particular circumstances. In my own note-book, I have a great number of cases where this condition has presented itself, both in particular organs and in a general manner. Thus, as a rule, in all bed-ridden persons, particularly if advanced in life, fatty degeneration occurs; or where confined by some chronic disease, excepting always, of course, cases where a very rapid and exhausting malady is going on. Thus it is mostly seen in long bed-ridden paralysed patients, in those long confined with scrofulous and cancerous affections. In the latter diseases, I have not time to discuss the question, why wasting at one time is produced, and at another a fatty degeneration; it is sufficient to remark, that this condition is constantly found. In patients who have suffered from any marked morbid state of the blood, it is particularly liable to happen, such as after puerperal fever or common fever. In two or three cases of sudden death, during convalescence from this latter disease, a fatty state of the heart has existed; one of the most marked causes, however, of fatty degeneration, is to be found in intemperance. This is mentioned by Bright in a former volume of these Reports, and seems to result from a constant imbibition of malt liquors rather than spirits. For this reason, in all those who have died from delirium tremens, induced by intemperate habits, I have found a fatty degeneration of organs. A fatty degeneration may be local, as in the liver of phthisis. I have alluded thus to the subject of fatty degeneration, because without its general consideration, that of the kidney cannot specially be understood, for I am sure that it has been by a too exclusive regard to one organ, that the true pathology of the particular case has been often misinterpreted. A fatty liver cannot be understood without a general reference to the body at large, much less be put down as a primary morbid condition; neither can a fatty heart be connected of necessity with sudden death, on account of the investigation of fatal cases where this has occurred, seeing that in the majority of cases where a fatty heart has been found, death has not occurred immediately through the failure of that organ. In the same manner, a fatty kidney may indicate nothing of itself. When I speak of this condition, I use the term exclusively to designate those cases where the fatty state seems the only morbid condition. It may be found existing in diseased kidneys. Thus the albuminous deposit in the large white kidney often undergoes fatty degeneration; so, again, we may find the small granular kidney very fatty. The state, however, I mean to refer to, is a simple fatty one, without any tendency to Bright's or other disease; indeed, the two conditions have nothing to do with each other. A fatty state may exist in an organ otherwise healthy, or in a diseased one. Bright's disease of the kidney may occur without the presence of any fat; and, on the other hand, a fatty state is often found, which can only be looked upon in the light of a degeneration. In certain subjects, particularly those under the conditions above mentioned, directly the body is opened, a general fatty state is recognized both in the integuments and in the interior, about

the intestines, &c.; in each case the viscera are found very frequently to contain more than usual fat. I never found a kidney containing very much fat, whether otherwise diseased or not, without very visible traces of the same condition existing elsewhere. All this shows a general pathological cause for it, rather than a special one in the organ itself, and that when it occurs in a morbid kidney it is altogether secondary to the disease itself. It may be true that Bright's disease may indirectly be connected with a train of causes which have resulted in the fatty degeneration; but then other organs are seen to share the fat with the kidney. I do not speak of every slight or local changes in a kidney, where a tube here or there may contain some fat. This may arise from a degeneration confined to that part from a special cause. When I speak of true fatty kidney, I allude to an organ which is in an analogous condition to that of the liver, where we suppose that the mere superaddition of fat has produced the morbid state: in fact, an organ similar to the permanent state of that found in the dog or cat, where it presents an appearance healthy to the naked eye, but yet containing an abundance of fat. So I have seen a remarkably fatty kidney in the human body pronounced healthy, because it was not otherwise structurally diseased. Thus, also, a very fatty liver may be overlooked, unless the fat be in such quantity as to alter perceptibly its colour and consistence; and, speaking of this organ, as we look upon the fat so commonly found in the nutmeg liver or cirrhosed liver as a mere consequence or complication of a more serious affection, and the true fatty liver where the organ only contains an excess of fat, so in an analogous manner do we speak of fatty kidney. In these cases, then, the cells are seen to contain many oil globules, and which sometimes burst, setting their contents free, which are found in drops throughout the tubes. In the large white kidney the fat is commonly found mixed with the exudation, as if this had undergone degeneration, and the separate granular corpuscles are found to have drops of oil within them. In the small degenerated kidney we often find the tubes very diseased, altered in shape, and in parts devoid of epithelium, and containing only granular matter and fat.-Guy's Hospital Reports, Vol. viii, p. 232.

63.-ON THE DROPSY OF BRIGHT'S DISEASE.

By DR. SAMUEL WILKS.

In

It was in the investigation of dropsy that Bright was first led to his discovery. As a symptom of renal disease, dropsy is found in a greater or less degree at some period, though not invariably so. the first form of the disease, when the inflammation is going on, to the enlargement of the organ, dropsy is a uniform symptom. In bad cases it is more excessive than in any other malady, and much more general. This universal anasarca, or its existence in all parts of the body, constitutes the peculiarity of renal dropsy, and testifies as to its

immediate dependence upon a general cause, that is, poverty of the blood. Thus we find among the first parts which become dropsical are the ankles, the face, with the conjunctiva, and the genital organs. Indeed, in the majority of instances, if we see the scrotum and penis included in a dropsical condition, we may safely conclude the presence of renal disease. The cause of dropsy, in many cases, as in obstruction to the flow of blood through the chest in lung or heart diseases, is simply mechanical, or in ascites from a cirrhosis of the liver; but in renal disease it depends upon the condition of the blood, and thus its universality, for a watery conjunctiva or oedematous scrotum could but rarely depend upon a local cause. This state of the blood is produced by two causes; first, by the scanty secretion of urine, by which much water is retained in the blood, and secondly, by the flowing away of its albumen, whereby also its specific gravity is much diminished. From the first cause a repletion of the vessels would occur, and, of necessity a dropsy ensue. This would be in part mechanical, and allied to the other varieties of the affection. It is, however, from the poverty of the blood, arising from the drain of albumen, that the dropsy generally occurs, and for the same reason as oedema of the leg is often found in chlorosis. Of the two causes which operate to produce a watery state of the blood, a scanty secretion of fluid by the kidney, and a plentiful secretion of albumen by the same organ, I should say the latter was the more influential of the two. With a very scanty secretion two results follow which are liable to produce a transudation through the vessels, a diminished specific gravity of the blood from the retained water, and an increased pressure from its superabundance; and yet I think the effect of these is less in the production of dropsy than the discharge of albumen which is constantly taking place from the vital fluid. I think my experience shows that a highly albuminous urine, even with a considerable amount of fluid, is more likely to be accompanied by dropsy than where a less secretion occurs, and consequently less albumen is thrown off. Little, however, can be said on this point, as an accurate measurement of the albumen is difficult, and so many other causes operate to influence the result. Thus, if the urine be plentiful and its contained salts abundant, but albumen at the same time be taken from the blood, the specific gravity of the latter fluid is lowered, and a disposition to dropsy is produced: whereas, if the urinary secretion be scanty, or all but suppressed, generally a diarrhoea is set up, or some other vicarious action, which. may relieve the blood, and so the immediate consequence in this respect is rarely seen. It is not common, however, to have dropsy to any amount in the chronic degeneration of the kidney, even if for days together the patient have his urine suppressed, and die from its toxœmic effect. On the other hand, dropsy is constantly seen to exist with a normal amount of urine secreted, leaving the abstraction of albumen from the blood as the sole cause of its production; remembering, however, always, a softened and relaxed state of the tissues,

which may assist the transudation of fluid. It is clear, then, why, in the first form of inflammatory disease, with a scanty albuminous urine, excessive dropsy should exist, and why, in the second form of chronic degeneration, where a plentiful secretion exists with but a slightly albuminous state, none, or but occasional dropsy should be. In this latter form, if, from cold or other cause, a dropsy come on, the urinary secretion is at the same time seen to be much interfered with. We see, too, the reason why Bright, in the first instance, coupled dropsy with albuminous urine, and how it was subsequent investigation which discovered the diseased kidney where neither of these symptoms had existed, or at least been observed. That the dropsy is dependent immediately upon the watery condition of the blood, has been proved satisfactorily since the first analysis of Bostock, and it is thus made to be in a similar condition to that of chlorosis. The experience of the symptoms, and the beneficial result of the treatment by iron, all point to the similarity of the two conditions. There is one symptom, however, so remarkable in chlorosis, which is rarely found in Bright's disease, I mean the cardiac bruit de soufflet and the bruit de diable. I have constantly placed my ear to the heart of very anemic cases of Bright's disease, expecting to hear a soft systolic murmur at the aorta, but have failed.—Guy's Hospital Reports, Vol. viii., p. 276.

64.-ON BRIGHT'S DISEASE.

By DR. H. BENCE JONES, F.R.S., Physician to St. George's Hospital. [In this lecture Dr. Jones dwells upon the peculiarities of the urine in this disease, relating chiefly to prognosis and treatment.]

Congestion causes the diffusion of albumen, fibrin, and bloodglobules, and a decrease in the specific gravity of the urine at the same time occurs, in consequence, probably, of the congestion hindering the escape of some substances out of the blood. By Bright's disease, precisely the same effect on the urine is produced. Between the urine passed by a patient after the cholera, or after scarlet fever, and the urine of a patient with Bright's disease, I see no difference whatever, either chemically or microscopically. The low specific gravity in Bright's disease is to me produced by exactly the same cause as the low specific gravity when the kidneys are inflamed after injury of the spine, or when they are congested in cases of chylous urine. Generally, the decrease of specific gravity may be taken as the index of the extent to which the kidney is affected; that is, the lower the specific gravity of the urine when albumen is present, the greater the alteration in the circulation through the kidney, the greater the congestion in chylous urine and after cholera; the greater the inflammation in spinal cases, and the greater the so-called degeneration (the effect of congestion and imflammation) in Bright's disease. There are two opposite classes of cases of Bright's disease which

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require to be pointed out as exceptions to this law. In one class of cases there is considerable thirst, and very large quantities of urine are passed daily, and the specific gravity is consequently thereby reduced. In the opposite class of cases, the quantity of urine passed daily is exceedingly small, and hence the specific gravity rises sometimes very considerably above the healthy standard.

I shall illustrate both these classes by some examples.

A medical man was sent to me from the country, under the impression that he was suffering from diabetes as well as Bright's disease. He had no urine with him, and I asked him to come the next morning with the urine made at night. The following day he brought four quart bottles full, which he said, was about the usual quantity passed in twelve hours. It contained no sugar; had a specific gravity of 1006, and was highly albuminous.

A woman, aged 43, who had oedema of the legs two months, was in the habit of passing three quarts of urine in twenty-four hours; the specific gravity usually was from 1007 to 1010. She always complained of great thirst. On one occasion, the quantity of urine was three quarts in fourteen hours; the specific gravity was then 1004. A farmer, aged 50, was brought to me for diabetes. The urine was highly albuminous, contained no trace of sugar. The usual quantity was seven pints in twenty-four hours; the specific gravity was 1010. His only complaint was of headache.

Many similar cases I might bring before you; but these are sufficient to show that the quantity of urine must be taken into account before any conclusions as to the extent of the degeneration of the kidneys can be drawn from the specific gravity of the urine.

I pass on to the opposite exception, to the law that the specific gravity indicates the degree of disease of the kidney.

A woman, aged 38, had swelling of the legs for three months. She had a healthy, florid look. The dropsy was excessive. At one period of her illness, only three ounces of urine were secreted during one night; the specific gravity was 1036-2. It was intensely albuminous, loaded with urates, and contained many fibrinous casts. For six weeks after her admission into the hospital, the quantity of urine was seldom more than half-a-pint in twenty-four hours; the specific gravity was from 1027 to 1033. In six weeks more, the urine became more plentiful, specific gravity 1017.4. She gradually became comatose, and died.

A woman, aged 21, had swelling of the legs for ten months. They were always most swelled when the catamenia were present. The face was flushed and full. In twenty-four hours, half-a-pint of urine was made; it was exceedingly albuminous, loaded with urates, specific gravity 1035. She complained of sickness and drowsiness. By aperients and the vapour-bath, the urine became clear. The specific gravity fell to 1030, and the dropsy was lessened. After she left the hospital, I lost all knowledge of the progress of the disease.