SPECIMENS FROM A CASE OF BRIGHT'SDISEASE.

BY ARTHUR WYNNE FOOT, M.D., F.K.Q.C.P.;Physician Meath Hospital; Professor of Medicine, Royal College of Surgeons

[Read in the Pathological Section, December 4, 1885.]

THE specimens which it is my privilege to lay before the Patho-

logical Section illustrated in a typical manner sonate of the patho-

logical events in Bright's disease.

The specimens are a pair of granular kidneys, symmetrically

diseased, an hypertrophied heart, and the occurrence of pericardial

inflammation as the terminal accident in the downward series of

changes.

The kidneys are obviously of the kind described by Richard

Bright as granulated; their surface is mottled by being broken

into minute areas of a pale colour surrounded by more pinkish

because more vascular—tissue; they are contracted in all their

measurements ; weigh -together, free from their adipo-cellular

envelope, six ounces; are firm, tough, and, on the whole, brownish-

red in colour; in fact, they are in the recent state, just as

represented in the excellent drawing done, while they were fresh,

underm y superintendence.

The heart weighs thirty-two ounces. The hypertrophy chiefly

concerns, and is most conspicuous in, the left ventricle. There

is neither valvular disease nor atheromatous change in the aorta

beyond a trifling degree, so that the enlargement may fairly be

assumed to have been due to increased capillary resistance. The

evidence of recent pericarditis is plain to be seen on the surface of

the heart in the deposition of a sheet of reticulated exudation. The

fluid parts of the exudation have escaped in the opening of the

sac. There are two points of clinical interest about the casewhich are deserving of notice. This man, who may be stated to

U

306 Specimens from a Case of Br ght's Disease.

have been fifty years of age, and by employment a steam-raiser-

i.e., a man who has to have the fires lighted and steam up for

the drivers of locomotives—was admitted to hospital for haema-

temesis, which had been of daily occurrence for three weeks. The

quantity of blood daily discharged from the stomach, while he was

under observation, varied from three to fifteen ounces. A history

of intemperate habits had, somehow or other, accompanied him

into hospital ; and the hwmorrhage was regarded as due to hepatic

causes. However, examination of the liver, stomach, or spleen,

afforded no explanation of its occurrence. He had no dropsy or

oedema, and made no complaint of defective vision. His colour

was pallid, but not more so than would be accounted for by such a

loss of blood as he had been subject to. His urine was examined

for the purpose of ascertaining if it would present the characters

called 11 hepatic," and was discovered to be albuminous. The

ha matemesis having subsided in four or five days under the use of

ice and ergot of rye, he was moved to another part of the hospital,

and, in his transference, seems to have caught cold, because the

day after his removal he complained of pains across the upper part of

front of the chest, which led me to examine that region for aneurysm,

on the possibility of such a disease existing and leaking into the

oesophagus. Two days after he complained of pain in the left infra-

mammary region, and on auscultation over the seat of pain I

heard nothing to suggest inflammatory action in the pericardium.

After twenty-four hours of great restlessness from this date he

expired quietly. At the autopsy at least eight ounces of turbid

serum, occupied with flakes of lymph, was found in the cavity of

the pericardium. The peritoneal and pleural cavities were free

from effusion, as was the subcutaneous cellular tissue—the pleuroo

were more or less agglutinated by recent adhesions, dry, fleecy, and

easily detached. The liver was smooth, and natural in shape,

colour, and consistence. The stomach was examined with some

care as the seat of the bleeding, for which he had been admitted.

Its contents had no appearance of blood—some of the rug ut on its

posterior wall presented an arborescent vascularity, but there was

no obvious breach of surface. This case had an interesting clinical

By DR. A. W. FooT. 307

feature in the fact that the primary—in fact the principal and only-

1,aemorrhage was from the mucous membrane of the stomach. If

called upon for an explanation of this, I can only say that it must

have been the locus minoris resistentice, or offer the usual explanations

for the ha morrhagic attacks in contracted kidney—viz., friability

of arteries, increase of arterial tension, and deficient coagulability

of the blood. Why, in one case, the haemorrhage should be an

epistaxis ; in another, a heematemesis ; and, in a third, should take

place from the female sexual organs (as West has pointed out) ;

why, again, it should be sometimes retinal, sometimes intracranial,

is difficult to explain, and I make no attempt to do so. The

complete absence of dropsy in this case appears to have been due

to the powerful action of the hypertrophied heart.

Pericarditis is the especial characteristic of the granulated

kidney, and furnishes one of the most frequent means by which

the fatal result is accomplished. It is induced by the most trivial

exciting causes, lasts but a short time, and is almost invariably

fatal. The first of Richard Bright's cases, and that which furnishes

perhaps his best drawing of the granulated kidney, died with peri-

carditis. It has been calculated (Tyson) that pericarditis occurs in

twenty-five per cent. of cases of granular kidney. The non-discovery

of pericarditis, when my attention was drawn to the region by the

complaint of pain, the day before his death, I can only explain on

the supposition that the effusion was sufficient to intervene between

the opposite surfaces; the lymph was also of a soft and buttery

consistence, such as is recognised as not productive of loud friction.

Theoretically it might be assumed that the murmur produced by a

hypertrophied heart in pericarditis should be both loud and exten-

sively diffused. I have met with cases where this expectation has

not been borne out by facts. These specimens are such common

results of granular kidneys, that I was at first unwilling to occupy

the time of the Section with their exhibition otherwise than by card,

and feel called upon to apologise for offering such trite subjects to

the consideration of the members of the Section.