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INTESTINES AND SKIN IN KIDNEY DISEASE.

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The following Observation shows that the intestinal canal is also liable to be affected in disease of the kidneys.

OBSERVATION 19.-In a man, aged fifty-seven, who had died of renal disease, the duodenum had a very granular appearance, arising from an hypertrophied condition of Brunner's glands. Numerous little pits were everywhere visible, showing the enlarged openings of these bodies. In a place about the size of a sixpence the surface of the membrane was greatly congested, and here the coats were exceedingly thin and wasted. On examination with the microscope, Brunner's glands were found greatly enlarged and loaded with epithelial cells. The basement membrane of these glands was thickened; in some places so much so, that the glandular structure was in a state of atrophy. The epithelial cells were much increased in size, dark and granular. The villi were large and loaded with nuclei, and presented in many places thickening of the basement membrane.

This condition of the basement membrane and the enlargement of Brunner's glands indicate, I believe, chronic inflammation of the duodenum; and excepting in cases of cancer of the breast, I have never met with these morbid appearances so well marked as in the foregoing case.

I have only examined the skin microscopically in one case of disease of the kidneys. The patient was a man fifty-eight years of age, and had also an affection of the bladder. The stomach was very large, and contained a few clots of blood. The gastric tubes were readily separable, but were choked with granular

matter and cells of large size. The sudoriferous glands were distended with fat and cells filled with oil. Indeed, they presented appearances precisely similar to those observed in the tubes of the stomach and kidneys when these organs are in a state of fatty degeneration.

But how can we explain the frequent occurrence of gastritis in diseases of the kidney? No doubt the similarity in the morbid changes leads to the belief that the affection in both organs has a common origin. No one can examine the secreting tubes of the stomach and kidneys, in an early stage of the disorder, without being struck with the very marked similarity in their morbid alterations.

The causes of disease of the kidneys seem to be such as are equally capable of exciting inflammation in the gastric mucous membrane. Thus, of twenty-one cases of tubular nephritis, in which Dr. Dickenson investigated the origin of the complaint, eight were attributed to scarlatina, and ten to exposure to cold. We have before shown that tubular gastritis is almost invariably found in persons who have died from scarlet fever, and we also know that the application of cold to the surface of the body is a fruitful cause of the same disease.

Again, in the majority of cases of chronic Bright's disease, the malady is found to be connected either with a tubercular or gouty constitution; and in both of these conditions, structural changes are apt to take place in the mucous membrane of the stomach.

Whether, therefore, we regard the anatomical changes in the organs affected or the causes tending

THE CAUSES OF THE GASTRITIS.

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to produce them, we see reason to believe that both the disease of the kidneys and the gastritis may often have a common origin.

Still, although we may account, in many instances, for the contemporaneous occurrence of these diseases in the same individual, we can scarcely, in this way, explain all the cases that come before us. In some persons affected with Bright's disease, no morbid changes can be found in the stomach, and in others, the gastric symptoms only make their appearance when the renal affection has existed for a considerable period.

Persons suffering from renal disorders are peculiarly liable to severe attacks of local inflammation; and death is, in a great number of instances, the result of these secondary affections. Thus pleurisy is found in 60 per cent.; and more than one-fourth of the whole number are attacked by pericarditis. Every other important organ in the body is liable to be injured in a similar manner, and we cannot, therefore, be surprised that the mucous membrane of the stomach and intestines should be likewise implicated.

This tendency to inflammatory action in other organs is usually, and I think with justice, attributed to an impure condition of the blood, arising from the imperfect elimination of the effete materials by the kidneys; and to this cause also, I believe, we must charge no small amount of the gastritis that so frequently accompanies this disorder.

But may not a gradual failure in the activity of the skin be as potent in producing the more chronic

1 Dr. Dickenson, Medico-Chirurgical Transactions.

affections of the stomach and kidneys, as the sudden suspension of its action is in giving rise to the acute form of these disorders? I think this is probable; and it was on this account that I mentioned the abnormal condition of the sweat glands found in a case of diseased bladder and kidneys. It may seem absurd to assert that we know but little of the part that disorders of the skin play in the production of maladies, when so much attention has been bestowed upon them; but it must be remembered, that the various eruptions so minutely described are usually the result of over-action. The skin is employed in eliminating materials retained in the circulation in consequence of the imperfect activity of other organs; and hence the various forms of inflammation to which it is subject. The question to be solved is What are the effects produced by a gradual diminution in, or total cessation of, the excreting powers of the surface of the body? The presence of moisture on the skin is not sufficient to prove that its functions are properly performed; for in diseases of other organs the secretions are often found altered in quality, although not lessened in quantity.

As we have not yet determined the exact nature of the substances eliminated by the skin in a state of health, we cannot by chemical tests ascertain when its functions are imperfect. A microscopical examination of the sweat glands in a large number of different diseases would, however, probably afford us some trustworthy conclusions, and, perhaps, show us that many maladies take their rise from alterations in the structure of this important organ.

The phenomena presented to us by disease of the

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kidneys may, I think, be sufficiently accounted for on the principles just mentioned, without having recourse to the hypotheses, that Bright's disease arises from a special degeneration of all the tissues of the body, or that albuminuria is an effect of imperfect digestion. That imperfect digestion does set up this complaint is, I believe, beyond a doubt; but it is by the production of abnormal substances which irritate the organ by which they are excreted, and not by pouring into the circulation albumen of so low an organization, that it passes through the renal bloodvessels.1

When we bear in mind the frequency with which the mucous membrane of the stomach is inflamed in chronic disease of the kidneys, we shall readily comprehend that the majority of persons affected with this disease will exhibit symptoms of derangement of the digestive functions. In many cases the patient first seeks medical advice on account of impaired digestion, and is not aware that he is the victim of any more serious disorder. This so often happens that practitioners should make it a rule never to commence the treatment of any severe case of dyspepsia without first carefully examining the urine for albumen.

One of the most prominent symptoms of renal disease is vomiting, which frequently occurs as soon as the patient arises from his bed, or sometimes takes place only after meals. This is usually attributed to sympathy of the stomach with the kidneys, but the more probable cause is, that the organ

1 Dr. Parkes's Clinical Lectures, Medical Times and Gazette, April 22, 1854.

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