rise to left-sided hypertrophy, though general cardiac hypertrophy is common.1 Amyloid kidney also closely resembles and is often mistaken for the large white and the fatty and contracted kidney. Such mistakes and the omission (to be referred to later) of some authors to separate the fatty and secondarily contracted kidney from the primarily contracted or granular kidney, cripple the statistics on the subject of hypertrophy of the heart quite decidedly. In recording my cases I have adopted the rather crude and old-fashioned nomenclature for the various forms of Bright's disease, but one which I am sure will be readily comprehended; whereas, did I use the proper technical terms, misunderstanding on the part of the reader, as to the exact form of Bright's disease meant, would be sometimes liable to occur.2 The classification adopted is as follows: I. The acute parenchymatous nephritis (syn., catarrhal, tubular, desquamative, croupous, scarlatinal, febrile, glomerulo-nephritis, acute degeneration of the kidney, acute exudative nephritis, acute diffuse nephritis) I will term acute Bright's disease. II. The early stage of the chronic parenchymatous nephritis (syn. same as above qualified by "chronic ") I will invariably call large white kidney, which well indicates the stage of the disease. III. The late or contracting stage of the chronic parenchymatous nephritis (syn., diffuse nephritis, secondarily contracted kidney, obstructive nephritis, fatty kidney, chronic diffuse nephritis with exudation) I will designate as fatty and contracted kidney. IV. The chronic interstitial nephritis or primary contracted kidney (syn., granular, cirrhotic, and gouty kidney, renal cirrhosis, atrophic, lithæmic and toxæmic nephritis, and chronic diffuse nephritis without exudation, etc.) I will call red granular kidney, which is an old and comprehensive name for this affection. Among the most serious sins of nomenclature we find that the term diffuse nephritis is indifferently applied to both the fatty and contracted and the red granular kidney. 1 It is remarkable how infrequent Bright's disease is in drunkards. I found that inflammatory kidney lesions generally occurred more frequently in the temperate than in the intemperate. Is it the constant excess of venous blood in alcoholic cyanosis of the kidneys that makes inflammatory changes in the latter less frequent, as it does in the right chambers of the heart? (See transactions of the Association of American Physicians, Vol. I). 2 I am not considering here the histology of Bright's disease, hence it is unnecessary to review the anatomical and histological features of the various forms of this affection; but stating the array of synonyms may prevent misunderstanding. The reasons for a separation of these two affections as distinct forms of Bright's disease are quite obvious, and I put myself strongly on the side of those who make it, viz., the dualists.1 For diagnostic purposes and for prognosis it is also quite essential that the fatty or secondarily contracted kidney should be differentiated from the red granular or primarily contracted kidney. Clinically it is, I believe, well established, that in the former the onset of the disease may nearly always be traced to acute nephritis, or at least to the large white kidney; that it is liable to occur at all ages; that transitions from scarlatinal nephritis in the young are traced to the large white kidney of the adult, and to the fatty and contracted kidney of late life, while rarely to the very old; that dropsy is very common in the earlier stages; that polyuria is more rare, and albumin is seldom missed; in fact, the duration of the disease is very uncertain, a fatal termination being liable to occur at any time. On the other hand, in the red granular kidney, which is common in gouty and rheumatic individuals, and is so often traced to disease of the genito-urinary tract, the initial stage is unknown, there being nothing to show that an acute inflammation of the kidney ever existed. It rarely occurs in the young, being almost peculiar to middle or old age; it may be of lifelong duration; dropsy and presence of albumin are rare, and polyuria is prominent. Polyuria in the fatty and contracted kidney, if it occurs at all, is late; the urine may be rich in albumin, whereas, in the everpresent copious flow in the red granular form, little or no albumin is present, as is well known. This, I believe to be an important diagnostic point. In my laboratory classes the urine examined is often from wellknown clinical cases, and in many instances I have traced the 1 It is interesting to observe that the father of Bright's disease, also, Grainger Stewart, Dickinson, Johnson, and the English school are strictly "dualists," being reinforced by the great original German workers Virchow, Traube, Senator, and Bartels; Charcot and Cornil in France, and in this country perhaps strongest by Tyson. The French are mostly "unicists" (i. e., advocates of the eventual transition of the three parenchymatous forms of nephritis into the red granular kidney), which is, however, also in accordance with the views of such prominent Germans as Frerichs, Rosenstein, Cohnheim, and Bamberger, and it appears also with the views of some of the New York authorities on the subject. Of late years "pluralists" have arisen, chiefly among the Germans, including Wagner, Weigert, and even Senator, who are inclined to ascribe every form of Bright's disease to different and independent morbid processes and causes, and place several complications of the morbus Brightii in the field as independent subdivisions of the disease. albuminous (fatty and contracted kidney) and non-albuminous polyuria (red granular kidney) to the post-mortem table. I may be permitted to introduce the following table relating to the more important anatomical and microscopical differences between the two affections referred to, because their separation is to a certain extent a point of issue in hypertrophy of the heart and fatty metamorphosis of the cardiac muscle. Fatty and Contracted Kidney. Contraction of kidney secondary. Size seldom below normal. Capsule adherent only in places, seldom thickened. Surface lobulated, often smooth; color, pale, mottled or yellow. Cysts usually large, and seldom numerous. Pelvis rarely dilated. Arterial changes are rare, or not pronounced. Cortex often normal in size. Atrophy very late. Renal epithelium much swollen, desquamating freely, often in a state of fatty degeneration, but cells always visible. Compound granule cells. Tube casts, epithelial, dark granular, and containing compound granule cells, and later fat globules. Red Granular Kidney. Contraction of kidney primary. Size, below normal; often reduced to one-half or even one-fourth. Capsule adherent, thickened. Surface granular, rough. Color, red or grayish-red. Cysts usually small-sized and numer ous. Pelvis often dilated. Arterial changes (endarteritis, or periartritis) almost invariably present. Cortex always much atrophied. Renal epithelium never desquamating, though it may undergo fatty degeneration (necrosis), and become diminished in size and partly lost. Tube casts, hyaline, pale granular, and waxy, but never containing cells, epithelial or any other. ANALYSIS OF THE CASES. The one hundred and fifty autopsies from which I draw my conclusions are, as stated, recorded in detail in the second part of this paper (Appendix). I thought it necessary and convenient. to record them here, as future studies of the same by anyone may reveal points of interest at present unconsidered. Each case has a reference to the autopsy records of the Philadelphia Hospital, so that, should additional information be desired, it may be gained therefrom. NOTE. If the classification and the definition of Bright's disease in its various forms were undisputed and a uniform nomenclature adhered to by all, then there would be no discrepancy in statistical results such as is seen in the literature of the subject. I would earnestly urge the adoption of a uniform nomenclature for the various forms of Bright's disease and the abolition of some of the synonyms. Some of the latter are misleading, and I have met with instances where pathologists and clinical teachers would designate one and the same form of Bright's disease by entirely different names (without thinking that they were identical) and also under a certain given name, affections entirely different from one another. Others delight in suggesting and using new names for the various forms without giving synonyms when writing on the subject, and leaving the reader to conjecture from the description, which form of the affection they really mean. The large general table is a summary of all the cases recorded in this paper, and gives the duration of life, the cause of death, the condition of the body, dropsy, cystic change of the kidney, and the prominent cardiac complications, such as hypertrophy, valvular disease, fatty metamorphosis, and dilatation of the heart, as well as the arterial changes in each form of Bright's disease, stating the number of cases. The figures expressing the percentage side by side with the number of cases, facilitate comparison with other statistics. Beside this, I have compiled several special tables which give interesting data relating to hypertrophy of the heart under varying conditions; fatty metamorphosis of the cardiac walls, valvular disease and pericarditis, and the weight of the heart and kidneys in each of these affections. I also present tables relating to age and sex, and further, some interesting figures concerning the weight of the heart in relation to the weight of the body, and finally, some data relating to the distribution of Bright's disease during the various periods of life. References will be found in the records to arterial changes and a summary of the various complications or concurrent affections of Bright's disease. CONCLUSIONS. From the accompanying general table the following conclusions may be made: HYPERTROPHY OF THE HEART. Considering the two forms of Bright's disease apart, we find that general hypertrophy co-exists more frequently with parenchymatous nephritis, viz., in 29 per cent.; while hypertrophy of the left ventricle alone was met with in 26 per cent. in this form of Bright's disease. Hypertrophy of the left ventricle predominates in interstitial nephritis, showing 44 per cent. to 26 per cent. of the parenchymatous. General hypertrophy occurred in interstitial nephritis in 28 per cent. Hypertrophy of heart in connection with parenchymatous nephritis occurred in 56 per cent. of all cases, and in the interstitial nephritis in 60 per cent.' 1There were six cases among the hospital records of red granular kidney in which the cause of death was designated senility. As there were many aged persons among the autopsy material of this series, I fear that some cases of senile atrophy of the kidneys with absence of hypertrophy of the heart, have crept into these records. |