On the pathology and treatment of albuminuria

Front matter

EXTRACT FROM THE FOURTH BY-LAW RELATIVE TO TAKING BOOK8 FROM THE ATHEXiEUM LIBRARY.

" If any book shall be lost or injured, — the writing of notes, comments, or other matter in a book shall be deemed an injury, — the person to whom it stands charged shall replace it by a new volume or set."

Deposited by the BOSTON ATHENvEUM

Preface

The rapid succession of works upon diseases of the Kidneys has apparently been due to the unexampled progress which, of late years, has been made in renal pathology; and it is the hope of the author that it may be said of this volume, as of its predecessors, that it is the offspring of advancing knowledge.

The great field of research which, until the time of Bright, was veiled in primeval obscurity, has since been cultivated with an assiduity which has. more than made up for centuries of neglect.

Bostock, Owen Rees, and Christison, supplied much that we know regarding the chemistry of the diseases which Bright had discovered, and Wilks as a pathologist established broad classifications which will probably never be entirely superseded.

The original treatise of Dr. George Johnson on this subject showed the importance of the microscope, both in its relation to morbid anatomy and as a means of diagnosis ; and while adding to our knowledge of disease directed the researches of succeeding enquirers.

But it would be impossible even to name the writers who, in England, on the Continent, and in America, have helped to advance this branch of medicine.

The great work of Eayer has a permanent place in medical literature. Prout, Bence Jones, and more

Vlll PREFACE.

recently Dr. G. Harley, have advanced urinary pathology in its chemical relations. Dr. Goodfellow, in the form of lectures, published a valuable and suggestive treatise, and Dr. Basham is the author of a work which has become well known, and has been commended as eminently practical. The important papers of Dr. Grainier Stewart contributed to elucidate the disorder to which Virchow had applied the term ' Amyloid ;' and Dr. Eoberts in his recent work upon Eenal Diseases has furnished an admirable compendium of our present state of knowledge.

While profiting by the labours of others it has been the aim of the author to record facts rather than to collect opinions, to appeal to observation rather than to authority, and of all books to consult chiefly the book of nature. In giving the results of clinical observations the naked distinctness of numerical statement has been often preferred to the more attractive vagueness of general description.

Some of the views which are advanced by the author, particularly as to the intertubular origin of Granular Degeneration, and as to the nature of the change to which the term ' amyloid ' has hitherto been applied, have been already made public through the medium of the Medico- Chirurgical Society, but he still feels that in other parts of his subject he is treading on new and dangerous ground, and particularly appeals to the forbearance of his readers in the chapter which bears upon the effects of climate. Even had he the capacity to deal with so large a subject as the relationship of atmospheric influences to disease, he could not do so with accuracy or completeness until meteorological stations

PREFACE. IX

are more widely scattered, renal disease is more generally understood, and systems of registration are more widely adopted.

At present have been considered only those renal changes which are declared by albuminous urine ; it is the purpose of the writer at some future time to treat of the remaining disorders to which the kidney is liable.

As to the pictorial part of the work, it may be hoped that it will help to make up for the shortcomings and deficiencies of the text. No pains have been spared either by Messrs. Hanhart, Dr. Westmacott, or Mr. Tuson, to secure truth in the coloured illustrations. As to the representations of microscopic sections, it may be said that their accuracy is sufficiently attested by the fact that they were all drawn with the camera lucida, and by Mr. TufFen West.

In conclusion, the author has to acknowledge his obligation to Dr. Sturges for revising the work in its passage through the press; he has to thank Dr. West and Dr. Hillier, his colleagues at the Children's Hospital, for allowing him to refer to their note-books of hospital practice; and he is indebted to his predecessors and colleagues at St. George's, whose liberality has enabled him to use without restriction all the resources of the hospital, and to bring forward numerous and various cases which may have value as faithful records of disease, whatever may be the worth of the inductive portion of the work which now asks for indulgent consideration.

Chesterfield Street, Mayfatr : December 1867.

Contents

CHAPTEE I.

INTRODUCTORY.

Structure of Kidney — Its Post-mortem State in Health — Tables showing Appearances presented by Tubes and Epithelium in sixty-five Healthy Kidneys — Fatty Degeneration of Epithelium — Normal Appearances of the Epithelium, Tubes, Fibrous Tissue, and Blood Vessels — Changes which may be taken as Signs of Disease — Classification of Renal Disease. — Disease of the Tubes, or Tubal Nephritis, of the Intertubular Fibrous Tissue or Granular Degeneration, of the Blood Vessels, or Waxy, Amyloid or Depurative Change — Mode of Examining Kidney with the Microscope . . . . ■

Chapter II

ALBUMINOUS URINE AND FIBRINOUS CASTS IN THEIR GENERAL RELATION TO THE PATHOLOGY OF THE KIDNEY.

Albuminuria from State of Blood — From Alterations in the Kidney — Transudation of Serum, caused by Renal Congestion, by peculiar alteration in Renal Vessels, or by loss by the Tubes of their Epithelial Lining— Fibrinous Casts derived like Albumen from the Liquor Sanguinis — Their Varieties and Indications . . .14

Chapter III. Pathology Of Tubal Nephritis

Change limited to Tubes — Acute Form of Disease, changes evident to Naked Eye and to Microscopic Examination — More Chronic Variety of Disease— Conspicuous Alterations in Organ, Increase of Bulk, and Change of Colour, Surface Smooth to the last, Obstruction of Tubes- Frequency of Fatty Degeneration . . . . .20

Xll CONTENTS.

Chapter IV. Clinical History Of Tubal Nephritis

PAGE

Sex and Age of Persons Attacked — Causes — Symptoms — Acute or Inflammatory Dropsy — More Chronic Form — Dropsy, sometimes Affecting Larynx, Inflammatory Attacks, Head Symptoms — Symptoms in Children and in Adidts — Table showing Symptoms in thirty-nine Fatal Cases — Urine : Appearance, Specific Gravity, Microscopic Sediment, Variations in Quantity of "Water, Urea, Uric Acid, Phosphoric Acid, Sulphuric Acid, and Chlorine — Presence of Albumen — Cases illustrating Natural History of Disease . . . .28

Chapter V. Causes Of Tubal Nephritis Considered In Detail

Cold, a more Common Cause of the Disease with Grown People than with Children — Examples — Circumstances under which Cold produces Disease —Nephritis occurs in Temperate Climates — Arctic Experiences — Relation of Nervous System to Inflammation of Kidney — Case of Nephritis produced by Exposure to Snow — Scarlatina as a cause of Renal Disease — Mode of Operation — Frequency — Period of the Fever at which Renal Symptoms appear — State of Kidney produced — Cases illustrating Symptoms and Pathology of Scarlatinal Dropsy— Measles — Diphtheria — Erysipelas — Typhus — Small Pox — Pysemia — Cholera — Jaundice and Acute Rheumatism as causes of Nephritis — Case of Nephritis from Acute Rheumatism — Irritants Foreign to the System as Causes of Renal Inflammation — Alcohol — Cantharides — Turpentine and Arsenic ........ 54

Chapter VI. Treatment Of Tubal Nephritis

Methods pursued by Bright, Christison, Prout, Todd, &c. — General Consideration of Principles and Details of Treatment: Blood-letting, Use of Water as a Diuretic, Digitalis, Acetate of Iron, &c. — Injurious Effects of Purging and Sweating — Antimony — Acupuncture — Treatment of Head Symptoms and of Inflammatory Complications — Cases illustrating Treatment . . . . . .84

Chapter VII. Pathology Of Granular Degeneration

Significance of the Granular Surface — Early Stage of Granular Degeneration— Advanced Stage — Alteration in Appearance of Organ — Changes in Fibrous Tissue, with consequent Alterations in Tubes, Malpighian Bodies, and Epithelial Cells — Cysts — Blood Vessels impervious . . . . . . .96

CONTENTS. Xlll

Chapter VIII. Subjects And Causes Of Granular Degeneration

PAGE Sex and Age — Causes and Antecedents — Tubercular Diathosis — Belongs to Temperate Climates — Causes, in Detail — Valvular Disease of the Heart — Cases of the Disease arising from this Cause — Pregnancy — Cases of Renal Disease produced thereby — Gout and Lead-Poisoning — Anatomy of Gouty Kidney — General Tendency to thickening of Fibrous Structures sometimes associated with Granular Degeneration . 106

Chapter IX. Symptoms And Effects Of Granular Degeneration

Insidious Commencement — Change of Complexion — Early Symptoms — Symptoms indicating more Advanced Disease— Dyspepsia — Dropsy — Mental Depression — Hypertrophy of Heart — Inflammatory Attacks — Hsemorrhagic Complieations — Apoplexy — Affection of Retina — Ursemie or Cerebral Symptoms — Table of Symptoms observed in sixty-eight Cases — Condition of Urine — More obvious Alterations — Casts, &c. — Chemical Changes — Alterations in quantity of Water, Urea, Uric Acid, Phosphoric Acid, Sulphuric Acid, and Chlorine — Cases illustrating Progress of Disease . . . . . . .127

Chapter X. Treatment Of Granular Degeneration

Capable of Alleviation though not of Cure — Change of Climate — Diaphoritics, Vapour Baths, &c. — Hon, Diet and Stimulating Liquors — For Dropsy, Diuretics, Scoparium, &c. Hydragogue Purgatives and Acupuncture — Treatment of Dyspepsia and Vomiting — Of Head Symptoms— Intolerance of Opium — Treatment of Inflammatory Attacks, of Apoplexy and of Epistaxis — Case illustrating Points of Treatment . 158

CHAPTER XL

PATHOLOGY OF THE DEPURATIVE INFILTRATION.

Change described as Waxy, Lardaceous, Amyloid or Depurative — General not Local — Parts affected — Deposition of new Material detected by Iodine — Situation and Character of Deposit — Consists of Dealkalized Fibrine — Analysis of Healthy and Waxy Livers — Chemical Examination of new Deposit — Artificial Production of ' Amyloid ' Matter —

XIV CONTENTS.

Disease usually the Result of Suppuration, not necessarily connected with Constitutional Disease — Kidneys described in Detail — Naked Eye appearances — Action of Iodine — Minute Alterations— Formation about Vessels and between Tubes — Changes in Tubes — Cysts developed — Connection between Morbid Anatomy and Symptoms . . .166

Chapter XII. Symptoms And Clinical History Of The Depurative Disease

Sex and Age — Easy Recognition of Complaint when Antecedents are evident — Access of Symptoms — Progress slow, sometimes latent — Thirst — Dropsy — Aspect of Patient — Inflammatory Attacks — Diarrhoea — Vomiting — Epistaxis — Rarity of Cerebral Symptoms — Causes of Death— Table of Symptoms observed in forty-eight fatal Cases- Urine, Changes in Quantity — Addition of Albumen, rarely of Blood — Casts, &c. — Diminution of Urea — Uric Acid — Phosphoric Acid — Sulphuric Acid — Chlorine and Alkalies — Cases illustrating Origin and Progress of Disease . . . . . . .186

Chapter XIII. Treatment Of The Depurative Disease

Prevention easier than Cure — Importance of arresting Purulent Discharge— Surgical Considerations — Means of compensating for Suppuration— Treatment of Symptoms — Anasmia. Diarrhoea, Dropsy, and Uraemia — Cases illustrating Treatment of the Disease in its Surgical and Medical Aspects . . . . . . .212

Chapter XIV

COMPARISON OF THE THREE FORMS OF RENAL DISEASE WHICH ARE PRODUCTIVE OF ALBUMINURIA.

Age selected by each Disorder — Diagram — Comparison of Symptoms in each, with a Table showing Percentage of Secondary Affections . 223

Chapter XV. Changes In The Blood In Albuminuria

General Alterations— Changes observed in each Disorder — In Tubal Nephritis, in Granular Degeneration, and in the Depurative Disease — Tabular Statement of the Results of Analyses in Cases where the Nature of the Disease was ascertained — Considerations relating to Albuminuria in general ...... 228

CONTENTS. XV

Chapter XVI. Alcohol As A Cause Of Kenal Disease

PAGE Sources of Error — State of Kidneys in Persons who have died of Delirium Tremens, and in known Drunkards — Inferences from Pathological Observations — Liver and Kidney differently influenced by Alcoholic Drinks — Geographical Distribution of Eenal Disease contrasted with prevalence of Intemperance, from Registrar-General's Reports — Conclusions as to action of Alcohol upon the Kidneys . . . 236

Chapter XVII. Climate In Relation To Eenal Disease

Sources of Information — Mortality from Renal Disease in various Cities — Prevalence of Albuminuria among British Troops in various Stations — Mortality from Renal Disease in various Counties of England and Scotland — General Prevalence of Albuminuria in Temperate Climates — Comparative Exemption of both Cold and Hot Countries — Details relating to prevalence of the Disease under various Conditions of Climate — Attempt to account for the prevalence of Albuminuria in Temperate Climates — Variability of Temperature a cause of Renal Disease — Practical Conclusions ..... 244

LIST OF CASES REPORTED,

TUBAL NEPHRITIS.

History, Symptoms, and Pathology : — A Medical Student, recovered Edward Nash, with Post-mortem Examination Worthy White, „ „

Erom Cold : —

Benjamin Patrick, „ „

From Scarlatina : —

Lydia Moore, „ „

Thomas Vallance, „ „

William Phillips,

Erom Acute Eheumatism : —

Hannah Newland, recovered, Post-mortem ultimately

To Illustrate Treatment : —

Eliza Crossland, recovered ....

Edward Hill, „

William Floyd, „

George Taylor, ,,

66 69 73

91 92 93 94

GEANULAE DEGENEEATION.

As resulting from Disease of the Heart : —

Sarah Uridge, with Post-mortem Examination Elizabeth Brennan, ,, ,,

From Pregnancy: —

Sarah Van G., ,, „

Amelia Teal, ,, „

General History, Symptoms and Pathology : —

William Tugwood, with Post-mortem Examination

Henry Todd,

A Literary Gentleman,

John Shave,

Hubert Jutsum,

Benjamin Harvey,

To Illustrate Treatment : — Henry Armstrong

a

116 118

143 145

147 150 153 154

XV1LL LIST OF CASES REPORTED.

JDEPURATIVE DISEASE.

PAGE

History, Symptoms and Pathology : —

Fanny White, with Post-mortem Examination . . .198

John King, „ t> ... 201

Richard Harrington, „ „ . 206

James Barry, ,, „ ... 209

To Illustrate Medical Treatment and Pathology : —

Isaac Grilhert, with Post-mortem Examination , . .216

To Illustrate Surgical Aspects of the Disease : —

Emma Denman, with Post-mortem Examination . . . 2 IS

Charlotte Carter, „ „ ... 220

LIST OF PLATES.

PLATE J., to face title-page.

Sectiox of a Kidney in a state of acute Tubal Nephritis, the result of Scarlatina. The case is given at length (Yallance, page 69). The kidney is much congested, though that condition is partly hidden by the opaque -white matter which occupies the tubes, and causes the increase of size in the cortex. Owing to this congestion, the organ is not so white as it is apt to become later in the disease. The surface of the organ is not shown. It was perfectly smooth.

PLATE II., to face page 26.

A Section cut from a Kidney affected by Tubal Nephritis, in which Fatty Degeneration of the Epithelium has taken place to a considerable extent. The tubes are not evenly obstructed, but patches of tubes are distended to opacity, while others are clear and translucent. The tubes are all in contact with each other, showing the absence of any intertubular growth.

The section was made from a portion of kidney which had been boiled.

The organ from which the section was obtained was a beautiful specimen of the speckled kidney described in page 26. The surface was smooth to the touch. The tubes were loaded with fatty epithelium.

The subject of the disease was a boy, who died during an attack of convulsions, having had albuminuria and general dropsy for ten weeks. The cause of the attack was uncertain.

PLATE IK., to face page 42.

Fig. 1.

State of the Tubes in Nephritis. The epithelial lining has generally beeu removed, while the tubes are occupied by epithelial cells and fibrinous matter. Both the epithelium and the fibrino\is matter are in some cases dotted with oil globides. Loth convoluted and straight tubes are seen, the former being th more distended. (See p. 23.)

XX LIST OF PLATES,

Fig. 2.

Casts of Tubal Nephritis. All the casts represented were obtained from patients in whom the nature of the disease was placed beyond doubt, either by post-mortem examination or by the fact of recovery having taken place. Most contain epithelial cells ; some, granular matter. Some are simple cylinders of fibrine. One bears evidence of having had a double origin, as explained in page 17, a large cast including others in its interior. (See p. 42.)

PLATE IV., to face page 96.

A pair of Kidneys affected by Granular Degeneration. They are of unequal size. The larger has had the capsule removed, so as to display the regular arrangement of granulations beneath. The smaller, which has the capsule partly removed, shows a number of cysts projecting from the surface. As not unfrequently happens, the contracting process has gone on unequally in the two kidneys, giving rise to the greater number of cysts where the shrinking has been the most. The outsides only have been shown, since it is by the state of the surface that granular degeneration is chiefly characterised. Had the organs been shown in section, the most noticeable fact would have been diminution of the cortical substance.

The kidneys represented were taken from the body of a well-known jockey, who died at the age of forty-eight, having had albuminuria, dropsy, and obstinate vomiting, followed by coma. He had had gout. At the post-mortem examination the kidneys were in the condition depicted, with extreme shrinking of the cortices, evident on section. The left ventricle of the heart was hypertrophied. The brain was ansemic and wet, and there was an incrustation of urate of soda upon the cartilages of the great toes. "With these exceptions all the organs were natural.

PLATE V., to face page 100.

Fig. 1.

Section of an advanced Granular Kidney, made by Mr. Lockhart Clarke's process (chrom:c acid, &c). It shows an extensive intertubular growth of fibro-nucleated tissue, which is most abundant in the neighbourhood of the capsule, a portion of which is seen along the upper edge. The surface is depressed opposite to the new formation. "Within the larger mass of new tissue two blood vessels are seen. The malpighian bodies are enlarged. The tubes are generally empty.

The kidney from which the section was cut was obtained from the body of a man fifty years of age, who had long been subject to gout. Latterly he had had dropsy, the urine being scanty, albuminous, and containing dark granular casts. He died suddenly, having had vomiting, rigors, and faintness. The lungs were found to be highly congested, and there was an extensive coagulum in the pulmonary artery, which apparently had been the immediate cause of death. There was valvular disease of the heart, the mitral valve being dotted with urate of soda. The kidneys were greatly contracted, the pair weighing only oh oz. The surfaces were highly granular, and showed numerous cysts. Urate of soda was seen in the renal tissue.

LIST OF TLATES. XXI

Fig. 2.

A Section from a Healthy Kidney, made in the same way as that represented above, and magnified to the same oxtont, given as a standard of comparison. The tubes are in apparent contact with each other, and with tho capsulo ; there are no spaces between, and no accumulations of fibroid material. Tho epithelium is seen in regular arrangement along the sides of the tubes.

PLATE VI., to face page 117.

Section of the Kidney of a woman who died of Puerperal Convulsions, having had Albuminuria and (Edema during her pregnancy. The case is given at length, page 116. (S. Van. Gr.)

The section shows a state of extreme congestion without any of that white opacity which is evidence of a deposit in the tubes. The cones are of a deep purple colour, the cortex rather more florid. The gland is considerably increased in bulk, chiefly in consequence of the injection of the vessels. The surface is not shown, but was perfectly smooth and of a similar colour to the section.

PLATE VII., to face page 140.

Fig. 1.

Eepresents all the varieties of Casts which were discovered in the cases of Granular Degeneration upon which the account of the disease is based, making use only, of the cases attested by post-mortem examination.

The greater number of casts contain coarse dark granular matter ; some are of finer texture ; a few contain blood globules or epithelial cells. (See page 140.)

Fig. 2.

Casts from the Depurative or Waxy Kidney. Cases all attested by post-mortem examination. The casts are of two varieties, simple cylinders of fibrine, and casts such as occur with nephritis imbedding epithelial cells. Judging by the casts alone it might be difficidt to discriminate between nephritis and the depurative disease. (Compare with Plate III.) See page 195.

PLATE VIII., to face page 178.

Section of a Kidney affected by the Depurative or 'Amyloid' change. The organ is much increased in size, the increase affecting chiefly the cortical portion. This has a pale buff colour, slightly variegated with spots of vascularity. The waxy change in this case, as often happens, was associated with the accumulation of fatty epithelium in the tubes, hence the great increase of size. A part of the section has been treated with iodine, and shows the effect of that reagent upon the malpighian bodies and the straight vessels of the cones. The former

b

XX11 LIST OF PLATES.

come out as black dots, the latter as dark lines, while the intervening structure is comparatively pale.

The outside of the organ was smooth and buff-coloured ; it has not been represented.

The kidney was obtained from the body of a soldier who had served in India, and had dysentery and abscess of the liver. He had albuminous urine with dropsy and vomiting, and eventually died in a state of semi-coma. There was extensive hepatization of the lungs.

PLATE IX., to face page 181.

Fig. 1.

Section made by Mr. Lockhart Clarke's process, from a large waxy kidney of which the surface was covered with large curved depressions.

The part represented was opposite to a depression. A large expanse of finely nucleated tissue is seen passing inwards from the capsule, separating the tubes and surrounding the malpighian bodies. The tubes in the neighbourhood contain detached epithelial cells.

At the right-hand side is a part of the new growth, highly magnified, so as to show its fibro-nucleated structure.

Part of a malpighian body appears at one corner ; at the other, convoluted tubes. (For comparison, see healthy kidney, Plate V.)

The kidney from which the section was cut was affected in a very characteristic manner. It was obtained from the body of a man who had had an arm amputated for disease of ihe elbow five, years before his death. The immediate cause of death was peritonitis, associated with infiltration of the coats of the duodenum with pus. The liver, like the kidneys, was waxy. No renal symptoms were recognised.

Fig. 2.

A Section of a characteristic Waxy Kidney, made after Mr. Lockhart Clarke's plan.

There is a general increase in the intertubular fibrous tissues. The tubes have lost their epithelial lining, and many contain fibrinous plugs, or casts, in their interior, These casts gave the iodine reaction in a most marked manner, taking exactly the same tint as the malpighian bodies. Another section from the same kidney, which displays the effect described, is represented in the ' Medico-Chirurgical Transactions,' vol. 1. (For comparison, see section of healthy kidney, Plate V.)

The section was cut from the kidney of a man who died of ulceration of the colon.* Latterly he had had some cedema, the urine at the same time becoming unnaturally copious. Owing to the disturbed state of the bowels none could be obtained for examination. At the post-mortem the kidneys were greatly enlarged, angemic, and of a yellowish white colour, much like that represented in Plate VIII. They gave the iodine reaction, as did the lining of the small bowel. There was a large suppurating cavity occupying the left side of the belly, and connected with the intestinal ulcers.

* The case is published, as an example of ulceration of the colon, in the Pathological Transactions for 1867, p. 102, case of C. Roberts.

LIST OF PLATES. XX111

PLATE X., to face page 182.

Section of a Depurative or 'Amyloid' Kidney, showing the action ofiodino upon tho malpighian bodies and small arteries. These are of bright reddish brown, as seen with transmitted light, while the rest of the section has acquired merely a faint yellow colour.

The darker marks upon the section are obstructed tubes. The section was made after freezing with ice and salt.

It was cut from a kidney in a very advanced state of disease, and much contracted, which was obtained from the body of a woman in whom the disease had followed upon severe syphilitic ulceration of the palate, &c.

She had oedema and ascites, the mine being copious and highly albuminous. There was nmch diarrhoea and vomiting. Latterly pneumonia occurred.

ALBUMINUKIA.

Chapter I. Intkoditction

The object of this treatise is to describe those diseases which are made known during life by the presence of Albumen in the urine. These have been classed together under the general term f Bright's Disease,' or more recently as Albuminuria. Since the publication of ' The Medical Reports ' — the work in which Dr. Bright first described the conditions of kidney associated with his name — pathologists have been busy in building upon the foundation he laid.

With the improved means of research which the microscope has given us, and with a rapidly advancing knowledge of animal chemistry, many refinements have been added to the great discovery of Bright.

Many and various subdivisions have been made of the Classifieaconditions which give rise to dropsy and albuminuria. It would be a weary and unprofitable task to follow pathologists into details of classification, frequently of a highly imaginative character, with which this part of medical literature is burdened. But, while avoiding fanciful distinctions, it will be seen that there are several disorders, different from each other in their cause, their symptoms, and their morbid anatomy, which Dr. Bright associated with albuminous urine.

It is the object of the present volume to remove some of the obscurity and confusion in which the subject has been

B tion.

INTRODUCTION,

[Ch. I.

Structure of kidney.

Tubes.

Fibrous tissue, and blood

vessels.

involved, by establishing such demarcations as are suggested by morbid anatomy, and warranted by clinical observation.

For the purposes of the physician the kidney may be divided into three parts. It consists, first, of a complication of tubes, which, with the malpighian bodies in connection with them, are the sources of its secretion, and are the essential elements of the gland. Secondly, these structures are bound together by a delicate web of fibrous tissue, which, in a section prepared so as to show it, has the appearance of a fine uniform network. This pervades the entire bulk of the organ surrounding and supporting every tube and each malpighian body. Thirdly, the gland is abundantly supplied with blood vessels, which lie with the fibrous tissue between the tubes. Some blood vessels, indeed, of the smallest size, enter into the construction of the malpighian bodies; but with this exception the blood vessels, like the fibrous tissue, are intertubular structures. It is unnecessary to describe with minuteness a structure which will be familiar to every person who is acquainted with the rudiments of physiological anatomy. It is only needful to insist upon the triple constitution of the organ by means of tubes, fibrous tissue, and blood vessels.

Post-Mortem State of the Healthy Kidney.

Since much of what is advanced in the ensuing pages is based upon alterations found after death in one or other of these components of the organ, it is necessary to ascertain first of all what is its normal condition. It is necessary to know what appearances are presented by the tubes, the intertubular fibrous tissue, and the blood vessels, in persons who have died of disorders other than renal. It will be necessary to remove from consideration such changes in the kidney as are of post-mortem origin ; and also those variations which depend upon conditions which are common to the whole body, and do not imply any deficiency or peculiarity in the kidneys themselves. The neglect of such precautions has been a fertile source of pathological mistakes.

Ch. I.] HEALTHY KIDNEY. 3

No detailed description will be needed of an organ so often Naked oye examined and so well known. The capsule of the kidney is ^^' thin and translucent, and holds very loosely to the smooth surface beneath. Upon this surface are no vessels large enough to be singly visible ; but it is uniformly covered with a fine network, the meshes of which are just evident without a glass, and of which each thread consists, not of a single vessel as might be supposed, but of a multitude of capillaries. On section the well-known brown substance of the cortex separates the cones, and forms a barrier ordinarily about a quarter of an inch in width, between their bases and the capsule. The appearance is liable to much variation within the limits of health, consequent upon the differences in the amount of blood contained ; and a delusive appearance of congestion often arises from staining of the tissues by blood which has become unnaturally fluid, as the consequence of febrile disease, or sudden death.

The ordinary appearances of the several renal structures, Under the as seen with the microscope, must be taken into consideration. With regard to the tubes and epithelium in particular it will be needful to be explicit, in consequence of the undue prominence which changes in the epithelial cells have obtained. These cells are sometimes charged with oil globules — a change at one time looked upon as the root of all evil. They have been variously described as ' granular,' ' opaque,' ' crumbling,' ' disintegrated,' l nebular,' ' degenerate,' &c. It will be shown that each of these conditions may be present independently of renal disease.

With a view of ascertaining what variations of the renal tubes and their contents may be consistent with health, and what must be held to indicate a diseased action, I examined with the microscope the cortex of the kidney in 100 consecutive subjects, in the post-mortem room at St. George's Hospital. The kidneys in 68 cases had the appearance of Examina health, and had belonged to persons in whom there had been ^'onlti-1 no symptom of renal disease. In 32, either in the appear- kidneys. ance of the organ or the history of the case there was some evidence or likelihood of renal change. It must be stated