NOTES, QUERIES, AND REPLIES.

He that questioneth much shall learn much.-Bacon.
"GASTROSTOMY AMD DUODENOSTOMY."

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-I was "ignorant of the fact that the word 'gastrostomy' is applied to an operation which provides an artificial mouth to the stomach;" but, used in that sense, I think the word as ill-formed and barbarous as if it were intended to mean something else. May 21. I am, &c., J. D. Deleterious Toys, France.-It is officially announced that the Secretary of State for Foreign Affairs has received a note from the French Ambassador in London stating that the French Government have prohibited the importation into France of all children's toys coloured with poisonous substances.

More Trouble for the Local Government Board.-At the last meeting of the Islington Board of Guardians, a petition praying the Local Government Board not to carry out their proposal of converting the West London House of the City of London Union, at Shadwell-road, Upper Holloway, into a small-pox hospital for the reception of convalescent patients was considered. In the course of the discussion which ensued, it was urged that a more dangerous spot, surrounded by a large population, could not be selected for "an epidemic hospital." A motion that a letter be addressed to the central authority, pointing out the danger of opening the said building for the purpose proposed, 'and expressing the hope that the Board would forego their intention, was unanimously carried. Infelix.-According to the annual report of the British Home for Incurables, the financial position of the institution was not satisfactory. The expenditure had exceeded the receipts, compelling the Board to draw upon the reserve fund by the sale of £3300 Three per Cent. Consols. Reckoning this sum the receipts amounted to £12,819 0s. 6d., and the expenditure to £12,131 1s. 5d., leaving a balance in hand of £687 19s. 1d. F.R.C.S., Manchester.-There were ninety-eight candidates at the primary examination for the Fellowship of the College of Surgeons. Of this number, nineteen were members of the College, the dates of whose diplomas ranged from July, 1858, to November, 1880. Seventy-five had previously passed the primary Membership, and four had not passed any examination.

The Crèche.-The utility and advantages of these establishments is exemplified by the fact that the number of attendances of children at the East-end Crèche, founded nine years ago by Mrs. Hilton, have considerably exceeded thirty thousand. The number last year was 2048. Practical Sanitary Knowledge for Plumbers.-Sanitation has become to almost all classes of society a daily increasing subject of interest. Public lectures and sanitary associations have largely, undoubtedly, promoted this general desire for knowledge on the question. The series of lectures recently commenced, under the auspices of the National Health Society, to working plumbers, with the view, inter alia, of instructing them in the best mode of affecting sanitary improvements in houses, has aroused an eager interest, among plumbers and other artisans, as testified by their large attendance on these occasions at the Hall of the Society of Arts. To the intelligent workman they can hardly fail to be both instructive and of considerable advantage. The lecturer remarked that, as to the trade of plumbing, in nine-tenths of the workshops where young men are apprenticed, painting and glazing were the occupations that they were really engaged in, and "plumbing was only an accessory"; and that there was generally a deplorable want of knowledge of sanitary matters.

Hospital Saturday, Birmingham.-The collections of the Birmingham Hospital Saturday Fund for the following years were-1873 (first year), £4215; 1874, £3850; 1875, £3606; 1876, £3484; 1877, £3069; 1878, £2994; 1879, £3330; 1880, £3666. The ninth collection was made on the 14th inst. The sum received on that day was £2947 13s. 9d., but other amounts were coming in.

Population and Mortality in "London within the Walls."-In the beginning of the last century the population of London within the walls was not much less than 140,000, as proved by deduction from the parish registers, and the annual mortality was as one to twenty of that population. In the year 1750, the population had decreased to 87,000; and, fortunately for the health of the citizens, space continues to become more and more valuable for counting-houses and warehouses rather than for human habitations, so that the population of the City within the walls became 78,000 in the year 1801.

An Incredible Excess of Zeal.-At the last meeting of the Bridgwater Guardians a complaint was brought before the Board by the Chairman that a child had been vaccinated by one of the medical officers of the Union in no less than twenty-five places, and that its arm in consequence had become "a mass of sores." Two of the Guardians stated that they had seen the child, and each of them counted twenty-three marks, and the child had evidently suffered a good deal. It was unaniznously resolved to request the attendance of the medical officer at their next meeting, and that Mr. Courtenay, of the Local Government Board, be invited to attend the inquiry.

Forewarned.-The Toxteth (Liverpool) Guardians, remembering that after the last two small-pox epidemics in the metropolis, the disease made its way to Liverpool, and noting that it has made its appearance at Warrington, have determined to take necessary precautions, and ordered a poster and handbills to be distributed, warning the inhabitants of a possible outbreak of the disease, and strongly urging the importance of vaccination and revaccination.

Hospital Out-patients.-Dr. Andrew Clark, speaking at a meeting held at the Mansion-house last week, in aid of the funds of the East London Hospital for Children and Dispensary for Women, at Shadwell, referred to his experience of the practical importance of the outdoor department of hospitals, and said he knew that in many parts there was now a crusade going on against out-patients generally, but, in his opinion, that was one of the saddest crusades ever undertaken. Inferior Building Materials.-At the instance of the Finchley Local Board of Health, a builder of Hornsey has been charged at the Highgate Petty Sessions, upon seven summonses, with offending against the bylaws of that Board by using inferior mortar and bad timber in the construction of eighteen houses built by him at Finchley. Fines were inflicted, amounting altogether to £26 1s., which, with the costs, made a total of £40 03. 2d.

COMMUNICATIONS have been received from

Mr. JAMES DIXON, Dorking; Mr. SAXON SNELL, London; Mr. A. B. Joy, London; Mr. E. W. WALLIS, London; THE SECRETARY OF THE OBSTETRICAL SOCIETY, London; THE SECRETARY OF ST. MARY'S HOSPITAL SCHOOL, London; THE REGISTRAR OF APOTHECARIES' HALL, London; Dr. F. R. HOGG, Netley; Lieut.-Col. BOLTON, London: Messrs. WILLIAMS, London; Miss DE LISLE ALLEN, London; THE SECRETARY OF THE LONDON FEVER HOSPITAL; Mr. HENRY MORRIS, London; Mr. J. CHATTO, London; Mr. GEORGE BROWN, London; Dr. SEATOS, Nottingham; Mr. CHARLES MERCIER, London; Dr. HERMAN, London; Dr. J. W. MOORE, Dublin; THE HONORARY SECRETARY OF THE BRITISH MEDICAL TEMPERANCE ASSOCIATION, Enfield; THE HONORARY SECRETARIES OF THE EPIDEMIOLOGICAL SOCIETY OF LONDON; Mr. THOMAS GRANT, Maidstone; THE SECRETARY OF THE ROYAL INSTITUTION; THE REGISTRAR GENERAL, Edinburgh; Mr. N. I. KABATH, London; THE SECRETARY OF THE SOCIETY FOR RELIEF OF WIDOWS AND ORPHANS, London; THE HONORARY SECRETARY OF THE SUNDAY SOCIETY, London; THE SECRETARY OF THE INTERNATIONAL MEDICAL AND SANITARY EXHIBITION, London; THE SECRETARY OF THE NATIONAL PROVIDENT INSTTUTION, London; Dr. BARNES, London.

BOOKS, ETC., RECEIVED

Supplement to Ziemssen's Cyclopædia of the Practice of Medicine-Wood's Household Practice of Medicine, Hygiene, and Surgery, vols. i. and ii.The Sanitary Chronicles of the Parish of St. Marylebone, during April, 1881-China Imperial Maritime Customs Medical Reports for the Halfyear ended September 30, 1880-Autobiography of Dr. Gheist-The Induction Current in Parturient Uterine Atony, by William R. D. Blackwood, M.D.-Die Wirkungen der Quebrachodroguen, von Dr. Franz Penzoldt-On the Localisation of Diseases in the Spinal Cord, by Edward C. Seguin, M.D.-The Cultivation of Specialties in Medicine, by E. C. Seguin, M.D.-Lehrbuch der Physikalischen Heilmethoden, von Dr. M. J. Rossbach-Rational Sunday Observance, by Rev. James Freeman Clarke, D.D.-Report on the Health of Bradford for the Year 1880.

PERIODICALS AND NEWSPAPERS RECEIVEDLancet-British Medical Journal-Medical Press and Circular-Berliner Klinische Wochenschrift-Centralblatt für Chirurgie-Gazette des Hopitaux-Gazette Médicale-Le Progrès Médical-Bulletin de l'Académie de Médecine-Pharmaceutical Journal-Wiener Medizinische Wochenschrift-Centralblatt für die Medizinischen WissenschaftenRevue Médicale-Gazette Hebdomadaire-National Board of Health Bulletin, Washington -Nature-Occasional Notes-Deutsche MedicinalZeitung-Louisville Medical News-The American-Revista de Medicina -Revue d'Hygiène-The Scientific Roll-Students' Journal and Hospital Gazette-Philadelphia Medical Times-Detroit Lancet-Monthly Index.

Medical Times and Gazette.

ORIGINAL LECTURES.

LECTURES ON OPHTHALMOLOGY.

By J. R. WOLFE, M.D., F.R.C.S.E., Lecturer on Ophthalmic Medicine and Surgery in Anderson's College; Surgeon to the Glasgow Ophthalmic Institution.

LECTURE VI.

FORMATION OF ARTIFICIAL PUPIL. THIS operation has for its object the opening of a passage through the iris for the rays of light, when the natural passage is closed or occluded by some pathological condition. It was first performed by Cheselden in 1728, and for a long period was considered a dangerous operation, which ought to be resorted to only in desperate emergencies. Thanks, however, to improved methods, it is now frequently performed without risk or danger; and, indeed, it is one of the safest operations, and yields very satisfactory results.

You must bear in mind that ophthalmic surgery means nicety and precision; and this operation, if properly performed, may even be practised on outdoor patients..

We form an artificial pupil in the following circumstances: 1. In central opacity of the cornea, when so extensive as to obstruct vision and annoy the patient when facing the light. In this case we make the pupil opposite the transparent portion of the cornea.

2. In zonular cataract-i.e., when there is a transparent zone at the margin of the lens; and hence we direct the pupil so as to face the transparent portion of the lens. (See Zonular Cataract.)

3. When the natural pupil has been closed by adhesion to the lens capsule (posterior synechia), either simply or when it has been occluded by a false membrane.

4. When the iris is adherent to Descemet's membrane (anterior synechia); but more particularly when there is a leucoma adherens. In these latter cases an artificial pupil may become necessary not only for optical effect for the restoration of sight,-but to prevent the injurious consequences resulting from dragging of the iris, which is involved in the cicatrix, as this might induce choroidal and other structural changes.

5. Although I stated that, in cases of iritis, the iris should not be touched until the inflammatory process has long passed away, it is necessary to bear in mind that the contrary ought to be the rule in cases of hernia iridis. Whenover the cornea is perforated, and the iris protruding from pressure forwards by the aqueous humour, neither pricking nor cutting of the hernia will do any good, while the formation of an artificial pupil will act instantaneously, as it releases the constriction, and thus allows the hernia to recede, and the cornea to granulate over it gradually.

The operation being a safe one, we ought to practise it even when the other eye is quite healthy, for it is always a prudent thing to provide for emergencies, and two eyes are better than one, although the one may not be quite so perfect as that which is normal. On the other hand, when the patient has only one serviceable eye, in which the pupil is contracted, although vision be imperfect, it should by no means be touched, as interference in such a case might injure the little sight which the person has. I have met with some sad cases of blindness where a young practitioner had endeavoured to mend the sight of the only eye which the patient had to rely upon. It should not be performed in recent cases of occlusion caused by iritis. We must rather wait for some months, until every vestige of inflammation has passed off, for otherwise dormant mischief may be awakened, and destroy any subsequent chance of restoration of sight. In cases of occlusion from syphilitic iritis you should wait for more than a year, during which time mercury alternated with potassium iodide should be regularly administered, and you should make sure that no trace of the virus remains in the system. During all this time there must be no trace of eye inflammation-neither conjunctivitis nor hyperemia of the conjunctiva,-the condition being perfect health of all the ocular tissues.

VOL. I. 1881. No. 1614.

We operate for artificial pupil at all ages-either in cases of old people, or of children two years of age who have anterior adhesion resulting from infantile ophthalmia; and it is most interesting to notice the change of physiognomy of infants after sight has been restored. In these cases it is necessary not to wait long, because the children will contract the habit of rolling or oscillating the eyeball; and the deep structures will by-and-by become involved in the disease. This applies with particular emphasis to cases of anterior adhesion at all ages, because the dragging of the iris is apt to tell upon the choroid and the other deep tissues, and abolish vision.

We must ascertain beforehand whether tension be normal, for a soft eye implies choroiditis, and perhaps detachment of the retina; while the existence of retinal disease can be pretty nearly ascertained in adults, although not in infants. It is of importance also to know whether the lens be opaque, for, if that be the case, the pupil must be made in such a direction as to facilitate the extraction of the cataract.

Operation.-In cases of central opacity or zonular cataract, when the iris is free from adhesions, we operate in the following manner (Fig. 9):-The eyelids being kept open FIG. 9.

by a speculum, and the eyeball fixed with forceps, the narrow curved lance is passed into the anterior chamber through the conjunctiva, half or one line from the corneoscleral junction, at the inner and lower segment, and is slowly withdrawn, pressure being made at the same time at the scleral lip of the wound, in order to cause the iris to protrude. If the iris advance and follow the course of the withdrawn lance, it is seized with small iris-forceps (Fig. 10) at the pupillary border, and a vertical cut is FIG. 10.

made into it without touching the ciliary margin; then with two other cuts the iris is trimmed round, and the rest is returned to float in the aqueous humour. If, however, the iris do not follow the lance, Tyrrell's hook is introduced flatly into the anterior chamber until it reaches the pupillary border, which is caught and withdrawn, and then seized with the iris-forceps and cut round. Care must be taken in withdrawing the hook to turn the point in such a way as not to catch at the lip of the wound. It may even be necessary to enlarge the conjunctival wound with scissors in order to give free exit to the hook. In this manner we are able to imitate the appearance of the natural pupil; and it is important not to make the pupil too large, as in that case you may do positive harm, for the patient can see better through a leucoma, when the natural pupil is dilated, than with a large coloboma iridis cut at random.

Place of Selection.-The best place for the formation of artificial pupil is downwards and inwards, so that the rays of light may fall upon the macula; somewhat less advantageous is straight inwards; while the third in point of choice is straight downwards; and the next, upwards and inwards. Fig. 11 represents artificial pupil in the left eye in the

order (a, b, c, d, e) in point of selection. A pupil directed outwards when the other eye is good is hardly of any use for practical purposes. I may also remark that a pupil directed straight upwards, when there is a central opacity of the cornea and the eyelid does not rise beyond the opaque spot, can be of little use. Mr. Carter resorted, in such a case, to the section of the superior rectus muscle, so as to cause the globe to protrude more (slight exophthalmos), in order to utilise the operation. I have in a similar case lifted the eyelid, which can be practised to a considerable extent by removing a skin flap without inconvenience to the patient.

FIG. 11.

To avoid the inconvenience of a large pupil, Mr. Critchett introduced the operation of iridesis-tying a small portion of the iris,-which answers well; but, unfortunately, it was found that this is apt to give rise to anterior synechia and all its injurious consequences. You must also take care, in cases of corneal opacity, to examine the cornea carefully by focal illumination, and see how far the opacity extends, for with the naked eye we are apt to be deceived on that point, as, in opaque cornea, the portion lying on a black ground (the pupil) is more readily seen to be opaque than that part which is opposite the iris; and, therefore, unless this source of error be eliminated, we may find, after the iris-section, that the corneal opacity is more extensive than you took it to be, and the result is disappointing; whereas this should rarely or never occur when the eyes are carefully examined, and the work properly executed.

In cases of posterior adhesion, or when the pupil is occluded by a false membrane, the broader lance is used (Fig. 12), and the iris drawn out gradually by means of the

FIG. 12.

THE HYPERTROPHY OF THE HEART IN BRIGHT'S DISEASE. BAMBERGER'S statistics show that hypertrophy of the heart was encountered by him in 344 out of 807 cases of primary Bright's disease, or in 42.6 per cent. He does not tell us that he excluded amyloid cases from the category; and, from his figures alone and our own experience, we should infer that the proportional occurrence of this complication would have appeared higher if he had done so.

The special form of the hypertrophy, and its incidence and relative occurrence in different stages or forms of the disease, are shown by the following table:

forceps, and rounded off if possible; but you will very likely find the iris atrophied, and then you cannot shape it at will.

When the presence of an opaque lens is suspected, the puncture should be made with a broader lance in the lower or upper vertical meridian; and the coloboma must, in these cases, be made rather larger, because, when a false membrane and an opaque lens are present, the chances are that a small pupil will contract. In cases of staphyloma or "hernia iridis," it is best to make the pupil exactly in the diameter opposite the hernia; but, if that would not answer optical purposes, these must have the primary consideration, for an iris-section in any place answers therapeutical purposes.

Iridotomy.-De Wecker introduced another operation for artificial pupil, consisting in puncturing the cornea and then making a simple slit in the iris by means of scissors devised by him for this purpose.

This operation may be useful in cases of spontaneous dislocation of the lens, otherwise I think it rather hazardous to work with scissors in the anterior chamber.

PERIODICALS PUBLISHED IN PARIS.-According to M. Daffis' catalogue of journals appearing at Paris, these, daily, weekly, etc., amount to 1264. Of this large number 71 are religious, 115 jurisprudence, 228 political economy, finance, and commerce, 23 geography and history, 127 recreative reading, 31 instruction, 65 literature, philology, and bibliography, 14 the fine arts, 4 photography, 10 architecture, 6 archæology, 16 musical, 19 theatrical, 74 fashions (four of these relating to hair-dressing), 119 technology (the various industries), 110 medicine and pharmacy, 40 science, 25 military and naval, 28 agriculture, 22 hippic sciences, and 22 miscellaneous. The number of daily political journals is 67, that of political reviews 28. Of all the journals, the political, financial, and medical are the only ones on the increase, their number having augmented by one-half in a year.-Union Méd., May 24.

It will be perceived that, in 41 per cent. of the entire cases of excentric hypertrophy, both sides of the heart were affected; but Bamberger informs us that in 48 out of these 142-one-third, that is, of the cases-notable emphysema of the lungs existed to help to explain it. Excentric hypertrophy of the left ventricle alone befell 31 per cent. of all the cases. Why both sides of the heart should undergo muscular hypertrophy, when it is pleaded that the left ventricle only has an extra task to fulfil, is not at first very apparent. Pulmonary obstacle doubtless is the chief explanation of hypertrophy of the right heart; and emphysema and bronchitis and pleuritic mischief are the commonest incidents to the history of Bright's disease. More than this, however, may be said upon the subject. My own experience teaches me that the cases in which the renal disease has lasted longest, and has been longest maintained at a period of standstill at comparative health, are those in which both sides of the heart have been most hypertrophied; and I am, therefore, inclined to explain the occurrence upon gradual establishment of the hyper-nutritive changes in the heart's structure, which would affect both sets of chambers pretty uniformly. The theories which have been broached to explain this hypertrophy offer no inconsiderable interest. Dr. Bright's Theory.-The altered state of the blood (he means its impurification, not its hydræmia) exerts an unwonted stimulus upon the muscle of the heart; and it also offers an obstacle to the easy transit of the blood through the smaller blood vessels, and therefore compels greater exertion upon the left ventricle to effect its circulation. Nothing, apparently, could be clearer than this explanation but it fails to grapple with many of the facts of which later observations upon the disease have informed us.

This hypertrophy of the heart, as Bright correctly noticed, especially occurred with the contracted and indurated kidney. Later observations have proved that, in this particular form, excess of water passes through the system; and the task of urinary depuration is effected in a method different to that which obtains in healthy bodies; the kidneys requiring flushing through with much more than normal water, to enable them to carry off the requisite solids and

effete materials. Still they do so; for the blood is maintained pure as in health. So long as the heart works well, what remains of the kidney fulfils the whole task; and not merely is there no diminution of the excretion of urea per diem according to the individual's mean average allowance, estimated by weight and nutriment, but what occurs is that actually sometimes the excretion is in excess of what is normal. Dr. Grainger Stewart, at page 218 of his work, in his chapter on Atrophic Kidney, relates such a case. "The amount of urea excreted," he writes, "was nearly as high as the maximum of the tables given by Dr. Parkes." The same fact is well brought out by Bartels's observations; so that, when no maintained impurity of the blood can be assumed to have existed, to have stimulated the heart or obstructed the passage of the blood through the vessels, the greatest amount of hypertrophy is found to exist. Further, against the theory of impurity of the blood, which must be vouchsafed to exist in other forms of Bright's disease indisputably associated with an impure blood, stands the fact that, in many other acute and chronic diseases besides Bright's disease, the blood is very impure, or maintained abnormal, and yet these do not bring about hypertrophy of the heart.

Traube's Theory.-Traube offered a double explanation. First, he attributed the hypertrophy to obstruction of the peripheral circulation at one spot-the kidneys themselves -and to excess of water in the blood. He urges the impermeability and destruction of so many bloodvessels as takes place in renal disease as the obstacle offered to the bloodpassage; and that, like the shutting of a sluice-gate upon a stream, this obstruction must lead to increased pressure upon the channels and banks above it, and especially to the accumulation of excess of water in the blood, since this cannot run off. According to him the order of events runs thus obstructed circulation, increased arterial tension, supplemented or not by abnormal hydræmia, lead to dilatation and hypertrophy of the heart. He places, as Bartels writes ("Ziemssen," vol. xv., p. 463), "the consequences of renal contraction in the same category with the results which valvular deficiency of the mitral valve and certain diseases of the lung indisputably exert upon the right chamber of the heart."

We cannot enter at this time and in this place into the relative merits of the objectors, upon one score or another, to Traube's theory. It has received and deserved ample discussion at the hands of Bamberger and von Buhl most recently, and by Campana, Erichsen, Ewald, Gull and Sutton, Lebert, Rosenstein, Schrötter, and Senator in the last few years.

The matter is summed up by Bamberger (loc. cit., page 1554) with great justice. He writes that in its totality it is untenable on three grounds:-1. This hypertrophy by no means accompanies the kidney which presents greatest destruction of its vascular channels, to the exclusion of all other forms of Bright's disease. 2. It occurs when there can be no question of any obstacle to the amount of the circulation through the kidney; for injection-fluids pass readily enough, as in the small contracted kidney they undoubtedly do. 3. Mere obstruction to the passage of the blood will not suffice to explain it, either, situated at the Malpighian tufts, because this is quickly remedied by collateral blooddirection in the kidney itself through the arteriola rectæ ; or placed anywhere else in the body by tying an artery, because of the ample room offered to collateral blood-flux. Cutting off a limb, which is surely suppression of a large vascular area, will not produce it; and, as Rosenstein showed, a dog, one of whose kidneys was removed, presented, many months afterwards, no hypertrophy of the heart. 4. Traube's theory, if it throw any light upon the hypertrophy of the left heart, throws none upon the hypertrophy of the right heart that frequently accompanies it.

Dr. G. Johnson's Theory, in his early writings, was very much the same as Bright's-impurity of the blood; but later on he referred the hypertrophy of the heart to the alterations that were brought about throughout the arterioles generally; their stopcock action stimulated by the noxious fluid in the blood; their hypertrophy; and the greater and greater resistance which they come to offer to the passage of the blood. (Med.-Chir. Trans., vol. li., 1858, page 60.) According to him, a noxious quality of blood is so disagreeable to the capillaries, that they, through the nervous system, urge the arterioles to forbid its passage. Incapable of saying "No"

themselves to it, they bid the regulators of the blood-supply -the arterioles-resist it; and this resistance stirs or works up the left ventricle to pump with redoubled vigour. Let us, however, quote Dr. Johnson's own words. At page 61 he writes: "In proportion to the destruction of the renal gland-cells, and the consequent diminution of the secretory power of the kidney, there is less demand for blood to be acted upon by the gland; the small arteries consequently contract upon their contents so as to maintain the balance between the blood-supply and the diminished secretory action of the kidney. This continued over-action of the small arteries in antagonism to the heart results in hypertrophy of their muscular walls." Again, page 65: "Action and reaction are equal; force must be met by an equivalent amount of force; and we shall probably find that the greater the hypertrophy of the left ventricle of the heart, the greater and the more general is the hypertrophy of the arterial walls in various tissues and organs throughout the body." At page 62 he states: " Although the muscular walls of the arteries are hypertrophied in the advanced stages of all forms of Bright's disease, the purest specimens of hypertrophy are found in the small granular kidneys." And here, as he truly remarks, there is least impediment to the circulation through the kidney itself.

His theory, then, places the cause of the hypertrophy of the heart in the hypertrophy and resistance offered by the general systemic arteries, not by those of the kidney alone. But, as may be seen by reference to what we have already quoted in discussing the hypertrophy of the coats of the arterioles, Dr. Johnson had already constituted the hypertrophy of the heart the cause of the hypertrophy of the arterioles. But surely it is more likely, or at least as likely, that the hypertrophy of the heart is provoked by increase of blood-tension independently of spasm of the arterioles ; and that the alteration in these small arteries is, as it obviously is in aortic regurgitant disease, secondary to the hypertrophy of the heart; and, as Bamberger justly objects, it fails to throw any light on the hypertrophy of the right heart.

Von Buhl's theory ("Mittheilungen aus der Path. Institut in München," 1878) is that the affection of the heart is due to an inflammatory process taking place in the heart, and stimulating it to over-action. He thinks that the granular kidney and the hypertrophy of the heart occur coincidently, but wholly independently of each other, and own some common source of origin, and that this is some subacute widespread inflammatory action. He found evidence of such past inflammatory changes in the endocardium or the valves, in the heart's muscular substance, and in the pericardium, in 65.7 per cent. of all cases of granular atrophy of the kidney. He also found relative constriction of the aorta, or an abnormal ratio between the circumference of the aorta and the length of the left ventricle, which he regarded an accessory stimulator of the hypertrophy of the heart. But then he leaves wholly unexplained a great many cases of hypertrophy of the heart, in which he can find no traces of past inflammatory action, and refers them to fatty degeneration.

Sir W. W. Gull and Dr. Sutton's theory refers the hypertrophy of the heart to a change in the bloodvessels of the heart itself, similar to that which they observed and described as happening in various parts of the body, their arteriocapillary fibrosis; a change which, occurring in the kidney, led to granular atrophy; in the dura mater, brain, and spinal cord, to various manifestations of sclerosis. Their publication appeared before that of Von Buhl, and perhaps suggested in some measure the lines of his inquiries and the opinions at which he arrived. It certainly serves to explain the occasional hypertrophy of both sides of the heart, and many of the widespread pathological lesions, bronchitic, pneumonic, hepatic, and cerebro-spinal symptoms and complications sometimes manifested. Further, that a widespread increase of nuclear interstitial tissue in the capillary meshwork is one of the most manifest pathological changes that occur in chronic Bright's disease, and especially in the very chronic forms of atrophied kidney, we can entirely confirm by our own experience, and prove by abundant microscopical specimens in our possession. But, at the same time, we are bound to state our conviction that the muscular hypertrophy of the arterioles is an equally well-established fact, which Gull and Sutton cannot be supposed to have either overlooked or denied, and is a matter wholly independent of the

thickening of the capillaries and of the external tunic of the artery, which it usually, but not invariably, attends. Why it was not more prominently alluded to by them we cannot tell. But we have seen marked thickening of the capillary walls in the kidney when little or no noticeable hypertrophy of the muscular coat of the arterioles existed in chronic renal disease, and believe it, therefore, to be the most important factor in the production of the increased bloodpressure and hypertrophy of the heart; in saying which it must be observed that we hold Ewald's views, and had done so for some time, quite independently of having read them. Ewald thus propounds his opinion in Virchow's Archiv, Band lxxi., page 453-1. In point of events (and in causation), he believes in the existence of the kidney-affection; 2. The blood-deterioration ensues; 3. The altered blood, he says, offers an obstacle to the capillary circulation everywhere. And we may digress for a moment to dilate upon the nature of this obstacle more than Ewald does. The impure blood fails to favour the circulation, as purer blood would and does; the nutritional changes, which doubtless are in health a blood-moving force, take place less easily and less perfectly when the capillaries are thickened and their walls hypertrophied from chronic inflammation, first in the kidney itself, later on, however, through the capillaries in various parts of the body in which the current would run sluggishly-because the blood is impure-if it were not driven onwards by greater pressure à tergo by the heart; and still, as life is prolonged, the capillaries wide and far suffer in their nutrition, and thicken interstitially as the blood becomes more impure (just as they do in any passive hyperæmia), until, as Ewald continues, the 4th stage is reached, when the general arterial tension is increased, and maintained, 5, by a compensative hypertrophy of the left heart; next, and 6, he says the right heart becomes hypertrophied; and, 7, the arterioles generally; all in the same endeavour striving to push the blood forwards through the capillaries.

Without feeling so sure as he is upon the later events, which are of minor importance so long as the great primary ones are placed rightly, we may pause to dwell a moment here to insist upon what Bartels and Cohnheim have ably advocated-the truly compensative, not degenerative, nature of the hypertrophy of the heart and muscular wall of the artery. The best evidence of this is to be derived from observation: first, of the pulse when its tension is best marked, when, as Galabin describes it by a sphygmographic tracing, the pulse-wave is bold, and high-peaked, and square-topped, like a heavy Atlantic swell after a storm, an event which takes place before the walls of the artery are much hypertrophied. This secondary hypertrophy of the arterial walls has corresponded, in our experience, with the surely sooner or later commencing cardiac degeneration. This stage of increased blood-tension is that during which the heart is vigorous, and when, in the granular atrophy, the patient passes excess of urinary water, and urea enough for ordinary purposes, with albumen in small quantity occasionally, and always most after over-exertion. In cases of chronic hæmorrhagic nephritis, we find the same hypertrophy, and a pulse of high tension, but not so high; here, too, the albumen varies in amount with the blood-pressure, and is less, just as the urine is more copious, when this is maintained high.

Ewald found that in every case of interstitial nephritis (kidney cirrhosis), the arteries were hypertrophied as well as the heart; that, in the mixed forms of kidney diseaseinterstitial and parenchymatous (or, as we should prefer to call them, more chronic forms of hæmorrhagic nephritis, mottled kidneys becoming granular, etc.),-two-thirds of the cases presented hypertrophy of the heart and of the walls of the vessels, while one-third presented hypertrophy of the heart only; whereas, in the pure parenchymatous cases, i.e., the most acute forms of nephritis (those with smallest discharge of urine and greatest dropsy, and shortest course), the heart was only found hypertrophied to the extent of about 33 per cent., and the arterioles were not affected at all.

Bamberger's theory is that an increased quantity of blood or heavier column of fluid in the systemic circulation, caused by a perpetually maintained excess of water in the blood, and itself due to the kidney-disease, is the source of increased blood-pressure. This increased blood-pressure must have one of three results-dropsy, dilatation of the heart, or

hypertrophy. The argument stands thus: normally, as after drinking, the passage of excess of water into the blood raises the blood-tension in the systemic vessels; when, presto! open fly the flood-gates of the kidneys, and out flows the excess of water; but if its passage outwards be partially obstructed, the pressure must tell backwards everywhere upon the systemic capillaries, and will show itself earliest and most of all by anasarca in those parts where the capillaries are least supported by muscular fibres and the connective tissue is loosest; such local anasarea temporarily relieves the circulatory channels.

Now, if the individual be in a state of bad or impaired general nutrition, or of lax fibre, or the subject of other tissue-wasting disease, like phthisis, the heart and bloodchannels yield to the increased pressure forced upon them, and dilate; whereas, if the subject be otherwise vigorous, and his digestion well maintained, and the increased strain not too suddenly forced upon his vascular system, hypertrophy of the muscular walls of the heart and of the arterioles follows. Next, a circulus vitiosus is reached by habit; the heart and blood vessels have had their channels enlarged; they hold more than was their wont; neither can they ever go back again to normal dimensions. The water-balance in the system is conformed to a different standard, in which the blood always presents a larger than normal water-content. Thirst is habitual; there are an abnormal absorption, an abnormal maintenance, and an abnormal excretion of water. Increased pressure in the arterial, and increased quantity of fluid in the general circulatory channels, soon show themselves, however, in the veins also by dilatation of these; and at length by dilate tion and hypertrophy of the right side of the heart as well as of the left.

As we have already said, simple dilatation of the heart only can ensue in the presence of bad general nutrition, or of local difficulties in the condition of the heart itself, such as degeneration of its coronary arteries, damaged valves, adherent pericardium. But, apart from these and an amyloid state of the blood vessels, which facilitates, as Bartels says, anasarca, and so obviates blood-pressure, the natural consequence of an increase in the blood-mass is for the channels to dilate, and the heart to hypertrophy and dilate, exhibiting excentric or simple hypertrophy.

Now, in granular contracting kindey, as Virchow and Thoma have more recently shown, certain remarkable alterations in the circulation through the kidney itself take place in the course and progress of the disease; and I may quote myself, for the fact is one I stated years ago, in 1865. First, as the blood's passage through so many Malpighian tufts is impeded by their wasting and gradual extinction, the topmost cortical layers become less vascular, the vasa ascendentia dwindle at their tops, and the direct branches to the arteriolæ rectæ enlarge, by collateral blood-flux; and further, in many instances, especially in those larger Malpighian bodies, those placed nearest to the vasa recta, the vas afferens, can be seen passing straight on into the vas efferens, without capillarising in the glomerule at all, and the circumtubular networks here become dilated and highly blood-filled. This is the stage in which the heart is highly hypertrophie 1, and is a well-nourished muscle, with no trace of degeneration attaching to it; when the kidney is red and highly vascular, the blood-passage through it is short, the blood-current swift; and when the secretion of urine is very little abnormal, except in quantity, which is notably increased, and in specific gravity, which is preternaturally low. This is the stage of thirst and polyuria.

But, later on, the blood-mass sinks again, the kidneys' power of excretion gains upon the body's faculty of absorbing, or the blood's power of maintaining, so much water; then, as the blood-pressure subsides, the dilating cause disappears, the dilatation of the heart's cavities diminishes, but the hypertrophy does not stand still, it only becomes more concentric.

Then, if we follow the life-history of the case of granular kidney further, we find that the impurity of the blood increases as the discharge of urine diminishes, the capillary obstacle due to impeded nutritional peripheral interchanges increases, the friction is greater, and the heart has a harder and harder burden cast upon it, while its own nutrition is inadequately provided for; it degenerates, becomes unequal to drive the blood on, and the end comes quickly, by uremic symptoms, or lung-œedema, or apoplexy.