viously to his admission." Dr. B. observes that there was no evidence whatever of organic disease in the liver, anterior to the patient's reception into the hospital-and that it is not at all improbable, that "the greater part of the mischief done to the substance of the left lung, had taken place between the 20th October, when he suffered the severe inflammatory attack, and the 29th November when he died." The serous effusion was, no doubt, a recent affection.

We are aware that Dr. Bright has the authority of Laennec for the sudden formation of hepatization in the lungs-even the grey hepatization, which is the third degree of that disease. With all due deference to M. Laennec, we conceive that, on this point, he may be mistaken. But, granting that hepatization of the lung may take place, say in ten or twenty days, from peripneumony, every pathologist knows that this same hepatization may continue for months or years, without affecting life. And, when we contemplate the state of the above patient when he first came into the hospital, we can have little doubt that hepatization of the lung existed there, and for a very long time before. It is not, therefore, very easy to say, with certainty, that the disorganization of the kidney preceded the hepatization of the lung--and it is still more problematical, that the kidney affection was the cause of the dropsical effusion in the chest. There can be no doubt, however, that the thoracic effusion, especially the inflammation and affection about the heart, was the immediate cause of the fatal termination.

Case 2. Eliz. Beaver, aged 37, was admitted on the 23d Nov. 1825, with swelling and fluctuation of the abdomen, attended, also, with tympanitis. The lower extremities, and the parietes of the abdomen were oedematous, with erythema about the ankles. Her face and arms had also swelled occasionally. Severe cough was excited by a deep inspiration, causing, also, some abdominal pain. Her breathing was short--inability to lie horizontally-bad sleep-pulse 112-tongue furred in the middle, and clean at the sides--bowels relaxed-urine clear, but uncertain in quantity. She had been ill about six months, her illness commencing with pain in the chest and increase of cough, to which last she had been subject for four or five years. The catamenia had stopped five months previously. On account of the diarrhea, confectio opii, and hyd. cum cretâ, were ordered thrice a day, with some other cordial medicines. 24th. Much the same. On the 25th, the urine was examined, and found to coagulate by heat. It was scanty in quantity. She gradually got weaker, and died on the 29th of the same month.

Dissection. There was some effusion into both sides of the chest

body generally anasarcous-lungs tolerably healthy-heart small in size, and feeble in texture, the parietes of the right ventricle being in a state of atrophy-an ounce and a half of water in the pericardium. There was much straw-coloured fluid in the abdomen. The liver, externally, appeared granulated, but this appearance was very much confined to the surface. The kidneys were both of unusual size, and, on external view, they were obviously granulated with yellow matters. The whole of the cortical structure appeared converted into a yellow substance, resembling fat. nothing else particular in the dissection.

There was

Remarks. Dr. B. thinks we may attribute the dropsy with coagulable urine, in this case, to the disorganization in the kidneys. He seems to doubt whether the state of the heart and liver had any thing to do with the dropsical effusions. There will be some who may doubt this exclusive blame on the kidneys.

In the following cases we shall be more brief in our analysis.

Case 3. A female, aged 25, of previous intemperate habits, was admitted Nov. 8th, with anasarcous swelling of the legs, diarrhoea, cough, dyspnoea, bloated and livid face. The urine was found to coagulate very considerably by heat. She died on the 12th of January following, after an unsuccessful exhibition of various remedies.

Dissection. Nearly two pints of turbid serum, in the left side of the chest--lung of that side oedematous and rather fleshy at the summit, with some incipient tuberculation. In the right side, there was, also, considerable effusion, and the lung was very much condensed, so that but a small portion admitted air. A thick adventitious membrane surrounded the greater part of it, and it was firmly glued to the pleura. The apex of the right lung was completely tuberculated, with some excavations. The liver was pale, yellowish, rather firm, and inclined to granulation. Ulcerations near the valve of the colon, in the ileum. The kidneys were entirely disorganized. The whole of the cortical substance was of a uniform yellow colour. This state of kidney is beautifully delineated in the second plate.

Case 4. A bricklayer, not of intemperate habits, was admitted on the 22d November. Two months previously, having heated himself much in working, he drank cold beer and lay down on the damp grass. His legs began to swell in a day or two afterwards. At the time of admission, he was generally anasarcous, and his legs were greatly swollen, with symptoms of effusion into the cavities. His breathing was much oppressed. Squill pill and mercury, with some other diuretics, were given, with temporary improvement only. His urine was scanty, and coagulated by heat. On the 12th December, a diarrhoea, with VOL. VIII. No. 15.

14

erysipelas of one leg, came on, and he died on the 16th of the same month.

Dissection. Three pints of clear yellow serum in the right side of the chest-lung on that side slightly puckered and hardened at the apex. In the left side, there was about a pint and a half of serum-left lung healthy. In the right lobe of the liver there was a small collection of tubercular bodies, and a similar collection in the small lobe. The whole substance of the liver was nearly in a healthy state-a little inclined to be granulated." The cortical structure of the kidneys, exhibited the commencement of granulation. They were rather large and soft-general colour pale, and, on stripping off their tunic, the whole surface was seen speckled with minute yellow bodies, which bodies were found pervading the whole cortical substance. These kidneys are delineated in plate the third.

Dr. Bright anticipated this state of kidney before death, and committed the diagnosis to writing.

Case 5. A stout looking sailor, aged 34, was admitted on the 29th November. Denied having been intemperate, only taking a good deal of spirits and water. Three years previously, he caught a bad cold, and has never been well since. Five months ago, he began to swell, and his legs and thighs are now decidedly oedematous. The urine is scanty, and coagulates into a complete gelatinous mass by heat. Mercury and squills were given, and the urine increased, becoming less coagulable. On the 22d December, dysenteric symptoms came on, and lasted a few days. On the 12th February, we find the urine very scanty, and strongly coagulable. He was evidently declining fast; and now, for the first time, it is stated that "his cough is more troublesome, the expectoration puriform, and for some days, there have been symptoms of inflammatory affection in the chest." He died on the 14th February.

Dissection. Edema of the lower extremities-considerable effusion into the left cavity of the chest-with flakes of coagulable lymph and other products of inflammation. The lung more firm and red than natural. Nothing wrong in the other side of the chest -heart rather flaccid-liver pale, "inclined to granulation in its appearance, but not enlarged, nor materially firmer than natural." Unequivocal evidences of peritoneal inflammation were observable, with considerable effusion. The kidneys were large-very dark on their upper surface, and mottled with yellow on their under surface. Internally, the structure had changed to a fatty substance, with some traces of granulation.

The foregoing half dozen of cases out of 25 put on record by Dr. Bright, will be sufficient specimens for this analysis: and we shall, therefore, proceed to give some account of our author's GENERAL OBSERVATIONS" appended to the narrative of facts.

From the facts which have come under Dr. B.'s notice, he thinks he is authorised to establish three varieties, if not three completely separate forms of diseased structure in the kidneys --generally attended by a decidedly albuminous character in the urine.

In the first, a state of degeneracy seems to exist, which from from its appearance might be regarded as marking little more than simple debility of the organ. In this case the kidney loses its usual firmness, becomes of a yellow mottled appearance externally; and when a section is made, nearly the same yellow colour slightly. tinged with grey is seen to pervade the whole of the cortical part, and the tubular portions are of a lighter colour than natural. The size of the kidney is not materially altered, nor is there any obvious morbid deposit to be discovered. (Plate II. Fig. 4.) This state of the organ is sometimes connected with a cachectic condition of body, attended with chronic disease, where no dropsical effusion has taken place either into the cellular membrane or into the cavities of the body; I have found it in a case of diarrhoea and phthisis, and in a case of ovarian tumour. In the former it was connected with slight and almost doubtful coagulation of the urine by heat; in the latter I had omitted to examine the state of the urine. I also met with nearly the same condition of the kidney, with some opaque yellow deposits interspersed through the structure, in the case of a man who died exhausted with diarrhoea brought on by hardships and intemperance, and in whose case the secretion of urine was very deficient, but whether coagulable or not, I had no opportunity of ascertaining. When this disease has gone to its utmost, it has appeared to terminate by producing a more decided alteration in the structure; some portions becoming consolidated, so as to admit of very partial circulation; in which state the surface has assumed a somewhat tuberculated appearance, the gentle projections of which were paler than the rest, and scarcely received any of the injection which was thrown in by the arteries. (Plate II. Fig. 1, 2, and 3.) In this more advanced stage, if it be the same disease, dropsy has existed, and the urine has been coagulable."

67.

The second form, is that in which the whole cortical part is converted into a granulated texture, and where there appears to be a copious morbid interstitial deposit of an opaque white substance. In the early stage, when the tunic is taken off, there is exhibited only an increase of the natural fine mottled appearance given by the healthy structure of the kidney. On slitting the organ longitudinally, a slight appearance of the same kind is discovered internally, and the kidney is deficient in its natural firmness. In time, the deposited matter becomes more abundant, and is seen in numerous specks of no definite form, thickly strewed on the surface. Internally, these specks are found distributed in a more or less regular manner throughout the whole cortical substance, no longer presenting a doubt

ful appearance, but manifest to the eye without any preparation. At a still more advanced period, the granulated texture begins to show itself externally, in slight uneven projections on the surface of the kidney, very apparent through the tunic. The organ is generally larger than natural, sometimes not at all increased in size.

The third form of disease is where the kidney is quite rough and scabrous to the touch externally, and is seen to rise in numerous projections not much exceeding a large pin's head, yellow, red, and purplish. The form of the kidney is often inclined to be lobulated, the feel is hard, and on making an incision the texture is found approaching to semicartilaginous firmness, giving great resistance to the knife. The tubular portions are observed to be drawn near to the surface of the kidney: it appears in short like a contraction of every part of the organ, with less interstitial deposit than in the last variety. This form of disease existed in a case from which I had a drawing executed about three years ago, it also existed in BONHAM, (p. 22.); and a most decidedly marked instance of it may be found in STEWART, (Plate III. Fig. 1 and 2,) where, however, the kidney was of a lighter colour than in the other cases, which were more of a purplish grey tinge. I believe the case of SMITH, (p. 23,) belonged to the same. In most of these cases the urine has been highly coagulable by heat, at times forming a large curdled deposit, though in one case (CASTLES) where an approach to this appearance was found on the outside of the kidney, but with marked structural change in the liver, and with confirmed bronchial congestion, only a dense bran-like deposit of a brown colour was produced by the application of heat." 69.

Although Dr. B. hazards a conjecture as to the existence of these three different forms, he is by no means confident as to the correctness of this view. So much for the descriptive part. We now come to

OBSERVATIONS ON THE TREATMENT,

It has been our author's object, in all that precedes, to prove that certain dropsical affections depend more on derangement of the kidneys themselves, than has generally been supposed-and that the particular cases in which these organs are the seat of disease, are pointed out by the albuminous nature of the urine. The author wishes he could add any thing very satisfactory as to the treatment. But he is inclined to doubt whether it be possible to effect a cure, or even afford much relief after the decided organic change has taken a firm hold on the kidney. In sudden attacks of anasarca from intemperance and exposure, in the early stage, and before organic