Kidneys may be affected without other signs of gout.

Alcohol

selects the joints, lead the kidneys.

Gout of the kid

ney;

labouring community who are exposed to saturnine influence is comparatively small, and it will be interesting to inquire what proportion lead poisoning bears to other morbid influences as a cause of the disease. I have notes of 45 men who died of granular degeneration, of whom the occupation was known. Of these 10 had been exposed to this influence, 9 were painters; 1 a compositor, with evidence of lead poisoning.

From these particulars it is not too much to assert that of painters at least one half eventually die of granular degeneration of the kidneys; while as compared to other external circumstances the influence of lead is a more fertile source of this disease than any other with which we are acquainted. It is certain that many cases of renal disease thus produced are associated with gout, and that urate of soda often exists in the kidney. At the same time granular degeneration frequently occurs apparently in consequence of the metallic poison in cases where there have been no external gouty symptoms. The gouty affection of the joints and granular degeneration are associated as springing from a common cause. If the morbid tendency affect the joints we have the ordinary symptoms of gout; if the kidney the characteristic granular degeneration. It appears that where the gouty condition has resulted from alcoholic liquors it tends chiefly to the joints; when from lead to the kidneys. The rich man enjoys long life with gout in his extremities, the artisan perishes perhaps before his limbs are touched, from change of the same nature in the kidneys.

The change must be regarded as gout of the kidney.

Gout manifests itself not only by a deposition of urate of structural soda in the cavities of joints, but by peculiar changes in changes. certain of the fibro-cartilaginous and fibrous structures. Fibrous tissue is a chosen seat for the morbid action. The fibrous structures and the cellular tissue around joints become incrusted and infiltrated with urate of soda, and are at the same time thickened and indurated as by chronic inflammatory action. The ligamentum patella, the tendo-achillis, and the tendons of muscles, have been found to be thus

altered, and sometimes are infiltrated with the crystalline
deposit, or contain it in the form of small white specks in
their substance. From what has been said elsewhere it will
be seen that the affection of the kidney in these cases is
analogous to the effects of gout elsewhere. We find, as
Dr. Garrod has pointed out, and I can confirm, that there
occurs a deposition of urate of soda between the tubes,
connected that is with the intertubular fibrous tissue of the
gland.*
This portion of the organ becomes thickened by a
sort of chronic inflammation; it contracts and compresses the

Section through one of the cones of an advanced granular kidney from a gouty subject, showing the crystalline masses of urate of soda in the intertubular fibrous tissue.

tubes, and the granular kidney results. This description holds good whether the gouty condition has resulted from intemperance, from the absorption of lead, or from any other circumstance.

DISEASE.

and withi

It is known that one of the tendencies of old age is to In old age, fibroid thickening,. and increase of fibrous tissue in many drunkards. parts of the body. A less general fibroid degeneration results from the excessive use of alcoholic liquors, particularly

*See Dr. Garrod on Gout.

Granular

tion,

with cirr

Change

ardent spirits. As the result of spirit-drinking, the most marked effect is upon the liver and lungs, though the kidneys are not exempt. The influence which alcohol has in causing renal disease is considered elsewhere.

This general tendency, from whatever cause it arise, may affect the kidney in common with other organs. As a means of estimating the frequency with which granular degeneration occurs as part of a general fibroid change, I ascertained the proportion of cirrhosis of the liver, and thickening of the capsule of the spleen as associated with granular kidneys. In 250 cases of granular degeneration, the liver was cirrhosed degenera- in 37, a proportion of about 1 case in 7, while there was association noticeable thickness or opacity of the capsule of the spleen hosis, &c. in 47, a proportion approaching 1 in 5. These numbers may give a rough estimate of the frequency with which the exaggeration of fibrous tissue which constitutes granular degeneration has affected other organs besides the kidney. The proportion is not large. In this country the kidneys are prone to morbid actions, especially to such as affect their fibrous element. They suffer from influences which are concentrated themselves, while at the same time they are upon prone to participate in such general disturbances as promote the encroachment of fibrous tissue upon other organs. Their sympathy in this respect is most evident when the source of the change is valvular disease. When venous obstruction has resulted from uterine enlargement, the kidneys are usually affected alone. The hepatic and splenic veins are, from their position, free from the injurious pressure which the gravid uterus exerts upon the vessels which return the blood from the kidneys. Gout, too, attacks the kidneys while other viscera are exempt from its influence, though in this case the reason of the preference is unexplained.

confined to

the kidney

more

often than

not.

See paper by Dr. Sutton on Fibroid Degeneration of the Lungs, Med. Chir. Trans., vol. xlviii.

CHAPTER IX.

SYMPTOMS OF GRANULAR DEGENERATION OF THE KIDNEY.

beginning,

disturb

ances

often of

THIS disease has been described in a preceding chapter, as the result of changes at first insignificant, beginning in a certain part of the gland, and then creeping on, step by step, until decided alterations are produced in its construction. The symptoms are developed in the same insidious manner. It is impossible to recognise the disorder until it has reached what is really an advanced stage. The symptoms which then Insidious declare its existence are often of such a kind as to be easily attributed to diseases of other organs. A patient who has reached adult life may come under observation, suffering other from dyspepsia and vomiting, or with general debility, or organs. complaining only of depression of spirits, or with dimness of vision, or with bronchitis, or with slight and transient oedema, or with decided dropsy. With one or more of these symptoms, it is noticed that he has an unhealthy look-somewhat of the 'pallor luteus.' He has perhaps sharpened features, and an Complexanæmic while a sort of sunburnt tinge upon ion appearance; the skin prevents the whiteness characteristic of the more acute disease, and gives a sort of whitey-brown hue to the face. The tendency to anæmia is less marked than with other Anæmia forms of renal disease, and the patient, particularly if the sometimes disease be early, or be associated with affection of the heart, marked. may even have somewhat of a florid complexion, giving a delusive aspect of health.

Perhaps, after various measures have been unsuccessfully directed to some troublesome symptom, its renal origin

changed.

little

is suspected, and albumen discovered in the urine. If Often now the patient be questioned as to his previous health, it latent. is found that for some time, perhaps for years, it has been

Cause seldom obvious,

ment ob

scure, progress slow.

more or less broken. The urine has been increased in quantity, and passed more often than formerly. Perhaps it may have been noticed, on one or more occasions, that it was black from the admixture of blood. If there should be any oedema, it has come on gradually, without any such obvious cause, as exposure, scarlatina, or intoxication.

This disease differs from other renal disorders in the obscurity of its commencement, and in the consequent commence- difficulty in fixing its duration. While other renal affections. are generally evident on their first appearance, and run a tolerably rapid course to recovery or death, it is scarcely possible with granular degeneration to say how long it may last. Essentially a chronic disease, it would be easy to multiply instances where it has been known to exist for ten, fifteen, or even twenty years. It happens, in the greater number of cases which end fatally in hospitals, that the symptoms can only be traced back for a comparatively short time, but this arises from the indifference of the working class to slight ailments, so that they only come under notice when the later symptoms of the disease have accumulated upon them, and they are incapacitated by dropsy or some of the consequences of uræmic poisoning.

Early

urine.

One of the earliest symptoms which may lead to a suspicion changes in of the disease is an increase in the quantity of urine, which is pale and of low specific gravity. It is passed more often than natural, especially at night, apparently in consequence of its increased quantity, not because it has acquired any irritating quality. If examined in this early stage it may be found perfectly free from albumen, or may contain only a minute. trace. Casts are sometimes found before the albumen is Progress of appreciable. So long as the urine retains its abunsymptoms. dance the patient will remain without any trace of dropsy. It is probable that his earliest constitutional symptoms will be such as point to the stomach; dyspepsia is seldom absent.

See case reported by Dr. Wilks, Guy's Hosp. Reports for 1852, p. 248, where a woman, who eventually died of apoplexy, had been under observation with albuminuria for ten years. The kidneys were granular.