London and metro

politan counties.

Lancashire.

Southern counties.

disorders, there are other agencies, in this respect more potent, by which it is overridden. The places where death from drunkenness or delirium tremens is most frequent are not those where renal disease most abounds, and indeed in some instances enjoy a remarkable immunity from such disorders.

Renal disease as a rule is more common in the sober agricultural districts than in large towns. In the metropolis there is more drunkenness, and less disease of this kind than in the rural parts of Middlesex, Surrey and Kent. Lancashire, which with its great manufacturing towns is preeminent among the counties for the proportion of deaths which are attributed to alcohol, is one of the most free from the class of diseases in question. The agricultural counties of the south, though necessarily free from intemperance as from all vices which spring from exuberant wealth, are among those which Rural and suffer most severely. The rural districts of Scotland are, generally speaking, less addicted to excess in alcoholic liquors, while they show a larger proportion of renal disease than the large towns of the same kingdom. Glasgow is remarkably free from such disorders, an advantage which cannot be attributed to abstemious customs.

town dis

tricts of Scotland.

Glasgow and Aberdeen.

General conclu

sions.

Glasgow and Aberdeen, though differing exceedingly in their renal proclivities, are much the same in their habits of intemperance. And comparing each city with the country around it, it appears that the greater inebriety of the urban population does not produce any appreciable increase in the amount of renal disease.

Hence it would seem that, in accordance with what has been derived from pathological observations, the use of alcoholic drinks is comparatively inoperative as causing disease of the kidneys.

It has, indeed, been shown, that such fluids when taken in great excess may set up a state of renal catarrh, though compared with other causes of tubal inflammation, this one is of rare operation and almost insignificant in its numerical results.

It appears also, that certain liquors, by causing gout, may

bring about granular degeneration, but that this sequence is less common than when the gouty diathesis is connected with the absorption of lead.

And lastly, granular degeneration may result from the extension to the kidney of a fibroid change, such as ardent spirit produces in organs more immediately exposed to its action-though this event is comparatively infrequent, and the organic alteration, when it occurs, is generally less decided in the kidney than in the liver.

But each of the issues which have been described is of rare occurrence. Alcohol attacks other structures in preference to the kidneys. As causes of renal disease there are other agents, the more obvious and immediate have been previously considered, which are greatly more mischievous; and there is a great atmospheric power, which overshadows all the other circumstances which tend to produce renal inflammation or granular change.

CHAPTER XVII.

Geographical distribution

CLIMATE IN RELATION TO RENAL DISEASE.

MANY diseases, like plants and animals, are distributed over the surface of the earth in obedience to laws which make of diseases. living subservient to inanimate nature. If we know the range of temperature of a country, we can predict with some approach to accuracy the diseases which will be found among the inhabitants. In Arctic climates, catarrhal ́affections of the organs of respiration; in temperate countries, tubercular and renal disorders; within the tropics, dysentery, hepatitis, and virulent febrile diseases, prevail.

Sources of informa

tion.

Renal disease in

various

cities, from

registrars' reports.

With regard to renal disease in particular, it will be necessary to follow its distribution somewhat in detail, so as to ascertain how far external circumstances are able to control its development. The recent spread of schemes of registration has given us a means of measuring the relative frequency of fatal diseases, in cities which present extreme differences of climate. The army medical reports, under the superintendence of Dr. Graham Balfour, giving as they do the health of large bodies of troops all over the world, furnish the results of a series of experiments in geographical medicine such as could have been made by no nation but Great Britain. In a more narrow area, the registrars' reports for England and Scotland supply important details.

It may be convenient to present in a condensed form some of the information which has been gained from such sources, before proceeding to further consideration of the subject.

The mortality from renal disease in several great citiestaking cities together so as to compare similar communitiesis placed first.

The proportion of deaths from renal disease to the total number of deaths is, in—

This is taken from published registers of causes of death. As renal disease, have been included all the deaths which, according to the phraseology in use in each register, are assigned to Bright's disease, albuminuria, nephria, nephritis or kidney disease. The numbers concerning the towns of Great Britain relate to the year 1863; with regard to the foreign cities, the latest sources of information in each case have been used. The places are arranged according to their liability to renal disease. The comparatively cold cities of Great Britain and Australia come first, Aberdeen occupying a bad eminence in this respect. Paris, though not differing very much in temperature from the warmer of these, has a somewhat less proportion of renal disease. Genoa, with its almost tropical climate, has an exemption, which, for reasons which will presently appear, does not extend to Bombay,

British

army,

from army

medical reports.

As a further exemplification of the effects of climate in the Renal disdevelopment of albuminuria, the following table has been ease in the calculated from the six published volumes of the army medical reports. The numerical strength of the garrison in each place, taking the average of the six years, has been used as the standard of comparison. The proportion of deaths from kidney disease, including both nephria' and 'nephritis,' is stated in the first column; the proportion of attacks of 'nephria' or chronic albuminuria is given in the second, both referring to the mean of the six years. It has been judged right to exclude the cases described as 'nephritis' from the second column, since it appears that especially in India disorders not renal, but probably of a rheumatic character, are

classed under this heading. Nephritis,' however, when not renal is not likely to be fatal, and therefore the confusion which has been alluded to will not interfere with the column which relates to the deaths. The nine most important stations of the British army have been included. In six of them the mean temperature and the monthly range of variation has been annexed, from the report for 1864. The table refers only to British as distinguished from native troops.

Table showing the proportion of Renal Disease among the British Troops in various places, with the Mean Temperature and monthly range.

Mortality

The places are arranged according to the frequency of renal disease as a cause of death. It at once appears that the temperate stations are most exposed to the disease, while those within the tropics are comparatively exempt.

The next source of information has been the reports of the Registrar-General for England and Scotland.

The following are the proportions of deaths from albumifrom renal nuria or kidney disease to the total number of deaths from

disease

in United specified causes in Great Britain, in the year 1863 :—

Kingdom, from

registrars'

reports.