Nephrol Dial Transplant (1999) 14: 1327–1329
The Iconographic Archives of European Nephrology
United Kingdom, 19th century
Nephrology
Dialysis
Transplantation
The description of renal ‘arterio-capillary fibrosis’ by William W. Gull
Giovanni B. Fogazzi
Divisione di Nefrologia e Dialisi, Ospedale Maggiore, IRCCS, Milano, Italy
William Withey Gull (1816–1890) (Figure 1) was one
of the best clinicians of his time, who graduated and
worked for many years at Guy’s Hospital, London
[1]. He owed his fame to ‘his power of diagnosis and
to his appreciation of the patient and his condition’
[2] as well as to his ability as a teacher. He also
contributed to the advancement of medical science
through the more than 90 papers he wrote on various
subjects, which included diseases of the nervous, vascular, respiratory, and digestive systems, rheumatic fever,
diseases of the skin, mixoedema, and others [3].
In 1872 Gull published, together with Henry Gawen
Sutton (1837–1891), a lecturer on pathology at the
London Hospital, a paper about the vascular changes
observed in the advanced phase of Bright’s disease [4].
By analysing the microscopical appearance of the
kidneys of 55 autopsy cases with chronic renal disease
Gull and Sutton observed a frequent lesion of the
small vessels, which they described with these words:
besides kidneys including the heart, which in the cases
studied was found to be always hypertrophied. Gull
and Sutton considered arterio-capillary fibrosis as an
affection of the whole arterial system, not one of the
kidneys only. They did not know its cause, but found
it was more frequent in patients above the age of 40
The muscular tissue appeared to be changed in some of
the vessels—it seemed thicker than natural, particularly
when the arterioles were viewed longitudinally. The
muscular nuclei were indistinct, and many of them were
so altered as hardly to be recognisable. External to the
muscular nuclei there was a quantity of hyaline-fibroid
substance, and the layer formed by this material was
much thicker than the muscular layer. This hyalinefibroid was in some of the arterioles bounded externally
by a few coarser fibres; in some it merged imperceptibly
into the fibroid tissue lying between the tubules. The
arterioles were often very much thickened and tortuous.
The lumen of some of them was encroached upon and
narrowed, and in some it seemed completely obliterated.
Two rather nice pictures accompanied the text, which
showed several examples of the lesion which had been
observed (Figures 2 and 3). The lesion, which Gull
and Sutton called ‘arterio-capillary fibrosis’, corresponds to what we define today as arteriosclerosis. It
was also observed in the small vessels of many organs
Correspondence and offprint requests to: G. B. Fogazzi, Divisione di
Nefrologia e Dialisi, Ospedale Maggiore, IRCCS, Via Commenda
15, I-20122 Milano, Italy.
Fig. 1. Portrait of William W. Gull (from reference 6).
© 1999 European Renal Association–European Dialysis and Transplant Association
1328
G. B. Fogazzi
Fig. 2. The microscopic appearances seen in the advanced phase of Bright’s disease by Gull and Sutton. (a=Malpighian bodies which are
lying clustered together and surrounded by a quantity of fibroid material; b=tubules which are lined with epithelial cells for the most part
healthy; c=isolated wasted tubules, containing shrivelled, ill-defined epithelial cells, and in some, in place of epithelium, nothing but fatgranules remain; d=a convoluted tubule coming down from one of the Malpighian bodies with its epithelial cells destroyed (from reference
4 quoting the words used by Gull and Sutton).
years. In addition, they were convinced that the lesion
they described was the cause and not the consequence
of the kidney disease. This view was in sharp contrast
with that formulated some years before by Richard
Bright (1789–1858), which was subsequently supported by George Johnson (1818–1896), who considered the vascular damage to be the result of the renal
disease [5]. However, Gull was so sure about his
hypothesis that during a lecture given at Guy’s Hospital
in 1872, while showing a specimen containing a much
hyperthrophied heart and a very contracted kidney
prepared under Bright’s own direction, he did not
hesitate to say ‘Bright observed the heart and the
kidneys, but he forgot the man between; the whole
man should have been included in the specimen’ [6 ]!
References
1. Wilks S, Bettany GT. A Biographical History of Guy’s Hospital.
Ward, Lock, Bowden & Co, London, 1892; 261–274
2. Anonymous. In Memoriam—Sir William Gull. Guy’s Hospital
Reports 1890; 47: XXV–XLIII
3. A Collection of the published writings of Sir William Withey Gull.
Medical Papers. Edited and arranged by Acland TD. The New
Sydenham Society, London, 1894
4. Gull WW, Sutton HG. Chronic Bright’s disease with contracted
kidney (‘Arterio-capillary fibrosis’). Medico-Chirurg Trans 1872;
55: 273–326
5. Rault R. Enigma of contracted granular kidney: a chapter in the
history of nephrology. Am J Nephrol 1991; 11: 402–408
6. A Collection of the published writings of Sir William Withey Gull.
Memoir and Addresses. Edited and arranged by Acland TD. The
New Sydenham Society, London, 1896; XXI
Iconographic Archives of European Nephrology
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Fig. 3. Various examples of arterio-capillary fibrosis as seen in different organs by Gull and Sutton (1=a capillary of the pia mater much
thickened by a homogeneous hyalin substance; 2=capillary very much thickened by a granular substance; 3=hyalin-fibroid thickening
outside the wasted muscular layer; 4=the arterioles in the choroid greatly thickened by the formation of fibroid material outside the socalled muscular nuclei; 5=arteriole of the skin thickened by fibroid formation outside muscular layer; 6=arteriole lying amongst muscular
tissue of heart greatly thickened by the fibroid material; 7=minute artery of the kidney greatly thickened by hyalin fibroid changes in the
outer layer of the vessels [magnification 750×]) (from reference 4 quoting the words used by Gull and Sutton).