On Granular Degeneration of the Kidnies, and Its Connection with Dropsy, Inflammations, and ...

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Preface

In the year 1827 Dr Bright announced in his " Reports of Medical Cases," that dropsy frequently depends on a peculiar degeneration of the structure of the kidnies ; and that this change of structure is likewise attended with a liability to other diseases, more especially of an inflammatory nature, and is indicated by the presence of albumen in the urinary secretion. It was afterwards found, as in regard to many other important discoveries in pathology, that various authors had previously made observations, which, if followed out, might have

IV PREFACE.

led them on to the general principles established by Dr Bright Among these the names of Dr Blackall, Dr Alison, Professor Andral, and especially of Dr Wells, may be deservedly mentioned. It is not however by a few fortuitous observations, and still less by obscure and incomplete inductions, that the merit of an original discoverer in medical science is to be either gained on the one hand or lost on the other. Formerly physicians were in possession of only a few scattered facts and dubious inferences respecting the connexion between dropsy and diseased kidney ; and these were almost disregarded, alike in science and in practice. Now they may become intimately acquainted with a disease of extreme frequency, which manifests itself by characteristic symptoms, and singularly modifies and engenders a great variety of other long familiar maladies. For this important step in the progress of knowledge medicine is indebted to Dr Bright,-* together with those inquirers,

PREFACE.

whom his discovery has called forth, to explore with more minuteness the regions he has pointed out.

Notwithstanding the novelty and interest of these researches, some time elapsed before they received the attention which they ought at once to have commanded. My position, as one of the physicians of the Infirmary of this city, having given me an opportunity of repeating and verifying the material parts of Dr Bright 9 s statements, I made the results public in a short paper in 18^9* And in 1831 my late lamented friend and colleague in the hospital, Dr James Gregory, ably followed up and strengthened this confirmation by a comprehensive digest of his own experience, as well as of that of myself and his other hospital colleagues, for the two preceding years.f

* Edinburgh Med. and Surg. Journal, October 1829, Observations on the variety of Dropsy which depends on Diseased Kidney.

f Ibidem, October 1831, On Diseased States of the Kidney connected during life with Albuminous Urine.

VI PREFACE.

Nevertheless several years more passed by before the subject was taken up anywhere else ; and to the present day, strange as it may seem, Guy's Hospital in London and the Edinburgh Infirmary continue to be the only institutions of the kind in Britain, which may be said to have contributed to the general stock in this branch of pathological knowledge.

* In 1834 the subject was also investigated by Dr Osborne of Dublin,* who showed that the disease is not less frequent there than in the two other metropolitan cities, and who has advanced some views as to the treatment, which have since been generally adopted. About the same time the subject began to attract notice in France. In Paris, Montpellier, and Strasbourg, Bright's disease has been unequivocally recognized

* On the Nature and Treatment of Dropsies accompanied by coagulable urine and suppressed perspiration. By Jonathan Osborne, M. D. Physician to Sir Patrick Dun's Hospital. Dublin Journal of Medical and Chemical Science, January 1834. The paper has been since published in a separate form, with additions.

PREFACE. Vll

by the first authorities in pathology ; and M. Rayer in 1837,* and M. Solonf in the present year, have published the fruits of their experience in distinct treatises/ During the last four years too, several important papers have appeared from time to time in the Medical Journals of Great Britain and of France J ; which, in common with the

* Traite des Maladies des Reins, &c. Par P. Rayer, M6decin de l'Hopital de la Charite. 2eme livraison. Niphrite Ah bumineuse. Paris, 1837.

f De I' Albuminuric, ou Hydropisie causee par maladie des Reins. Par le Docteur Martin Solon, Medecin de l'Hopital Beaujon. Paris, 1838.

% 1. On the Epidemic Scarlatina and Dropsical Affection as it prevailed epidemically in 1832. By Mr G. Hamilton. Edin. Med. and Surg. Journ. January 1833.

3. Observations on Renal Dropsy by John Anderson, London Medical Gazette, xv. 835. 1835.

4. On Scarlet Fever as it prevailed epidemically in Edinburgh in 1835-6. By James Stark, M. D. Edin. Med. and Surg. Journ. October 1836.

5. The Article Urine in Dictionnaire de Medecine et de Chirurgie Pratiques. Par M. Martin Solon. 1836.

6. Cases and Observations, illustrative of Renal Disease, accompanied with the secretion of Albuminous Urine. By Richard Bright, M. D., &c. in Guy's Hospital Reports, No. 2. 1836.

Vlll PREFACE.

more extended researches already specified, all tend towards the same conclusions, — namely to establish the exceeding frequency of the disease, and the accuracy and comprehensiveness of Dr Bright' s original description.

Some idea of the prevalence of the disorder may be formed from the following facts. Confining the attention to the most common of its consequences, the several forms of dropsy, — it appears from the researches of a late author, Dr Mateer of Belfast, extending through a period of twelve years and over 2000 cases of all diseases except fever, that one-sixth at least is formed of cases of dropsy ; and that of these

7. On the coagulability of the Urine as a Diagnostic and Therapeutic sign of Dropsies. By William Mateer, M. D. Physician to the Belfast Fever Hospital, Edin. Med. and Surg. Journal for January 1837.

8. Lettre sur T Albuminuric, par M. C. Forget, Professeur de Clinique Medicale a Strasbourg, Gazette MSdicale de Paris, Septembre 1837.

M. Solon also mentions several Parisian Theses on this subject which have been published since 1833, but which I have hot seen.

PREFACE. IX one-half prove fatal. But from the inquiries of Dr Wells, it may be deduced that 55 per cent of all dropsies are connected with diseased kidnies ; toy own observation would raise the amount to fully three-fourths of the whole ; and according to the experience of Dr Bright, the ratio is even higher. - The last author found on one occasion, from an extensive trial among the patients of Guy's Hospital indiscriminately, that one in eleven presented signs of an affection of the kidnies; and on another occasion the proportion was so high as one in six. '

In such circumstances, the apathy with which the invaluable discoveries of Dr Bright continue to be regarded by many is most unaccountable. It is only within the last two years that medical men in this city have generally admitted the accuracy of his researches. I still meet with respectable members of the profession who seem inclined to adhere to their scepticism. And in a late visit to London I found to my

PREFACE.

surprise that by some medical gentlemen of the metropolis the doctrines of Dr Bright continue to be called in question. This is surely a very strange result of the numerous extended inquiries which have now been made, and all with one invariable result. I do not know a single investigation, of such extent as to deserve the name, which has contradicted in any material point the general principles first announced in 1827. And as to confirmatory researches, I shall take the liberty of expressing my sentiments in the language of Dr Osborne, who remarks, that " the number of observations recorded" (and this be it observed so far back as 1 834) " must be admitted to have been greater than has within many years been brought to bear on any one individual proposition in medical science."

Were an apology wanted then for the appearance of the present treatise, the preceding exposition might perhaps be considered not inadequate. But other rea-

PREFACE. XI sons have also actuated me. The subject I have undertaken to elucidate has been more or less an express object of study with me ever since the publication of Dr Bright's Reports in 1 827. Some of the general facts which have thus been deduced have gone forth in an imperfect form through the medium of my lectures delivered from time to time in the Clinical Courses of this University during the last six years. Occasionally I perceive from the Journals, that others have been expending much pains in ascertaining points which have here been for some time determined ; and that others call in question facts which have been long placed out of the reach of controversy. A few received doctrines, of much importance both to pathology and to practice, have appeared to me doubtful, if not inconsistent with facts, and therefore to deserve early revision. One interesting department, the pathological condition of the blood, has hitherto been barely touched upon, and that chiefly in points which were started in my

Xll PREFACE.

paper in 1829. On farther investigation it has appeared to me, not only that the special facts formerly advanced in an isolated shape may be now stated with full confidence in more general terms, but likewise that the entire subject may be presented with new features of interest. Lastly, I had long thought that the students of this University and the profession at large stood in need of an easily accessible work on Granular Degeneration of the Kidnies. Nor has the publication of the excellent memoir of Dr Osborne altered this opinion ; since the ground we have taken up is somewhat different, and the doctrines to which we have been conducted are not always in accord.

It is necessary to explain, that this treatise was framed in the first instance exclusively from the results of personal experience, based on the earliest work of Dr Bright. Its substance indeed formed part of my Clinical Lectures delivered in 1831, as well as frequently since ; and it was first

PREFACE. Xlll written without reference to any researches published subsequently to those of Dr Gregory, which made their appearance during the same year. Some valuable observations have since been added from the publications of later authors. But these authors may also recognize apparently some of their facts unacknowledged ; for I did not think it necessary to refer to others what had long been previously known to myself, and repeatedly made public in the discharge of my professorial duties.

The designation of the disease has been felt as a stumbling-block by every pathologist who has written upon it. Dr Bright did not venture to name it at all ; inconsequence of which physicians, foreign as well as domestic, have very generally in familiar discourse taken the liberty of naming it after himself, — a convenient appellative certainly, — but which I have hesitated to adopt, because I am not sure that in sober narrative we are entitled to use so great a freedom. M. Solon has termed the primary

XIV PREFACE.

disease Albuminuria from its principal symptom, the discharge of albumen with the urinary secretion. And M. Rayer, assuming that it is essentially an inflammation of a peculiar kind, terms it Albuminous Nephritis. Both titles are objectionable. Its inflammatory character in many instances may be doubted ; and besides, albuminous urine seems to be secreted in at least one other variety of inflammation of the kidnies, namely inflammation of its pelvis. The euphonious elegance of M. Solon 9 s designation will not altogether atone for the philosophical error of naming a disease from one of its symptoms, and from one too which is neither quite invariable nor peculiar. It must at the same time be admitted, that the term adopted in this treatise can as little be successfully defended; for the structure of the morbid deposit is far from being always granular. But it seemed right to retain some reference to the original description of Dr Bright. Future pathological research will probably show that

PREFACE. XV there is more than one organic derangement concerned in the question of nomenclature. Till this point be settled, and until the precise nature of the foreign deposit be determined by chemical analysis or otherwise, it seems almost hopeless to attempt discovering an appropriate and convenient title.

I consider it an improvement upon some prior English notices of this subject, to abandon that view of the organic disease of the kidney, which holds it as subsidiary ^merely to dropsy, — dropsy being no more than one of its symptoms, or rather one of its secondary affections. There seems a decided advantage in discussing the disease as one primary and idiopathic, which engenders many secondary disorders, and dropsy among others. It is thus only that correct ideas will be formed of its pathological relations. These relations are becoming more and more numerous and interesting every day ; so that I am much mistaken if there is any chronic

XVI PREFACE.

disease of the viscera, excepting pulmonary consumption, which presents features of more importance, either in itself or on account of its intricate connexion with a host of common disorders, than granular degeneration of the kidneys.

The Appendix of Illustrative Cases is selected from a much larger number which have come under my immediate observation during the last ten years. The number might have been easily increased ; but those which have been chosen are probably sufficient to exemplify the varying features of the primary disease as well as its secondary affections ; and they are the cases whose particulars were ascertained with the greatest minuteness and accuracy. On account of the latter reason it has appeared to me advisable to transfer to these pages a few of the cases formerly published in my paper in 1 829 or communicated by me to Dr Gregory in 1831.

University of Edinburgh, 30th November 1838.

Contents

Section First. — Pathology and Morbid Appearances, Page I Incipient Stage, .... 4 Middle Stage, . . . . 12 Final Stage, .... 18 Section Second. — Symptoms and History, . 25 General Symptoms of the Acute Form of the Disease, 26 Of the Chronic Form, ... 29 State of the Urine in the early stage, . . 32 As to quantity and general properties, . 32 In Density, .... 34 Coagulability, .... 35 Supposed fallacies of coagulability as a test of Granular Degeneration of the Kidnies, . 38 State of the Solids discharged by Urine. . 47 State of the Urine in the advanced stage, . 48 As to quantity and general properties, . 49 Density, . . . . 50 Coagulability, ... 51 Solid contents, .... 54 Summary of the properties of the Urine as diagnostic

of Granular Degeneration, . . 55

Its state in the early stage, • . 60

Section Fourth — Causes of Granular Degeneration of

the Kidnies, . . . .107

Cold a frequent cause, . ib.

Some constitutional predisposition necessary, 109

Intemperance a common cause, • • 110

Struma a probable predisposing cause, . 112

Scarlatina a frequent cause, . . 114

Influence of age, sex, rank of life, and profession, 116

Section Fifth. — Prognosis, . . . 120

Is the disease curable ? . . . ib.

Prognosis in regard to the secondary disorders, 123

Special prognostics. . . . 126

From the state of the urine, . . 129

CONTENTS. XIX

Section Sixth. — Treatment, • Page 132

Treatment of the primary disease in the early stage, 132 Blood-letting, . . . . 133

Counter-irritants ; Diaphoretics, . 135

Cathartics, . . . . 137

Diuretics, . . . . 138

Mercury, . . . . l4l

Treatment of the advanced stage, . 142

The progress of the disease may sometimes be retarded or arrested for a long time in this stage, 143 Treatment of the Secondary Disorders, . 145

Of Dropsy, .... 146

Of Disorder of the Functions of the Stomach, 155

Of Diarrhoea, . . . . 156

Of Inflammation of the Serous Membranes, 158

Of Catarrh, .... 159

Of Rheumatism, Pneumonia, Diseased Heart and Diseased Liver, . . • 163

Illustrative Cases, with Remarks.

Cases Fatal in various stages and from various secondary affections, with the appearances after death, both Primary and Secondary, . 167

Cases of Recovery, temporary and permanent, • 242

ON

GRANULAR DEGENERATION

OF THE

KIDNIES, &c.

Section First. Pathology And Morbid Appearances

The disease which forms the subject of the following pages is a morbid degeneration of the kidnies, whose exact nature has not yet been ascertained. In its progress it is essentially chronic* The morbid deposit appears to be always thrown out gradually and slowly. Yet it is occasionally preceded, and often throughout its course becomes for a time accompanied, both by local and general reaction. It is attended by irritation of the kidnies of that kind which is characterized by the excretion of blood or of its albuminous portion. It tends to diminish or suppress the excretion of the solids of the urine, both in the early stage by causing func* tional disturbance, and likewise in the advanced stage by inducing extensive derangement of organic structure. It also tends singularly to im-

A poverish the blood, by depriving it of a large proportion of its colouring matter.

Ultimately its intrinsic result is to overwhelm the functions of the brain, probably in consequence of the blood, the proper stimulant of that organ, being on the one hand poisoned by the accumulation of urea, and deprived on the other of its colouring matter. But it also engenders in the constitution a certain infirmity or susceptibility ; which, while indicated in some measure by a proneness to diseases at large, is more peculiarly characterized by a liability to serous effusions, as well as inflammation of the serous membranes and internal viscera. And it is through the intervention of these secondary circumstances that the disease of the kidnies most generally proves fatal,— much more so than by its intrinsic consequence* the direct annihilation of the cerebral functions.

The disease has been variously divided by authors into several forms, by Dr Bright into three, by M. Martin Solon into five, by M. Mayer into no fewer than six. Of these varieties some, or even all, have been considered mere stages of the same morbid affection. The latter view is exceedingly doubtful. For not merely does the disease thus supposed to be one and the same in nature present a very great diversity of anatomical characters, — the kidney being sometimes much enlarged, sometimes excessively shrivelled, at one. time little firmer than recent brain, at another

MORBID APPEARANCES.

harder than the hardest tubercular liver, in some cases composed of a smooth, homogeneous mass, in others finely granulated like herring-roe, and in others coarsely tuberculated, so as to present somewhat the appearance of being thickly studded with peas ; — but likewise the several opposite characters here enumerated may occur in different cases, where the amount of suppression of the solids of the urine during life, and the extent of disorganization of the healthy structure of the kidnies, which are the best measures of the stage or progress of the disorder, seem entirely the same. It is highly probable then, that the various forms mentioned by authors do not exactly belong to the same morbid formation.

When pathologists shall succeed in arranging these forms according to their exact relationships and true differences, some obscure points in the history of the disease, more especially in its symptomatology, will in all likelihood be cleared up. Meanwhile however such an arrangement is impracticable. And the resemblances are such between the manifestations of all the forms during life, — the leading characters of the urine in particular are so much alike, and above all there is such an identity in the secondary diseases to which they lead, and which are the direct sources of danger to life, as well as the chief subjects of treat* ment, — that there can be no impropriety in considering the whole forms for the present under one head. And to avoid pathological error as far as possible, it may be preferable, in following out the disease in its progress through successive stages, to look rather to the destruction of the healthy structure, than to the morbid deposit.*

In this point of view the progress of the disease may be conveniently divided into three stages, — the incipient stage, which in some instances, if not in all, is a state of congestion or reactiop, — . the middle stage, where the cortical structure of the kidney is nearly qt entirely destroyed, — and the advanced or final stage, where the tubular masses are also invaded and more or less obliterated.

1. Incipient Stage. — The organic alterations of structure which constitute the essence of granular degeneration of the kidney are not very easily traced in the early stage. In the generality of instances the change of structure goes on for a long time insidiously. There are scarcely any symptoms to attract the attention either of the patient or of his physician ; much less is there any functional disturbance adequate to endanger life. Hence an opportunity seldom occurs at this period for ascertaining the precise state of the kidnies by anatomical inspection. But on the whole it seems probable that their state in such obscure cases is at the commencement simply a minor de-

* See Note, p. 21.

gree of what will immediately be described as presenting the pathological characters of the middle stage, namely the deposition of a grayish-yellow, obscurely-granular matter in the cortical structure, with, or possibly without, some degree of sanguineous congestion.

In some cases however, though comparatively few in number, the disease commences more with the characters of an acute affection. And then it may prove fatal soon after its appearance, either simply from the immediate effects of the disturbance to the renal functions, or from the developement of acute, secondary disorders. Several instances of the kind have now been published by the different authors who have made the subject a study;* and I am enabled to add one more to the list. From an examination of the facts hitherto collected it appears, that where the disease in its acute form proves fatal in the early stage, the kidnies are found flabby, friable and unusually large, sometimes more than twice the natural sizef ; much darker and more vascular externally, and with points and star-like spots of ecchymosis ; internally dark, brownish-red, or almost reddishblack, gorged more or less with blood, which drops from a cut surface in unusual quantity ; and

• Bright, p. 33, Plate 5. Gregory, xxxvi. 349. Solon, p. 121. Rayer, Plate vi. Fig. I.

f Rayer has found the kidney to weigh sometimes twelve ounces, the natural weight being four.

they often present throughout their whole structure, but more especially in their cortical portion, lines, small roundish specks, or stellated spots of still darker colour, like ecchymosis, and not easily removed by washing. Mayer thinks he has ascertained that these spots are often the Malpighian glands in a state of congestion. Sometimes this congested state of the kidney prevails throughout the whole organ equally. At other times, as in the case recorded in the Appendix (Case 1.) the cortical structure seems chiefly affected, and pre* sents a more distinct and more coarsely striated appearance than natural, probably from blood being injected or extravasated in lines into the fundamental cellular tissue. The cortical structure almost always seems considerably broader than in the healthy state, as if it were distended towards the circumference by its gorged condition, — a state which the French pathological writers consider to be hypertrophy of the organ. Occasionally there is also an appearance in the cortical substance of a granular matter of a dark reddish-yellow tint deposited here and there ; so that its natural striated texture is somewhat obscured. But the dark colour of the parts renders it very difficult to determine these points accurately. Case 1. however seems a clear example of the kind now referred to.— The lining membrane of the pelvis of the kidney is commonly very vaseular and red.

MORBID APPEARANCES.

The bladder is always found much contracted ; and it commonly contains only a drachm or two of urine, which is for the most part pale, always very strongly coagulable by heat, and varying in density frdm 1014 to 1025. The appearances in other organs vary with the immediate cause of death. These it is unnecessary to state at present, with a single exception, — namely where death is caused directly by the disease inducing suppression of urine and consequent coma. Here it is shown from the appearances within the head, that the immediate cause of death, fatal coma, has frequently nothing to do either with extravasation, congestion, or serous effusion ; for in none of these respects do the brain and its membranes necessarily present any marked deviation from their ordinary state, where death was not preceded by head symptoms of any kind. Sometimes however there is found extravasation on the surface of the brain, thickening of the pia mater, effusion of serosity- in the subarachnoid cellular tissue, or into the ventricles, congestion of the vessels of the membranes or brain, darkness and injection of the cineritious substance, morbid tumours, &c. — some one or another in short of those organic changes which are wont to be found after death from apoplexy. These appearances, more especially congestion and serous effusion, have been far from uncommon in the practice of Dr Bright. M. Sabatier mentions that effusion of serosity is common enough among children. In this city they are certainly much lesa frequent ; and the generality of cases of death by coma present no marked morbid appearance of any kind within the head.*

Morbid appearances of other organs, indicating the existence of secondary or concurring diseases, are sometimes met with, but not so frequently as in the more advanced stages of the primary disorder ; — under the description of which they will therefore be more appropriately arranged. The most frequent of them are the signs of inflammation of the serous membranes, and hydropic effusions into the cellular tissue and the sacs of the pleura, pericardium, and peritoneum.

The blood often contains urea in large quantity ; and this principle also exists in the serosity of the brain. It may be presumed to be also present Jn other secretions. This impregnation of the fluids with urea is an invariable fact where the urine has been suppressed or much reduced before death. It was first announced by myself in my paper in 1829 ; since then I have repeatedly verified the fact ; and on several occasions it has been corroborated by the experience of my hospital colleagues. Those therefore who have called in

* In this respect my experience, as well as that of others, is at variance with a statement of Dr Osborne, that " in almost all his fatal cases, when not complicated, life terminates in the production of a low form of arachnitis, as is evinced by examination after death."— <P. 30.)

question the accuracy of the original statement have either manipulated incorrectly ; or they have looked for urea where it was not to be expected,— namely in cases of death from other causes besides coma, and where the urine was not defective materially in the amount of solids daily discharged. *

Between this, the incipient stage of acute cases, and the next unequivocally morbid condition of the kidney, which may be called the middle stage, •—where the cortical structure is in a great measure or entirely destroyed, — it is by no means easy to trace the progress of the disease by gradual steps. And for the simple reason, that opportunities are rare ; since death, for reasons not very apparent, seldom takes place during this interval.

It may be asked then, what proof there is of the two states of the kidney being connected together as antecedent and consequence ? Are they really mere stages of the same disease ? Do the cases which commence with obvious local reaction actually lead to a deposit of granular matter, as the proper termination of that reaction where it does not prove fatal in the congestive stage ?

There certainly seems some reason for doubting the affirmative as a universal fact. On the one hand it is not improbable, that some of the instances where a dark, flabby, enlarged, congest-

* The process for detecting the urea will be found under the head of the Symptoms.

ed state of the kidnies has been found in connexion with coagulability and gradual suppression of urine, have been nothing more than cases of ordinary inflammation, or pure nephritis ; which, if not cut short by fatal coma, might have continued to run the course of an acute disease, and terminated in resolution or in suppuration, rather than in granular deposition.* And on the other hand there can be no question that granular degeneration is for the most part a chronic disease from first to last, exhibiting at its commencement, and

* M. Solon conceives that true nephritis is quite a distinct disease from that which leads to granular degeneration ; that it is marked by different symptoms, namely the absence of oedema, and the presence of severe pain, nausea, and vomiting. Both diagnostics however are incorrect. In very many cases of granular degeneration, as will appear from the sequel, nausea and vomiting are most distressing symptoms ; frequently pain in the loins or flank is acute ; and repeated instances occur where the same affection presents the negative sign considered by M. Solon as diagnostic of nephritis, the absence of oedema. M. Mayer again considers granular degeneration to be a variety of inflammation, which he supposes to be distinguished from others by the discharge of albumen with the urine, and which he therefore names Albuminous Nephritis. And he especially describes as distinct from this another variety which he terms Chronic Simple Nephritis ; but which, according to his description, seems to differ little in anatomical characters from some varieties of granular degeneration admitted by British pathologists. The respective characters of the urine are said by him to differ ; but he does not say how. According to the experience of Solon however acute nephritis is attended with albuminous urine. In this city we have few opportunities of ascertaining the diagnosis between nephritis and granular degeneration ; as the former is an extremely rare disease.