent of defective renal excretion. Kidney function can only be understood through the physiology of the general circulation; kidney disease can only be known through the disturbances in the general circulation. Clinical and anatomical facts show that the disturbance in the general circulation associated with, or dependent on, kidney disease, varies according to the kind of morbid change in the kidney; for instance, the disturbance in cases of suppuration of the kidney, (1) "surgical kidney," is altogether different from the disturbance in cases of (2) "large white kidneys" or (3) granular contracted kidneys. The antecedent conditions of kidney disease, as in cases of scrofulous pyelitis, lardaceous disease of kidney, or large white kidneys, cause of themselves disturbance in the general circulation-as, for instance, in phthisis, syphilis, abuse of alcohol, fevers, heart disease, &c.; and when from these the kidney disease supervenes and increases there is additional disturbance from that source in the general circulation. How much of the whole disturbance is due to the primary causes, and how much to the secondary kidney disease itself, is an exceedingly difficult problem; the actions and reactions may be considered until the answer is in many cases reduced to this paradox, that the disease is local because it is general, and general because it is local. Kidney disease may be grouped into tubular, vascular, and mixed forms; in mixed, both tubular and vascular structures are about equally affected. This latter is the common form. I. The tubular, in its most traceable form, is seen in "surgical kidney," or in strumous pyelitis. The morbid changes extending from the pelvis along the tubules to the cortex. There is retained excretory matter, and a pathological experiment is thus performed, showing the effect of such retention on the general circulation. There is often ultimate decomposition in the organic matters of the excreta into ammonia and carbonic acid, and an extreme poisoning of the system. It is thus clear what kind of disturbance is produced in the general circulation, when excretory matters are poisonously retained. There is not oedema, nor symptoms of uræmia, so called; little or no vomiting, little or no dyspnoea, and no cardiac hypertrophy. There is increasing failure of nervous and muscular energy; the pulse and heart become feebler, mucous membranes become hyperæmic and catarrhal, consciousness remains clear, and there is yellowness of skin, denoting change in blood-corpuscles. II. In cases of "intratubular nephritis," glomerular or other, there must of course be disturbance in the vascular system of kidney congestions and exudations, aud in many cases more or less fibroid intertubular change, so that these are often inseparable anatomically from the mixed group. But it is useful here to consider the intratubular cases in their simpler form, without fibrosis and without cardiac hypertrophy, so as to estimate what disturbance occurs in the general circulation when the water function of the kidney fails. These cases are characterised by great disturbance both in the general vascular and general interstitial circulations. Speaking generally, in these intratubular cases, the urine, at the outset of the disease especially, is diminished day by day, but weeks usually thus elapse before there is any marked oedema. The skin after awhile becomes puffy, the breath short, the nervous system much disordered, &c. Failure of water function of kidney does not cause marked oedema, until the skin and lung water functions fail also. It is an induction from clinical and anatomical facts, that as the outflow of water from the kidneys lessens, cæteris paribus, the water increasingly accumulates in the interstitial tissues, lymphatic spaces, and serous cavities: with this increased hydræmia the arterial tension is raised, and there is increased tension in skin and lungs; breathing becomes more difficult, skin becomes choked with serous fluid (edema), and ultimately air cells and bronchi filled with serum (oedema of lungs), or may be of pleura. As aspiration of chest (inspiration) lessens, the venous circulation is obstructed and the right heart over-distended. As the lungs are choked by serous fluid, the air circulation in blood and interstitial tissues is hindered, less air being inspired, the water (blood) circulation diminishes and gradually ceases, since the evaporation of air from the venous blood is itself a factor in the blood movement. For it cannot be overlooked that gases in a fluid being less affected by gravitation, and their particles, especially under the circumstances, being more prone to separate from those of the fluid itself in which they are contained, they would concur with the circulating force as against the inertia of the fluid itself. Anæmia supervenes and increases, indicating that oxidation is diminished, and that less heat is produced. It is here to be remarked that air being much lighter than water, it is more easily responsive to heat than water; more quickly expanded and compressed; whilst water, being more easily controllable and incompressible, dissipates energy less quickly; it is adapted to store more; it may consequently be inferred, and it is demonstrable, that in the general circulation there is an auxiliary action and mutual dependence between these two mediums, the water and the air circulation, and that as one fails, the other fails. An increasing anæmia is the worst sign; it reveals that heat and light energy have greatly diminished in the circulation, and that the normal protoplastic operations in the production of the blood-corpuscles are failing. The sense organs, lungs, red corpuscles, and locomotive. organs are, in the course of animal life, correlatively and proportionately developed; and they correlatively and proportionately fail, as in phthisis and Bright's disease. With the failure of the water and of the air circulation, there is disturbance in the nervous system; partly due to oedema and anæmia of sense organs; skin, retina, spinal cord, brain, &c. It can be shown that there is local disturbance in the interstitial circulation of cerebro-spinal system, coincident at least with the so-called uræmic symptoms; albumenoid and corpuscular exudations, swelling of nerve tissues, &c. It is common experience also that the tissues-mucous membranes and others-swell through oedema, and become additionally swollen by inflammatory exudations; and life is thus ended by pericarditis, peritonitis, pneumonia, myelitis, &c. Taking a wide survey, it is clear that the special and the general functions fail coincidently; that as the special water function of kidney, lung, and skin fails, the water function of the general protoplasm (connective tissues, capillary walls, &c.) fails also; that as the air function of lung fails, the air circulation of interstitial tissues fails also. Of these cases of intratubular nephritis, it is here to be noticed that their antecedents, viz., phthisis, heart disease, abuse of alcohol, syphilis, &c., bear witness in themselves that there is primary failure of nutrition throughout the body in the protoplastic circulation; and that the interstitial excretory function fails before the special (renal). The cardiac changes are those of dilatation of right ventricle, or chiefly. They may, however, not be more than is answerable to the impeded circulation from the causes here detailed. The vascular form of kidney disease is witnessed in the granular contracted kidney, and in many such cases it is mixed with intratubular nephritis. The granular contracted kidney may anatomically be regarded as one morbid condi |